Ectopic pregnancy

An ectopic pregnancy is a pregnancy that grows outside the uterine cavity (womb) instead of inside the uterine cavity. Most ectopic pregnancies develop in the fallopian tubes, but rarely they can occur in other places such as the ovaries, the cervix or abdominal cavity. Around 1-2% of all pregnancies are ectopic pregnancies. An ectopic pregnancy unfortunately cannot be moved back into the uterus. It can be life-threatening when it grows and ruptures, causing severe pain and internal bleeding.

What is pregnancy of unknown location? 

A pregnancy of unknown location means a woman is pregnant but the pregnancy cannot be identified on an ultrasound scan, either intra-uterine or extra-uterine. This may be due to three possible reasons:

1) It is a very early pregnancy within the uterus that is too small to be seen on a scan;
2) It is a miscarriage. The pregnancy hormone (βhCG) can remain in the body for a few weeks following a miscarriage;
3) It is an ectopic pregnancy.

What are the symptoms of an ectopic pregnancy?

Each woman is affected differently by an ectopic pregnancy. Some women have no symptoms at all especially when the pregnancy is early. Most women start to notice symptoms in the 6th week of pregnancy (about 2 weeks after a missed period). The symptoms of an ectopic pregnancy may include:

1) Pain in the lower abdomen that may develop suddenly or may come on gradually over several days.

2) Vaginal bleeding. The bleeding may be lighter, heavier or darker than a normal period.

3) Pain in the shoulder tip that is persistent and worse when lying down. This can be a sign that blood is leaking into the abdomen.

4) Feeling dizzy, faint and passing out. This can be a sign that the ectopic pregnancy in the fallopian tube ruptures and causes internal bleeding. This is an emergency situation and urgent medical attention should be sought immediately.

How is ectopic pregnancy diagnosed?

Most ectopic pregnancies are diagnosed between 6 and 10 weeks of pregnancy. The diagnosis is made quickly if a pregnancy outside the womb cavity can be seen on ultrasound, but this is uncommon. If the pregnancy cannot be seen on ultrasound, it is labelled as a pregnancy of unknown location. Blood will be taken to check βhCG level. If the βhCG is higher than a level in which a normal pregnancy inside the womb should be visualized on ultrasound, ectopic pregnancy will be suspected. If the βhCG level is still low, repeated blood samples and ultrasound scans will be arranged. Sometimes it may take a week or more to reach the diagnosis of an ectopic pregnancy.

What are the options for treatment of tubal ectopic pregnancy?

Because an ectopic pregnancy cannot lead to the birth of a baby, all treatment options will end the pregnancy. These options include surgery, injection of medication or expectant (wait and see).

Expectant Management (Wait and see)

Ectopic pregnancies sometimes end on their own – similar to a miscarriage. Expectant management is only suitable for a very small number of patients with ectopic pregnancies: those who do not have symptoms, and whose βhCG level is low (< 1,500IU/L) and continues to fall. βhCG is tested regularly until it is back to normal. If it stops falling well or symptoms develop, medical or surgical treatment are needed.

Medical treatment 

Patients who have no symptoms and a low βhCG level can consider injection of methotrexate (MTX) to the muscle. MTX prevents the ectopic pregnancy from growing and the ectopic pregnancy gradually disappears. Around 85% of patients with ectopic pregnancy can be successfully treated with only one injection of MTX. However, 15% of women need to have a second injection, while 7% will need surgery even after MTX.

Medical treatment is more likely to fail if the ectopic pregnancy is large or live and in women with high βhCG level (> 5,000 IU/L). Medical treatment is not suitable for those with symptoms of ruptured ectopic pregnancy or internal bleeding, who cannot attend regular follow-ups till βhCG falls back to normal, or in whom pregnancy inside the womb cannot be excluded.

Many women experience some abdominal pain in the first few days after taking the MTX, but this usually settles with paracetamol (Panadol). Although long-term and high dose treatment with MTX for other illnesses can cause side effects like hair loss, nausea, vomiting, stomatitis, elevated liver enzymes, these rarely occur with one or two injections as used to treat ectopic pregnancy. MTX is not known to affect the ability of the ovaries to produce eggs or ovarian function.

The patient will be admitted to hospital, and can go home on the same day after MTX injection.  Follow-up appointments and blood tests for βhCG levels will be arranged on Day 4 and Day 7 after the injection, then weekly if βhCG level drops satisfactorily until normal. This usually takes 2 to 4 weeks but can be up to 8 weeks.  Contraception for 3 months after the injection is advised.

There is still a small chance for the ectopic pregnancy to rupture after medical treatment. It is important to seek immediate medical advice in case of severe, increasing abdominal pain and distension, shoulder tip pain or feeling faint.

Surgical treatment 

An operation to remove the ectopic pregnancy will usually involve a keyhole surgery (laparoscopy) under general anaesthetic. Open surgery (laparotomy) is necessary in case of severe internal bleeding or if the patient is at high risk for keyhole surgery.

During the operation, either the affected fallopian tube together with the ectopic pregnancy is removed (salpingectomy), or to cut open the fallopian tube to remove the ectopic pregnancy without removing the tube (salpingotomy). If the patient had salpingectomy before and now has only one fallopian tube, salpingotomy may be considered to preserve the possibility of a natural conception in the future without the need for in-vitro fertilization (IVF). However, there is a chance of incomplete removal of the ectopic pregnancy during salpingotomy. It is important to follow up with weekly blood tests to check βhCG level until it returns to normal. If the βhCG level does not go down or even goes up, further treatment with either MTX injection or another operation to remove the tube will be needed. Patients who have salpingectomy do not need βhCG monitoring after the operation.

Can I conceive again in the future?

The chance of having a successful pregnancy in the future is optimistic, even if the woman has only one fallopian tube after treatment of ectopic pregnancy. However, women who have had ectopic pregnancy will have a higher chance (around 7–10%) of having another ectopic pregnancy in the future. Therefore, when they conceive again, they should seek medical advice and have an ultrasound scan between 6 and 8 weeks to confirm the pregnancy is developing in the uterus.

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