Ectopic pregnancy overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.[1] In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This bleeding expels the implantation out of the tubal end as a tubal abortion. Some women thinking they are having a miscarriage are actually having a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is locally irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.
Epidemiology and Demographics
Ectopic pregnancy (EP) remains one of the few life threatening diseases where the incidence is increasing (19.7/1000 pregnancies in 1992) but the mortality is decreasing.
Risk Factors
There are a number of risk factors for ectopic pregnancies. They include: pelvic inflammatory disease, infertility, those who have been exposed to DES, tubal surgery, smoking, previous ectopic pregnancy, multiple sexual partners, current IUD use, tubal ligation, and previous abortion.[2]
Diagnosis
Laboratory Findings
Diagnosis can be made by the 7th week of pregnancy (~ 4.5 weeks after conception).
Treatment
Medical Therapy
There has only been one randomized controlled trail comparing medical to surgical therapy, and there was no difference as far as elimination of the EP or tubal preservation, however the methotrexate (MTX) group had a higher incidence of side effects.
Surgery
About half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound.
References
- ↑ Serdar Ural (May 2004). "Ectopic pregnancy". KidsHealth. Retrieved 2006-11-26.
- ↑ "BestBets: Risk Factors for Ectopic Pregnancy".