Ectopic Pregnancy - How To Manage It?

The normal process is for the fertilized egg to get itself embedded within the uterus. For various reasons, however, it can happen that the fertilized egg gets embedded outside the uterine cavity. This is known as extra-uterine pregnancy or ectopic pregnancy. The incidence of this is 11 per 1000 pregnancies. The most common location (97 % of the times) for these pregnancies is the fallopian tube, and so also known as tubal pregnancies. Rarely (1 in 30,000 pregnancies) an ectopic pregnancy can coexist with an intrauterine pregnancy.

Risk factors: This is not a normal pregnancy, and there are certain risk factors, which increase the chance for ectopic pregnancy.

1. Pelvic inflammatory diseases
2. Prior tubal surgery
3. Endometriosis
4. Prior ectopic pregnancies
5. Assisted reproductive techniques such as IVF
6. Congenital structural anomalies of uterus
7. IUCD use reduces the risk of ectopic pregnancy compared to no contraception that is 1 in 1000. However, where an IUCD fails, the risk of pregnancy being ectopic is high

All causes of ectopic pregnancy have a common factor – the fallopian tube is affected and does now allow for movement of the egg up the uterus. This could be due to infections or adhesions

Symptoms: Ectopic pregnancy would present with symptoms similar to a normal pregnancy like amenorrhea, abdominal pain, pelvic pain, breast tenderness except that the implanted egg puts pressure on the surrounding organs and this causes additional problems like shoulder tip pain, urinary symptoms, rectal pain, diarrhea and vomiting.

There could also be vaginal bleeding, passage of tissue per vaginum and in this case, it needs to be differentiated from a miscarriage

Sometimes, the tubes may rupture and bleeding ensues which can be life-threatening. Treatment is often done on an emergency basis.

1. There is a sharp stabbing pain in the pelvis and abdomen, which can sometimes go up into the diaphragm.

2. Bleeding which is often heavier than the normal period

3. Weakness and fainting

Diagnosis: For an ectopic pregnancy to be confirmed, imaging is necessary. In addition,

1. The HCG levels can be lower than expected with a normal pregnancy

2. Confirmation happens with an internal ultrasound, which will also tell where exactly it is situated.

Management: Treatment can involve one of the 3 ways.

1. Conservative if the serial beta hcg are falling adequately

2. Methotrexate, which will dissolve the pregnancy tissue and allow for the body to absorb it. The tubes are often spared in this, and they heal over time.

3. If the tube or tubes are affected, then they will have to be removed. This may even be done as an emergency procedure if the bleeding is severe.

4. Laparoscopic surgery is often considered to remove the fallopian tube and the ectopic pregnancy. If the same cannot be carried out laparoscopically, then an open surgery needs to be done.

Prognosis: Once an ectopic pregnancy occurs, the chances of recurrence are about 10 to 20 %. HCG levels will have to be monitored periodically. If the levels continue to be high, it is possible that there is still some ectopic tissue left. This may require methotrexate or surgery.