Ectopic pregnancy
What Is It?
Dr. David Kiragu Explains
Ectopic in layman’s terms means ‘out of place’. Ectopic pregnancy refers to a condition, in which a fertilised egg is implanted outside the uterus. The uterus is divided into two main parts. The upper part is known as the fundus uteri. This is where a fertilised egg is normally implanted. If the pregnancy is implanted in other sites, for instance in the fallopian tube, cervix, ovary or outside the genital system like in the abdominal cavity, it becomes an ectopic pregnancy. If embedded in the abdominal regions it is referred to as an abdominal pregnancy.
Other than the uterine cavity, none of the other areas have much space or nurturing tissue for a pregnancy to develop. When the foetus grows in the site of an ectopic pregnancy, the organ that contains it eventually bursts. This can cause severe bleeding and endanger the mother’s life. An abdominal pregnancy can develop to full term, but poses the danger of severe intra-abdominal bleeding to the mother.
What Causes An Ectopic Pregnancy?
Some causes of ectopic pregnancies are known, but some occur without any obvious explanation. Of the known causes the following have been noted:
An ectopic pregnancy may occur if the internal surface of the fallopian tube is destroyed. This is commonly due to infections of the fallopian tube which, can lead to partial blockage. Most of these infections are sexually transmitted like gonorrhea and chlamydia. Infection can also occur after an abortion or during the period following childbirth (a duration of 6-8 weeks, known as puerperium).
Partial blockage can also occur in the inner lining of the fallopian tubes, as a result of previous surgery. For instance, if surgery was performed on the fallopian tubes in an attempt to reverse tubal ligation (a surgical procedure in which the uterine tubes are tied), or to unblock a tube because of infertility, an ectopic pregnancy could occur because of the resultant scar constricting the fallopian tube. This would arrest the fertilised egg as it travels down towards the uterus.
Taking hormones, particularly progesterone as a postcoital contraceptive, could in the infrequent cases of failure lead to an ectopic pregnancy. Postcoital contraceptives are oral pills used as an emergency measure—taken within 72 hours of unprotected sexual intercourse—such as ‘morning after’ pills. Such hormones slow the normal movement of the fertilised egg through the tubes and can lead to ectopic pregnancy due to their effects on tubal motility (capability of motion of the egg within the fallopian tube).
Symptoms Of An Ectopic Pregnancy
Ectopic pregnancies can be difficult to diagnose, because the symptoms often mirror those of a normal early pregnancy. These include missed periods, breast tenderness, nausea, vomiting and frequent urination. Diagnosis requires a high index of suspicion. Pain is usually the first symptom of an ectopic pregnancy. You might feel a sharp and stabbing pain in your pelvis and abdomen. It may concentrate on one side of the pelvis. The pain also tends to be crampy and varies in intensity. Lower abdominal pain may be caused by stretching of affected tissue, and intensifies after the rupture of the ectopic pregnancy. This causes irritation on the abdominal cavity causing pain, dizziness or sometimes fainting due to loss of blood.
Another common sign is irregular bleeding. This presents as unexpected vaginal bleeding or spotting. A woman may have irregular bleeding in between periods. She may not even know that she is pregnant. This type of bleeding may range from spotting to heavy bleeding, which is irregular in amount and duration. Any sexually active woman in reproductive age with an abnormal menstrual period, especially if it occurs for the first time; has to be considered for possibility of having an ectopic pregnancy.
A pregnancy test can be negative
Often a woman misses her period, as happens to women occasionally, and then starts bleeding irregularly. She may not even notice any lapse in the onset of her period, or that she has been bleeding irregularly for some time. She may even doubt being pregnant since symptoms of pregnancy may not be dramatic. A pregnancy test can even be negative in very early stages of an ectopic pregnancy, or if the embryo is not alive.
Clinical examination of the patient and palpation or touch on the abdomen, makes the patient feel a lot of pain.
In advanced cases, the patient may go into shock and collapse because of internal bleeding.
Low blood pressure, caused by blood loss and lower back pain are some of the other features.
The Dangers Of An Ectopic Pregnancy
The major danger is death. Massive internal bleeding, which can occur within a very short time, can lead to death.
The person can also be in shock, which may be misdiagnosed because there are so many other clinical possibilities which can also present with shock. In addition, the patient may not be in a stable condition to give an accurate history.
After an ectopic pregnancy there is increased incidence of infertility due to potential damage of the fallopian tubes. Patients who have had ectopic pregnancies, may quietly suffer infertility consequently. The infertility can be treated through surgical intervention. This is however not always successful.
If fallopian tubes are badly damaged, one can still get pregnant through In vitro fertilisation (introduction of the sperm to the ovum outside a living organism, for instance in a test-tube), followed by embryo transfer. This is however a very expensive procedure. It also requires sophisticated equipment and expertise which may not be readily available.
Who Is At Risk Of An Ectopic Pregnancy?
Anybody can get an ectopic pregnancy but certain persons are at higher risk. These are women who have had sexually transmitted infections, particularly gonorrhea and chlamydia. If the infections have advanced to involve the fallopian tubes, they may damage the tubes if not treated on time.
Women who have had reconstructive surgery of the fallopian tubes are also at risk.
Can An Ectopic Pregnancy Go Full Term?
A classical ectopic pregnancy affects the fallopian tubes. Unlike the uterus which nurtures the baby, fallopian tubes are passageways. The placenta, anchored in the uterus, supplies the foetus with oxygen and nutrients. It also facilitates and ensures removal of waste products from the developing baby. Ectopic sites are on the other hand compromised in space, blood supply or tissue matrix, to satisfy the demands of a growing pregnancy.
In some cases an ectopic pregnancy terminates as a result of tubal abortion. The embryo, and accompanying fluid separate from the lining of the fallopian tube, and get pushed out of the fallopian tube by peristaltic action (wave-like contractions). It is shed through the wider end of the tube away from the uterus, into the abdominal cavity. From this location it is broken down by enzymes and absorbed into the body. Slight vaginal bleeding may be noticed as the decidua is shed from the uterus. Decidua is the mucous membrane lining the body of the uterus ready to receive and provide nutrition to the ferilised ovum.
If the developing foetus has penetrated the fallopian tube more deeply, the tube raptures, leading to internal bleeding, severe pain and profound shock. This will most likely occur before the pregnancy reaches the third month.
Abdominal delivery
Abdominal pregnancy which develops outside the genital system, and is planted on the surface of other organs in the abdominal cavity, has occasionally lived to a fully-grown foetus. Practically speaking, when you detect abdominal pregnancies early the intervention is to terminate them because they are high-risk pregnancies. The foetus is not well supported if attached on some of the abdominal structures and accidental separation of the vessels and the foetus can lead to massive internal bleeding. It is not an easy decision for a doctor to make when one has an abdominal pregnancy, and wants to retain it to full term.
However, some of these rare abdominal pregnancies have been detected when it is too late to terminate the pregnancy or when one thinks that it does not add value to terminate the pregnancy at that point. This includes those that have been detected late so that the doctor has little choice but to deliver the baby because it has already attained reasonable maturity. The baby is removed through an abdominal delivery (similar to a uterine C-section) as there is no-way the baby can access the uterus from the abdomen and be delivered through the birth canal.
Ectopic pregnancies are also terminated through surgery by an incision of the abdomen, similar to that done for a Caesarean section, except this time the incision is not on the uterus because ,the pregnancy is outside the uterine cavity.
Can Ectopic Pregnancy Be Prevented?
Most ectopic pregnancies potentially can be prevented though indirectly, for instance by avoiding septic abortions (abortions complicated by infection). This occurs when abortion is done in unsterile or in unsanitary conditions.
Secondly, avoiding sexually transmitted diseases or treating them early and completely when they occur. Enforcing moral issues, promoting condom use and making early diagnosis and treatment, of infected persons are some of the preventive measures of ectopic pregnancy.
Safe deliveries with high quality care in well equipped facilities, ensures prevention of infections. Such infections can lead to damage of the fallopian tubes. It is the infected fallopian tubes, when partially damaged, that predisposes a patient to the danger of having an ectopic pregnancy.
The above mentioned are the indirect measures, that help prevent ectopics. You can reduce the extent of suffering and death by making an early diagnosis of an ectopic pregnancy.
Can Ectopic Pregnancy Be Treated?
Basically ectopic pregnancy is managed through surgery. The ectopic pregnancy is removed from the fallopian tube. The bleeding is controlled from the bed where the ectopic embryo was developing. All the tissues around the area of the implantation that would lead to bleeding are also removed. In the common scenarios where a tube has ruptured, a segment or the whole fallopian tube may need to be removed.
The surgery is done under anaesthesia. It can be performed through an abdominal incision, or by laparoscopy—a procedure in which a thin microscope is inserted through the abdominal wall, to view the organs in the abdomen and permit small-scale surgery. A very small incision is made in the abdominal wall leading into the abdominal cavity, and the laparoscopic tool is introduced and used to remove the ectopic embryo. Subsequently, bleeding is controlled.
What Is The Possibility of Recurrence?
One has a fifteen per cent chance of getting another ectopic pregnancy, once you have suffered a previous ectopic. It is therefore prudent to have focused reviews, in the early stages of subsequent pregnancy.
Dr. David Kiragu is a gynaecologist/obstetrician based at KAM Health Services, IPS Building, Nairobi.
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