Ectopic pregnancy ” pregnancy of unknown location ” : _
A fertilized ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%).
If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal hemorrhage.
Symptoms and signs of ectopic pregnancy
Be aware that ectopic pregnancy can present with a variety of symptoms. Even
if a symptom is less common, it may still be significant. Symptoms of ectopic pregnancy include:
* common symptoms:
abdominal or pelvic pain
amenorrhoea or missed period
vaginal bleeding with or without clots
* other reported symptoms:
breast tenderness
gastrointestinal symptoms
dizziness, fainting or syncope
shoulder tip pain
urinary symptoms
passage of tissue
rectal pressure or pain on defecation.
Be aware that ectopic pregnancy can present with a variety of signs on examination by a healthcare professional. Signs of ectopic pregnancy include:
* more common signs:
pelvic tenderness
adnexal tenderness
abdominal tenderness
* other reported signs:
cervical motion tenderness
rebound tenderness or peritoneal signs pallor
abdominal distension
enlarged uterus
tachycardia (more than 100 beats per minute) or hypotension (less than 100/
60 mmHg)
shock or collapse
orthostatic hypotension.
How do I get a diagnosis?
Most ectopic pregnancies are suspected between 6 and 10 weeks of pregnancy.
Sometimes the diagnosis is made quickly, but if you are in the early stages of
pregnancy, it can take longer (a week or more) to make a diagnosis of an ectopic
pregnancy.
Your diagnosis will be confirmed by the following:
Consultation and examination
The doctor will ask about your medical history and symptoms. The doctor will
examine your abdomen and may also do a vaginal (internal) examination. You
should be offered a female chaperone (someone to accompany you) for this. You
may also wish to bring someone to support you during your examination.
If you have not already had a positive pregnancy test, you will be asked for a urine sample so this can be tested for pregnancy. If the pregnancy test is negative, it is very unlikely that your symptoms are due to an ectopic pregnancy.
Ultrasound scan
Most women are offered a transvaginal scan (where a probe is gently inserted into
your vagina) to look at the uterus, ovaries and fallopian tubes. If you are in the early
stages of pregnancy, you may be offered another scan after a few days when it may be easier to see the pregnancy.
Blood tests
● A test for the level of the pregnancy hormone human chorionic gonadotrophin (hCG) or a change in this level every few days may help to give a diagnosis.
● A test for the level of the hormone progesterone may be taken.
Laparoscopy
If the diagnosis is still unclear, an operation called a laparoscopy may be necessary. This operation takes place under a general anaesthetic. The doctor
uses a small telescope to look at your pelvis by making a tiny cut usually into the
umbilicus (tummy button). This is also called keyhole surgery.
If an ectopic pregnancy is detected, treatment may take place during the same
operation.
Expectant management (wait and see)
Ectopic pregnancies sometimes end on their own – similar to a miscarriage.
Depending on your situation, it may be possible to monitor the hCG levels with
blood tests every few days until these are back to normal (see Follow-up appoint-
ments: what happens next?). Although you do not have to stay in hospital, you
should go back to hospital if you get any symptoms.
Expectant management is not an option for all women. It is usually only possible
when the pregnancy is still in the early stages and when you have a few or no
symptoms. Up to 29 in 100 (29%) women undergoing expectant management may
require additional medical or surgical management.
Medical treatment
In certain circumstances, an ectopic pregnancy may be treated by medication
(drugs). The fallopian tube is not removed. A drug (methotrexate) prevents the
pregnancy from developing and so the ectopic pregnancy gradually disappears.
The drug is given as an injection. If your pregnancy is beyond the very early stages
or the hCG level is high, methotrexate is less likely to succeed. Many women
experience some pain in the first few days, but this usually settles with paracetamol
or similar pain relief. Although long-term treatment with methotrexate for other
illnesses can cause significant side effects, this is rarely the case with one or two injections to treat ectopic pregnancy.
You may need to stay in hospital overnight and then return to the clinic or ward a few days later.
● Fifteen in 100 (15%) women need to have a second injection of methotrexate.
● Seven in 100 (7%) women will need surgery, even after medical treatment.
Surgery
The aim of surgery is to remove the ectopic pregnancy. The type of operation you have will depend on your wishes or plans for a future pregnancy and what your
surgeon finds during the operation (laparoscopy).
To have the best chance of a future pregnancy inside your uterus, and to reduce the risk of having another ectopic pregnancy, you will usually be advised to have your fallopian tube removed (salpingectomy).
If you only have one tube or your other tube does not look healthy, this already
affects your chances of getting pregnant. In this circumstance, you may be advised
to have a different operation (salpingotomy). This operation aims to remove the pregnancy without removing the tube. It carries a higher risk of a future ectopic pregnancy but means you retain the possibility of a pregnancy in the uterus in the future. Some women may need to have a further operation to remove the tube later if the pregnancy has not been completely removed.
An operation to remove the ectopic pregnancy will involve a general anaesthetic.
The surgery will be either:
● Laparoscopy – the stay in hospital is about 1 to 2 days and the recovery is
about 2 to 4 weeks .
● Open surgery – known as a laparotomy – is performed through a larger cut
in your lower abdomen. It is usually done if severe internal bleeding is suspected. You will need to stay in hospital for 2 to 4 days. It usually takes about 4 to 6 weeks to recover.
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