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Ectopic or Tubal Pregnancy:Problems,Causes and Treatment

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                                                                         By: Dr. Sabeen Jalal Khan

Ectopic pregnancy is a pregnancy in which the fertilized ovum implants in any tissue other than endometrial lining of the uterus.

95% of the ectopic pregnancies occur in the Fallopian tubes. 1.5% are abdominal, 0.5% are ovarian and 0.03% are cervical.

The first tubal pregnancy treated and reported was in 1985. Most ectopic pregnancies occur in women aged 25-34 years. Surveillance data of pregnancy-related deaths in 1987-1990 demonstrated that women aged 30 years or older had a higher risk for pregnancy-relates death than that of younger women. But there has been a large drop in the ectopic death rate since 1970. In other words, it is much safer to have an ectopic than it was in 1970. Women aged 35-39 years have a 2.6 fold higher risk for death than women aged 25-29 years old. The risk is 5.9 fold higher for women aged 40 years or older.

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The history of patients with a ectopic pregnancy may include the following features:

  • Late or delayed menses
  • Abdominal and/or pelvic pain or cramping
  • Absence of viginal bleeding
  • Shoulder pain
  • Faintness
  • Marked or painful fetal movements

Causes of ectopic pregnancy may include the following:

  • Previous tubal pregnancy or surgery
  • Pelvic inflammatory disease
  • Pelvic adhesions
  • Pelvic tumors
  • Atrophic endometrium
  • Septate uterus
  • Presence of an intrauterine device
  • Oral contraceptive use

Risk factors for ectopic pregnancy

  • Pelvic inflammatory disease(PID). The rate of ectopic pregnancy in women with a known history of PID is 6-10 times higher than in women with no previous history of the problem.
  • Progestin contraceptives
  • Progesterone-bearing IUDs
  • Pregnancy after tubal ligation or sterilization.After non-laparoscopic tubal ligation about 12% of pregnancies are ectopic.
  • Pregnancy after tubal coagulation. After laparoscopic tubal coagulation about 51% of pregnancies are ectopic.
  • Ovulation induction or ovarian stimulation
  • In vitro fertilization

Diagnosis of ectopic pregnancy

A timely diagnosis of ectopic pregnancy is vital. The diagnosis can be made either through HCG levels, or ultrasound.

Class signs

  • Pelvic pain or abdominal pain, which is initially localized and then generalizes
  • Abdominal tenderness
  • First trimester bleeding

Common associated signs

  • Adnexal tenderness
  • Amenorrhea
  • Shoulder pain
  • Fainting after bowel movement
  • Nausea or vomiting
  • Diarrhea
  • Dizziness

Other signs

  • Tachycardia
  • Low-grade fever
  • Hypoactive bowel sounds
  • Tender pelvic mass

Surgical treatment of ectopic pregnancy

The possible procedures for ectopic pregnancy can all be done by laparoscopy(same day surgery) or by laparotomy(bigger incision).

Usually, if the tube is not ruptured it is done by laparoscopy. Cases of rupture with significant hemorrhage into the abdomen are almost always done by laparotomy because it can be done much faster.

Procedures

Salpingotomy or ostomy: Making an incision on the tube and removing the pregnancy.

  • Salpingectomy: Cutting the tube out.
  • Segmental re-section: Cutting out the affected portion of the tube.
  • Fimbrial expression: Milking the pregnancy out of the end of the tube.

Resolution of the ectopic has been reported in about 70-95% of cases treated.

Getting pregnant after ectopic pregnancy

The prognosis with an ectopic pregnancy is good for patients with an early diagnosis. Fertility may be preserved in patients with an early ectopic pregnancy, such as those with a tubal ring.

Patients with a previous ectopic pregnancy should be educated regarding the potential increased risk for another ectopic pregnancy. Patients taking fertility drugs should also be aware of the increased risk of ectopic pregnancy.

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