An ectopic pregnancy is a condition where a fertilised egg implants and grows in a location outside the main cavity of the Uterus (womb). The most frequent site is the fallopian tube, but it can also occur in other areas, such as the ovary, cervix, or abdomen. About 1 in 80 pregnancies are ectopic.
After an egg (Ovum) is released by the ovary, the end of the fallopian tube’s finger-like projection catches the egg and transfers it towards the uterus. During this transfer, the Sperm fertilises the egg in the lateral portion of the Fallopian tube (ampulla). Then the fertilised egg ( Embryo / Baby ) travels along a Fallopian Tube towards the normal uterine cavity and develops after getting implanted. Usually, a fertilised egg will then implant in the Uterus and start to develop.
In an ectopic pregnancy, the fertilised egg either does not reach or does not stop in the uterus. Instead, it gets implanted somewhere it cannot fully develop.
In most ectopic pregnancies, the fertilised egg implants in one of the fallopian tubes. Less commonly, the fertilised egg implants in the Ovary, Cervix, or Abdomen. It can also be implanted in a caesarean scar or other places within the womb wall.
Any woman of childbearing age who is sexually active can have an ectopic pregnancy. Some women are at greater risk, including women who have had the following conditions:
1. History of Pelvic Inflammatory Disease (PID), or Pelvic infections, such as Chlamydia, Gonorrhoea, etc
2. Previous abdominal surgery, such as caesarean section, ectopic pregnancy, Tubal ligation or reversal surgery.
3. Previous sterilisation or reversal of sterilisation.
4. Intra-Uterine Contraceptive Device (IUCD/coil) use. The incidence of ectopic pregnancy is almost similar to women who do not have an IUCD.
5. IVF treatment.
6. Women who conceive following the use of Emergency Contraception (morning after pill or IUCD).
7. Women with a previous history of Ectopic Pregnancy
8. Increased Age: Pregnancy above the age of 30 has a higher risk of ectopic pregnancy.
Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks of pregnancy.
Initially, most of the women don’t have any symptoms. Mild cramps on one side of the pelvic region can be the only symptom during the early stage. Sometimes diagnosed accidentally while doing an Ultrasonography to confirm pregnancy. If we don’t do the sonography, we can not diagnose the ectopic pregnancy until the woman develops more serious symptoms later on.
1.A missed period and other signs of pregnancy, like nausea, vomiting, etc. Many times, women get spotting on the expected date of menses, and some women mistake this bleeding for a regular period. Hence, every delayed menstrual period or scanty bleeding during menses needs to be observed for ectopic pregnancy.
2. Tummy Pain :
Women may experience tummy pain, typically low down on one side. It can develop suddenly or gradually, and may be persistent or come and go.
Tummy pain can have lots of causes, so it doesn’t necessarily mean you have an ectopic pregnancy.
3. Vaginal bleeding or a brown watery discharge :
Vaginal bleeding tends to be a bit different to your regular period. It often starts and stops, and may be watery and dark brown in colour.
Vaginal bleeding during pregnancy is relatively common and isn’t necessarily a sign of a serious problem, but one should seek medical advice if they experience it.
4. Pain at the tip of the shoulder :
Shoulder tip pain is an unusual pain during pregnancy.
It’s not known exactly why it occurs, but it can be a sign of an ectopic pregnancy, causing some internal bleeding, which irritates the diaphragm muscle, so the patient should get medical advice right away if she experiences it.
5. Discomfort while peeing or pooping :
In a few cases, an ectopic pregnancy can grow large enough to split open the fallopian tube. This is known as a rupture.
Ruptures are very serious condition, and Laparoscopic/ Robotic surgery to remove or repair the fallopian tube needs to be carried out as soon as possible.
1. A sharp, sudden and intense pain in your tummy.
2. Feeling very dizzy or fainting.
3. Vomiting.
4. Feeling sick.
It can be difficult to diagnose an ectopic pregnancy from the symptoms alone, as they can be similar to other conditions. Hence, Doctors and patients need to be ectopic-minded to diagnose the Ectopic pregnancy and prevent complications after rupture.
If a woman has the symptoms of an ectopic pregnancy and a positive pregnancy test ( usually a faint positive line ), she may be referred to an early pregnancy ultrasound for confirmation.
Some other tests that may help to diagnose are Blood Tests ( Serial Beta HCG Hormone test)
Keyhole Surgery, ideally not recommended for diagnosis, but can be useful for diagnosis as well as treatment in the setting.
If not diagnosed on time or treated early, because of haemorrhage into the tummy, a woman can end up with complications like haemorrhagic shock, DIC, renal failure, and rarely death due to cardio-respiratory failure.
There are 3 different treatment options for ectopic pregnancy depending on the circumstances :
This is managed as an outpatient and involves no active medical or surgical intervention. The patient is simply kept under observation if they fit into the criteria – “No symptoms or mild symptoms, and the pregnancy is very small, there’s a good chance the pregnancy will dissolve by itself.
The main advantage of monitoring is that there are no side effects of treatment.
A disadvantage is that there’s still a small risk of 1 of your fallopian tubes splitting open (rupturing), and you may eventually need emergency Laparoscopy or Robotic surgery.
1.Medical Management :
If an ectopic pregnancy is diagnosed early but active monitoring isn’t suitable, treatment with a medicine called methotrexate may be recommended.
This works by stopping the pregnancy from growing. It’s given as a single injection into the buttocks.
No need for the patient to stay in the hospital after treatment, but regular blood tests will be carried out to check if the treatment is working.
A second dose is sometimes needed, and surgery may be necessary if it doesn’t work.
The patient should use contraception for 3 months. This is because methotrexate can be harmful to a baby if you become pregnant during this time.
It’s also important to avoid alcohol, as drinking soon after receiving a dose of methotrexate can damage the liver.
Other side effects of methotrexate include:
There’s also a chance that the fallopian tube ruptures after treatment, and it may require Laparoscopic or Robotic surgery
3. Surgical Management :
In most cases, Laparoscopy / Robotic / Minimal Access Surgery / Keyhole surgery will be carried out to remove the pregnancy if the fallopian tube is ruptured, not ruptured, but if the fetus is alive or before it becomes too large and ruptures.
1. A General Anaesthesia or Regional anaesthesia is given.
2. Small cuts (incisions) are made in the tummy
4. a thin viewing tube (laparoscope) and small surgical instruments are inserted through the incisions
5. The entire fallopian tube containing the pregnancy is removed if the other fallopian tube looks healthy (Salpingectomy)
Removing the affected fallopian tube is the most effective treatment and isn’t thought to reduce the chances of becoming pregnant again.
If the pregnancy is towards the end of the fallopian tube, then the fallopian tube can be preserved by pushing out the pregnancy from the end (Milking of the tube).
If a woman is desirous to preserve the Fallopian tube, then a small cut is made over the tube and the pregnancy and products are taken out, and the fallopian tube is left for natural healing or sutured back with a very thin suture (Salpingostomy / Salphingotomy)
Most women can leave the hospital in a day after surgery.
If your fallopian tube has already ruptured, you’ll need emergency surgery.
Rarely, the surgeon may make a larger incision in the tummy (laparotomy) to stop the bleeding and remove the fallopian tube, if a Laparoscopy facility is not available.
After either type of surgery, a treatment called anti-D rhesus prophylaxis will be given if a patient’s blood type is RhD negative
Consultant Gynecologist with specialisation in laparoscopic and robotic-assisted surgeries.
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