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An ectopic pregnancy occurs when the fertilized egg implants outside the uterus. Almost all (more than 95%) ectopic pregnancies occur in a fallopian tube, which is how the term "tubal" pregnancy originated ("Ectopic Pregnancy"). On rare occasions, the egg may implant elsewhere, such as in the abdomen, ovary, or cervix. Because the narrow fallopian tubes are not designed to hold a growing embryo, the fertilized egg in a tubal pregnancy cannot develop normally. Eventually, the thin walls of the fallopian tube stretch to the point of bursting (rupture). If this happens, a woman is in danger of life-threatening blood loss (massive hemorrhage).
Most cases of ectopic pregnancy are caused by an inability of the fertilized egg to make its way through the fallopian tube into the uterus. This is often caused by an infection or inflammation of the tube that has caused it to become partially or entirely blocked. Scar tissue resulting from a previous infection or sexually transmitted disease such as chlamydia or gonorrhea may impede the egg's movement.
Approximately 50% of women with ectopic pregnancies have a history of salpingitis or pelvic inflammatory disease (PID). An estimated 60% of ectopic pregnancies develop after tubal sterilization (Marchiano). Women who have successful surgery to have this procedure reversed are also more prone to develop this condition.
Taking estrogen and progesterone can reduce the normal movement of the fertilized egg through the tubal epithelium and result in implantation in the fallopian tube. If a woman becomes pregnant while taking a progesterone-only contraceptive, she is 5 times more likely to have an ectopic pregnancy. Taking the "morning after pill" (progestin or progestin with estrogen) increases a woman's risk of ectopic pregnancy 10 times if it fails to prevent pregnancy (Marchiano).
A condition such as endometriosis, in which the tissue normally lining the uterus is found outside the uterus, can also cause blockage of a fallopian tube and predispose the individual to ectopic pregnancy. Another possible cause of ectopic pregnancy is an abnormality in the shape of the fallopian tube that may be due to abnormal growths or a birth (congenital) defect. There is a slight (5%) increased risk of ectopic pregnancy in the fallopian tube if a woman uses a nonmedicated intrauterine device (IUD) for contraception, and a 15% increase if the IUD is medicated. It is very rare for a woman to become pregnant while using an IUD.
Risk: Risk factors include smoking and previous ectopic pregnancies, which pose the highest risk: the recurrence rate is 15% after the first pregnancy and 30% after the second ("Ectopic Pregnancy"). Other factors may include having multiple abortions, exposure to sexually transmitted diseases (STD), diethylstilbestrol (DES) exposure, and being between 35 and 44 years of age. Incidence and Prevalence: An estimated 1 in 60 pregnancies is an ectopic pregnancy ("Ectopic Pregnancy"). The incidence of ectopic pregnancies has increased fourfold between 1970 and 1992 (Marchiano). |
Source: Medical Disability Advisor
| History: Symptoms may initially include lower abdominal pain (sharp, dull, or cramping). The pain may be constant or intermittent and is usually located on only one side of the abdomen. The individual may also experience vaginal bleeding, nausea, vomiting, and frequent urination. Breast tenderness may be reported.
After the fallopian tube has ruptured, lower abdominal pain becomes sharp and may spread (radiate) to the shoulders, neck, and lower back. The individual may experience fainting. Ectopic pregnancy is usually discovered in the first 2 months of pregnancy when the woman may not even realize she is pregnant. Physical exam: Prior to rupture, a tender mass may be felt in the area of one fallopian tube. After rupture, pain that has spread to the neck and shoulder area becomes severe when pressure is applied to the affected area or to the cervical area. Symptoms of internal bleeding or shock may occur, including a weak, rapid pulse (tachycardia) and low blood pressure (hypotension). Tests: A pregnancy test is usually done for any sexually active woman of childbearing age. Ultrasound or laparoscopy may also be performed in order to examine the abdominal cavity. These tests are considered diagnostic if motion of the fetus or the fetal heart is seen outside the uterus. Blood tests for pregnancy hormone (human chorionic gonadotropin [hCG]) or progesterone are often diagnostic of pregnancy but do not distinguish an intrauterine from an extrauterine pregnancy. A white blood cell count may be normal or increased. A culdocentesis may also be performed. In this procedure, a thin needle is inserted through the vaginal wall just below the uterus. A sample is taken of any fluid found in the space and the needle is then withdrawn. Finding free blood in the peritoneum (a positive culdocentesis) can be consistent with a ruptured or leaking ectopic. A laparoscopy or a laparotomy may be performed to confirm diagnosis. |
Source: Medical Disability Advisor
| If rupture has occurred because of an ectopic pregnancy, internal bleeding and/or hemorrhage may lead to shock. Nearly 20% of ectopic pregnancies present in this manner (Marchiano). Shock is treated by keeping the woman warm, elevating her legs, and administering oxygen. A blood transfusion is performed, and emergency care begins as soon as possible.
Surgical technique depends on whether the fallopian tube has ruptured. If the tube has ruptured and there is significant hemorrhage, a laparotomy is usually performed. This procedure involves a larger incision and can be performed faster in an emergency situation. If the tube has not ruptured, and it is not an emergency situation, a laparoscopy, or minilaparotomy, which is less invasive, is usually done. After performing either the laparotomy or the laparoscopy, the surgeon then proceeds to perform either a salpingotomy, a procedure in which another incision is made on the fallopian tube and the pregnancy is removed (thus saving the fallopian tube), or a salpingectomy, a procedure in which the fallopian tube (or tubes) is removed. Every attempt is made to save the fallopian tubes, but if the damage to them is too great or the salpingotomy fails, a salpingectomy is performed.
With prompt surgical treatment, a complete recovery is expected. Chances of conception may be slightly reduced, but a normal pregnancy is still possible, even if one fallopian tube has been removed.
Nonsurgical (medical) management is being implemented by some hospitals for very early ectopic pregnancies that do not carry an immediate threat of rupture. In such cases, a drug that stops cell division (methotrexate) is administered, and the woman is observed while various blood tests are obtained. This medical approach is relatively new but appears to be a promising treatment. When methotrexate is used, the woman's progress should be closely monitored for up to 4 to 6 weeks by her physician or healthcare provider since treatment with medication is a relatively new option. |
Source: Medical Disability Advisor
| With prompt surgical treatment, a complete recovery is expected. The maternal death rate has decreased to less than 0.1%, and an estimated 85% of women who have had one ectopic pregnancy experience a normal pregnancy (Marchiano). The rate of a recurrent ectopic pregnancy is 15% to 30% ("Ectopic Pregnancy"). |
Source: Medical Disability Advisor
| If the site of the ectopic pregnancy ruptures, shock from the severe loss of blood is a serious complication and may require a blood transfusion. Delayed or absent treatment may result in death, but this is very rare. Surrounding tissue structures may also be damaged by the developing pregnancy. After the fallopian tube is repaired, another tubal pregnancy may develop later. The tube may be damaged beyond repair and have to be removed (salpingectomy). Infertility occurs in 10% to 15% of women who have an ectopic pregnancy (Marchiano). |
Source: Medical Disability Advisor
| Work responsibilities may need to be largely sedentary at first. Heavy work, especially any work involving heavy lifting, may be temporarily restricted. Lifting and climbing may have to be limited initially after salpingectomy. Long periods of standing may need to be avoided. Work restrictions may also apply for several weeks after medical management of ectopic pregnancy with methotrexate. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does the individual have a history of STDs?
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Has the individual had previous surgery on her fallopian tubes?
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Does the individual have a history of PID or endometriosis?
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Has the individual experienced an infection or inflammation of the fallopian tubes?
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Does the individual have a history of ectopic pregnancy or of repeated, induced abortions?
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Does the individual use an IUD for contraception?
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Does the individual take medication to stimulate ovulation?
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Does the individual have lower abdominal pain on one side only?
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Is there vaginal bleeding?
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Is nausea, vomiting, or frequent urination present?
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Is there a tender mass that can be felt in the area of one fallopian tube?
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Has a pregnancy test been done if the individual is a sexually active woman of childbearing age?
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Were ultrasound and laparoscopy done to determine if motion of the fetus or the fetal heart is seen outside the uterus?
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Were blood tests for human chorionic gonadotropin (hCG) or progesterone done?
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Has a diagnosis of ectopic pregnancy been confirmed?
Regarding treatment:
- Was early ectopic pregnancy, without immediate threat of rupture, treated with an anticancer drug (methotrexate) while the individual was monitored and various blood tests were obtained (medical management)?
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Was medical management successful and without complications?
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If not, was minilaparotomy or laparoscopy required?
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Was the surgical procedure successful and without complications?
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If rupture occurred, was shock prevented?
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Was a blood transfusion required?
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Was surgical laparotomy performed to stop the immediate loss of blood?
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If so, was surgery successful and without complications?
Regarding prognosis:
- Is this a recurrent ectopic pregnancy?
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Did the individual obtain prompt medical and/or surgical treatment?
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Did the individual experience a complete recovery after treatment?
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Was the loss of blood significant enough to cause shock?
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Does the individual require removal of the fallopian tube (salpingectomy)?
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Did the individual experience significant blood loss and shock?
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Is there a recurrent ectopic pregnancy?
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Would the individual benefit from psychotherapy or counseling for grief or depression?
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Would the individual benefit from consultation with an infertility specialist?
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Source: Medical Disability Advisor
| "Ectopic Pregnancy." MedicineNet.com. 26 Apr. 2002. MedicineNet, Inc. 3 Jan. 2005 <http://www.medicinenet.com/Ectopic_Pregnancy/article.htm>.Marchiano, Dominic. "Ectopic Pregnancy." MedlinePlus. 14 Apr. 2004. National Library of Medicine. 3 Jan. 2005 <http://www.nlm.nih.gov/medlineplus/ency/article/000895.htm>. |
Source: Medical Disability Advisor
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