Now that we believe that you have mustered up the courage to learn about the bleak side effects of pregnancy, here is a detailed account of ectopic pregnancy symptoms and its treatment. Although, we do not intend to scare you off, but it is important for you to have an insight into the potential complications of pregnancy so that you may become a well-informed expecting mother.
It’s no secret that during pregnancy, the mother becomes more susceptible to physiological and pathological diseases. This occurs frequently because of a compromised immune system. Nonetheless, with some knowledge about pregnancy and the precautions, you can go throw this phase like a blissful mother.
The word ectopic means “out of place”, which implies that ectopic pregnancy is one form of pregnancy that is characterized by fertilized ovum implantation outside of the uterus.
Often, ectopic pregnancy takes place in the fallopian tube and thus it is stratified as tubal pregnancy.
However, it is important to note that not all the ectopic pregnancies take place in the fallopian tube, in some cases these pregnancies take place in the abdomen, cervix or the ovaries.
As the embryo develops in the region outside of the uterus, the pregnancy becomes hard to be retained.
With the growing embryo in any of the regions outside of the uterus, the ability of these structures to hold the baby becomes limited and soon they burst. At this point, the ectopic pregnancy is confirmed.
The cases of ectopic pregnancies can be life-threatening for both the mother and the child, as it may lead to still birth. The health hazards for the mother are increased due to the excessive internal bleeding.
According to the Ectopic Pregnancy Surveillance report from the CDC, ectopic pregnancy cases account for a significant number of maternal mortality in the US. During 1970-1978, 261,600 females visited their doctor and got discharged with a diagnosis of ectopic pregnancy. At that point in time, 7.1 pregnancies were the cases of ectopic pregnancies in every 1,000 pregnancies.
During this time, the mortality rate was high and about 437 women died from having an ectopic pregnancy. With time, the mortality rate has seen a sharp decline; however, the exact figures of the incidence rate have not been formally established.
On the other hand, the statistics quoted by British Medical Journal (BMJ) suggest that in the developed countries, 1% to 2% of all the pregnancy cases consequently result in ectopic pregnancy.
The incidence rate in the developing countries, however; are higher but due to the lack of probing, no exact figures from developing countries can be derived. However, it is estimated for the developing countries that 10% pregnant women who are admitted to the hospital with a diagnosis of ectopic pregnancy die from this pregnancy complication.
From year 1972 to year 1992, experts recorded a six-fold rise in the incidence rate of ectopic pregnancies in the developing countries. Interestingly, in the past recent years, the statistics have remained consistent and no significant increase has been recorded.
In the UK alone, ectopic pregnancy is the most common cause of maternal death during the first trimester of pregnancy and it has an incidence rate of 0.35 per 1000 ectopic pregnancies.
Ectopic Pregnancy Symptoms
It’s difficult to diagnose ectopic pregnancy initially because it can progress asymptomatic in the beginning. The pregnancy tests are positive, missed periods, morning sickness; fatigue, breast tenderness and nausea are essentially present which are primarily present in all pregnancies.
Due to the absence of any unusual symptoms right in the beginning of an ectopic pregnancy, an early detection of ectopic pregnancy becomes difficult. However, in some cases, early symptoms might indicate towards a case of ectopic pregnancy. These early ectopic pregnancy symptoms include;
- Abdominal pain
- Abdomen point tenderness-feeling pain in the abdomen when a specific area is pressed.
Abdominal tenderness is present in over 75% cases of ectopic pregnancy.
- Vaginal Bleeding
If you encounter these symptoms, then it is important for you to meet with your obstetrician at the soonest. Any delay in your doctor’s appointment can lead to further complications which include hemorrhage and organ rupturing.
However, if you are meeting regularly with your doctor for antenatal checkup appointments, then your doctor will be able to suspect a case of ectopic pregnancy, if present. This is yet another reason why you shouldn’t be missing out your antenatal appointments. Regularly meeting with your doctor during gestation helps foresee pregnancy complications which can save you from developing pregnancy complications.
Following are the details over look of ectopic pregnancy symptoms:
- Abdominal Pain Or Pelvic Pain
As we had discussed earlier, the abdominal pain is a commonly observed symptom of ectopic pregnancy but, it is a symptom of normal pregnancy as well. However, the pain experienced during ectopic pregnancy is severe and it can have a sudden onset, accompanied by vomiting and nausea.
During other times, this pain can be mild and it can have intervals in between. It may also arise under certain situations such as during a physical activity, while having cough or during a bowel movement.
This pain might start with a sudden sharp trigger localized in one area which gradually spread through the abdominal area.
Therefore, it is extremely important for you to meet with your doctor immediately after having abdominal or pelvic pain. After your physical examination, the doctor will give you an accurate diagnosis, confirming if the experienced abdominal pain is normal or if it hints toward a case of ectopic pregnancy.
- Shoulder Pain
It is important to look for this symptom, particularly when you are lying down. Shoulder pain remains a salient feature of ectopic pregnancy that arises due to the hemorrhage resulting from organ/tissue rupturing. This internal bleeding causes discomfort in the diaphragm as you continue breathing in and out. As a result, the nerves going into the shoulders are involved and they are irritated which consequently causes pain in shoulder tip.
Shoulder tip is the area which serves as a conjunction between the end of shoulder and beginning of arm and this exactly is when the pain is experienced by women you are having an ectopic pregnancy.
This pain to suddenly begin and as this pain settles in, other symptoms are followed which further confirms a case of ectopic pregnancy.
According to a study from BMJ, shoulder tip pain is prevalent in 20% cases of ectopic pregnancy.
- Persistent Vaginal Bleeding
This again is a symptom which requires your attention but, it also doesn’t always suggest that you are having an ectopic pregnancy. This vaginal bleeding can either be continuous or periodic (intermittent bleeding). This vaginal bleeding is often marked by a heavy flow.
So, you should not take vaginal bleeding lightly and must consult your doctor as soon as possible. Once your doctor thoroughly examines you, only then you can heave a sigh of relief.
- Signs Of Shock
If the fallopian tube is ruptured and internal bleeding has initiated, then you are likely to experience some signs of shocks which include palpitation, having dizziness and skin turning clammy and pale.
- Fainting Or Lightheadedness
As a result of excessive internal bleeding, it is most probable for you to faint or experience lightheadedness. In case, you are fainting during your pregnancy, rush immediately to your doctor and get a checkup done.
These symptoms are manifested between 6th and 10th week of pregnancy.
Diagnosis of Ectopic Pregnancy
Once you go and meet with your doctor after experiencing the symptoms of ectopic pregnancy, your doctor runs some tests and thoroughly examines you to reach an accurate diagnosis.
In this context, early diagnosis of ectopic pregnancy before the tubal rupture can help the doctors treat the ectopic pregnancy through the use of conservative treatment options. However, over half of the ectopic pregnancy cases are not detected in first clinical presentation. Here is a list of ectopic pregnancy diagnosis methods used widely in healthcare settings:
- Ultrasound Scan
Your doctor will run a transvaginal ultrasound scan to check the state of your pregnancy. During the procedure, your doctor will insert a probe in your vagina and you won’t require the help of local anesthetics to undergo this scan. The probe which would emit sound waves to hit your reproductive system and bounce back and create an image; will help your doctor visualize and closely observe the position of the fertilized egg.
If you are having an ectopic pregnancy, then this scan will show that the egg is implanted in either of the fallopian tubes.
According to BMJ, the ultrasound scan helps in the detection of an ectopic pregnancy by:
- Ø Identifying the absence of normal intrauterine pregnancy
- Ø Identifying the presence of ectopic pregnancy tissues, marked by the presence of inhomogeneous mass, empty adnexal (at the adnexa or appendage of uterus) gestation sac or the presence of adnexal sac containing fetal pole or yolk sac.
- Ø Identifying the presence of blood (free fluid) in the absence of intrauterine pregnancy
- Human Chorionic Gonadotropin (hCG) Blood Test
This test is highly accurate and valid in almost every case of ectopic pregnancy. There are few cases where the ultrasound scan fails to visualize the fetal state, which makes the diagnosis of ectopic pregnancy difficult for the doctor. In this case, the hCG blood test is the most suitable test to confirm a case of ectopic pregnancy.
hCG hormone levels are on a constant rise during the first trimester and it levels off during later pregnancy. During early pregnancy, rise in the hCG hormone level is regularly monitored by the doctor though the appointments, to confirm the viability of a pregnancy. If the hormone levels are stagnant over days or if the increase in the levels doesn’t correspond to the reference range of increase, then it becomes an alarming sign for pregnancy complication or an early loss of pregnancy.
In case of looking at the likelihood of ectopic pregnancy, hCG blood tests are carried out to match the obtained levels with the expected levels corresponding with the gestational week.
Sometimes, these hCG blood tests are taken twice over a period of 48 hours to have a clearer picture of the situation and to get rid of any ambiguity in the test results. As the ectopic pregnancy case is confirmed by this test, best treatment options can then be taken.
- Other Serum Biomarkers
In some cases, serum progesterone may also be checked. This assessment doesn’t essentially diagnose ectopic pregnancy, but it can identify a case of unviable intrauterine pregnancy (IUP). If the serum progesterone levels are over 50ng/ml then the IUP is classified as viable pregnancy.
Apart from this, BMJ claimed that other clinical biomarkers for the detection of ectopic pregnancy are proposed however no novel biomarkers are used as a clinical practice to diagnose ectopic pregnancy.
In rare cases, when the ectopic pregnancy is not diagnosed through ultrasound scan and pregnancy hormone blood tests, laparoscopy is carried out to make the diagnosis. Also, known as keyhole surgery, this procedure helps to closely observe the location of pregnancy to make the ectopic pregnancy diagnosis.
The procedure is carried out under the influence of general anesthesia. To locate the position of the mother’s womb, fallopian tube and embryo; the procedure requires a small incision in the belly, through which a surgical tube is inserted into the abdominal area to visualize the mother’s reproductive system.
If during this procedure, an ectopic pregnancy is detected then the doctors prefer performing an additional surgical procedure to remove the embryo, so that the woman doesn’t require undergoing another surgery to get treated for her ectopic pregnancy, later on.
- Endometrial Biopsy
It is only used in selected cases of pregnancy of unknown location (PUL) and the cases of ectopic pregnancies also come under the category of PUL. Endometrial biopsy looks for the presence or absence of chorionic villi which are tiny, finger-like projections housed in the placenta. Upon analyzing the chorionic villi, the levels of hCG hormone are measured and static levels indicate a case of ectopic pregnancy.
What Causes Ectopic Pregnancy?
As you learn about the symptoms of ectopic pregnancy, it is important to know what factors can cause ectopic pregnancy. Here is the list of some factors which can be the underlying cause of ectopic pregnancy.
- Tissue scarring in fallopian tubes due to undergoing a surgery in the past or due to an infection; causing hindrance in the way of fertilized ovum movement.
- Presence of an inflammation or infection in the fallopian tube leading towards partial or complete blockage.
- A history of pelvic surgery which had intervened with the fallopian tubes causing them to adhere together.
- Untreated sexually transmitted diseases, like gonorrhea and chlamydia
- Congenital abnormality in the shape of fallopian tubes.
Risk Factors Of Ectopic Pregnancy
It is advised that if you start experiencing any of the above mentioned symptoms, you shouldn’t wait, rather go and see your doctor immediately.
While, it is rare that one is encountered with ectopic pregnancy, some women are at a high risk of having an ectopic pregnancy compared to the general population. Identifying women at increased risk of ectopic pregnancy helps in early identification and diagnosis of ectopic pregnancy cases which in turns help them get timely medical help and reduce the ectopic pregnancy linked maternal mortality.
Following are some instances which increase your risk of having an ectopic pregnancy.
- Chlamydia Trachomatis
Chlamydia trachomatis is a common sexually transmitted disease which can be treated easily. If you have an abnormal vaginal discharge or you experience a burning sensation at the time of urination, then you may have contracted this infection. On the other hand, if your partner has swellings in his testicles, burning sensation while urination or discharge from penis, then he had contracted the infection. Thereby, if you or your partner shows the symptoms, get treated for it as this STD has the ability to increase your risk of having an ectopic pregnancy in future.
According to a study, 30% to 50% of all ectopic pregnancies are associated with the presence of chlamydia trachomatis. While the absolute connection between the disease and occurrence of ectopic pregnancy is not known. Experts propose that the presence of this bacterium in a woman’s reproductive system leads to disruption in the structure of fallopian tubes (tubal architecture) which is a result of disturbance in the tubal microenvironment.
- Smoking And Previous Exposure To Smoking
Excessive smoking is also associated with increased risk of having in ectopic pregnancy. If a woman smokes over 20 cigarettes in a day, the dose and effect relationship is established with the risk of ectopic pregnancy. The risk of ectopic pregnancy is increased as smoking causes delayed ovulation, changes uterine and tubal motility (alternation in muscular contraction in the uterus and fallopian tubes), alteration in the microenvironment of the uterus and fallopian tubes and/or altered immunity.
If you had been suffering from infertility in the past, then again you have an increased risk of suffering from an ectopic pregnancy. If you are seeking help from assisted reproductive technology (ART), then again you are at an increased risk of having a miscarriage. The procedures which come under the umbrella of ART include, intrauterine insemination (IUI), in vitro fertilization (IVF), third party assisted ART (surrogates & gestational carriers, sperm donation and egg donation). The risk factor of 2% to 5% is associated with the use of IVF which is further increased if you suffer from a tubal disorder.
- Contraception Use
The use of progesterone-only contraception is also associated with the risk of ectopic pregnancy. The use of intrauterine contraceptive device also results in the increased risk of ectopic pregnancy in case of contraceptive failure.
- Maternal Age
The risk of ectopic pregnancy is directly associated with increasing maternal age. If you are over 35 years of age at the time of conception, your risk of having an ectopic pregnancy is increased.
Experts believe that with increasing maternal age, the age-linked changes in the fallopian tube function; cause delayed ovum transport that in turn leads tubal implantation to take place which -is the prime feature of ectopic pregnancy.
Furthermore, with increasing age of the mother, the likelihood of chromosomal abnormalities in the developing embryo is also increased that increases the chance of ectopic pregnancy.
History Of Ectopic Pregnancy
If you have had an ectopic pregnancy in the past then you are at increased risk of having it again.
- A history of tubal disease
- A history of induced abortion
- A history of spontaneous abortion
- Genital infection in the past
- Pelvic inflammatory problems
- Fallopian tube damage caused by previous tubal surgeries including ovarian cystectomy (surgical removal of ovarian cyst), female sterilization surgery or other pelvic surgeries like caesarean section.
- History of abdominal surgeries which include bowel surgery and appendicectomy.
Ectopic Pregnancy Treatment
Once an ectopic pregnancy is diagnosed, it becomes extremely important to remove the ectopic tissues for the prevention of complications in future.
The management of ectopic pregnancy has some routes which include:
- Ø Surgical management of ectopic pregnancy
- Ø Medical management of ectopic pregnancy
- Ø Expectant management of ectopic pregnancy
Depending upon the individual case of ectopic pregnancy, the route of treatment is decided by the obstetrician. It is also important to learn that some early ectopic pregnancy diagnosis is made before tubal rupture but usually the diagnosis is made after the tubal rupture has taken place, thereby the best approach to treat ectopic pregnancy is different from one situation to the other.
Surgical management of ectopic pregnancy: it is the most effective way of treatment in case of tubal rupture (or ruptured ectopic pregnancy).
- Laparoscopy: As we had discussed earlier, the use of laparoscopic procedure along with the diagnosis of ectopic pregnancy can be employed for the management of ectopic pregnancy.
The laparoscopic removal of ectopic pregnancy is carried out when laparoscope (a thin tube with a camera) is inserted in the abdominal cavity with another tube to pump gas (that helps in making the procedure easier to be carried out by the surgeons). After the ectopic tissue removal, the incisions are stitched.
This procedure has advantages over other surgical treatments which include short operation time, reduced drug (analgesia) requirement, shorter stays at hospitals and lesser blood loss during the operative procedure. This procedure is accompanied by two surgical procedures, named as salpingectomy and salpingotomy.
- Salpingectomy: During this surgical procedure, a segment of fallopian tube is removed and the remaining parts of the tubes are reconnected. A case of ectopic pregnancy would require this surgical procedure if the ectopic pregnancy has stretched the tubes, damaged them a lot or ruptured them.
- Salpingotomy: This procedure is carried out when the ectopic pregnancy tissue is required to be removed from the fallopian tube. In the surgery, a lengthwise incision is made through the fallopian tube. Once the ectopic tissue is removed, the cut is either stitched or left to heal on its own, according to the situation.
- Laparotomy: This is another surgical procedure which makes use of large abdominal incisions. Although this is a more invasive procedure compared with laparoscopy, it is often the preferred choice of treatment in emergency cases of ectopic pregnancy requiring tubal ectopic removal or cases of abdominal ectopic pregnancy.
If you have an Rh-negative blood type, then you will be given anti-D rhesus prophylaxis i.e. you will be given RhoGAM injection so that if you become pregnant in future with Rh-positive baby, your immunity doesn’t cause harm to your baby.
Medical management of ectopic pregnancy: Ectopic pregnancy can be treated with medicines only in cases of unruptured tubal ectopic pregnancy, which means that this treatment modality can only work when the growth of embryo in the fallopian tube has not caused the tube to rupture.
It is also suggested that this treatment modality can be used in cases where the ultrasound scans have only detected low volumes of flood fluid. In addition to this, the doctors also observe if the blood flow to all organs and tissues is in a stable state (hemodynamic stability) and the symptoms of ectopic pregnancy are minimally manifested to recommend the use of medicine for the ectopic tissue removal.
In this context, the injections of methotrexate (folic acid antagonist) are given which arrest the process of cell division by stopping mitosis.
The efficacy of methotrexate injections are monitored by analyzing hCG levels, if the levels are high then another dose of methotrexate is required.
The working principle of the medication involves arresting cellular activity by inhibiting the cytotrophoblast cells which reduces the viability of pregnancy cells an lowers the pregnancy hormone secretion. These changes consequently lead to the inhibition of progesterone support required for a pregnancy to remain viable.
Now that these responses are triggered by the use of methotrexate in the body, the ectopic pregnancy is managed and the tissues are reprogrammed. After this procedure, abdominal discomfort and abdominal bloating may last for over a period of 3 days and following this time, one can resume to normal daily to daily routine quickly.
However, it is important to note that, following this process, the hCG levels are to be monitored regularly until the hormone level dips down to a value below 5IU/I.
Although, the use of methotrexate is safe and normally no serious side effects are associated with the use, however, in extremely rare cases, the use of methotrexate is associated with serious side effects which include bone marrow toxicity (bone marrow damage), alopecia (baldness) or hepatotoxicity (liver damage).
Expectant management of ectopic pregnancy: This is also known as the ‘watch and wait’ method of ectopic pregnancy or pregnancy loss which is not treatment through a medical intervention.
This is recommended treatment modality in cases where the conception product is small and when no or mild symptoms of ectopic pregnancy is experienced. After observing your case, if your doctor recommends an expectant management for your ectopic pregnancy, then you will be required to be prepared for some clinical visits and activities.
You will have to have regular blood tests to check the hCG levels periodically till the time, this pregnancy hormone is completely removed from the body. If the pregnancy hormone doesn’t clear out from the system, then you will be required to go for either surgical treatment or medical treatment.
During this time, you are likely to experience vaginal bleeding which is normal and it will end in a few days.
Ectopic Pregnancy And Impact On Future Pregnancies
If you didn’t have fertility issues before having an ectopic pregnancy, then there is a good chance for you to have a normal pregnancy in the future.
However, having previously had ectopic pregnancy, your chances of suffering from an ectopic pregnancy is increased by 15% in the future. The risk rate also depends upon the extent of damage done to the reproductive organs by the previous ectopic pregnancy.
Research has shown that over 60% women can have a normal pregnancy after having an ectopic pregnancy. On the other hand, the risk of recurrence of ectopic pregnancy remains between 5% to 20% percent, if you have had one ectopic pregnancy in the past. If you have had more than one ectopic pregnancy in the past, then your risk of another ectopic pregnancy is increased by 32%.
However, the good news is that with every normal pregnancy following an ectopic pregnancy, the risk of subsequent ectopic pregnancy is reduced significantly.