Introduction
Pregnancy is the process by which the fertilized egg gets implanted in the uterine wall lining, where it divides and grows into an embryo. Ectopic pregnancy is a condition when the fertilized egg gets implanted in a tissue other than the uterine wall most often in the fallopian tube, cervix, ovaries, and abdomen. Most of such ectopic pregnancies occur in the fallopian tubes. The embryo in the fallopian tubes adheres and actively invades the blood vessels, causing bleeding. This process expels the embryonic implantation causing tubal abortion which is painful due to the release of prostaglandins. If untreated, leads to surgical intervention due to rupture of the fallopian tubes. Although smoking, consuming alcohol, advanced maternal age, and prior tubal damage of any origin are well-known risk factors for ectopic pregnancy, specific causes are still unknown. Any damage to the hair-like cilia located on the internal surface of the fallopian tubes that move the fertilized egg to the uterus, Pelvic inflammatory disease that causes occlusion of the fallopian tubes, tubal ligation, and a tubal reversal is speculated causes of ectopic pregnancy. Untreated sexually transmitted diseases like gonorrhea increase the risk of such pregnancies. An increased level of hormones like estrogen and progesterone also seem to contribute to ectopic pregnancy due to their ability to slow down the movement of a fertilized egg in the fallopian tube. The role of intrauterine devices in ectopic pregnancies has not been proved (N Kadar et.al.,1981). Women who have undergone vaginal douching and have been exposed to diethylstilbesterol also have a high risk of ectopic pregnancy.
Symptoms
Ectopic pregnancy can be detected clinically at 7.2 weeks after the last menstrual cycle and the early symptoms include pain and discomfort, mild vaginal bleeding due to falling progesterone levels, and hemorrhage. Severe internal bleeding also causes lower back, abdominal, pelvic pain, shoulder pain, cramping, or tenderness of the pelvis. The most common complication is a rupture with internal bleeding that leads to shock and death.
Diagnosis
Any sexually active pregnant woman with lower abdominal pain, an abnormal increase in blood Hcg (human chorionic gonadotropin), and unusual bleeding can be suspected for an ectopic pregnancy. A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy can be presumptive evidence of ectopic pregnancy, and an empty uterus with levels lower than 3000IU/ml of hCG may be evidence of an ectopic pregnancy. An ultrasound scan showing a gestational sac with a fetal heart is clear evidence of ectopic pregnancy. An Echogenic free fluid also suggests the presence of a blood clot and is suggestive of free blood in the peritoneum typical of ectopic pregnancy. A laparoscopy confirms an ectopic pregnancy. Transvaginal ultrasound scan examination detects a cervical pregnancy. An ovarian pregnancy can be differentiated from a tubal pregnancy by the Spiegelberg criteria (N Kadar et.al.,1981).
Treatment
Early treatment with the drug methotrexate has been found effective instead of surgical intervention (Stovall et. al,1991). Surgical intervention may be necessary if there is evidence of ongoing blood loss and is done with laparoscopy or laparotomy to gain access to the pelvis. Surgical intervention can either incise the affected Fallopian tube and remove only the pregnancy by salpingostomy or remove the affected tube along with the pregnancy by salpingectomy (Vermesh et. al,1989).
Reference
M Vermesh, PD Silva, GF Rosen, AL Stein, GT Fossum, and MV Sauer, Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy, Obstetrics & Gynecology 1989; 73:400-404.
N Kadar, G DeVore, and R Romero, Discriminatory hCG zone: its use in the sonographic evaluation for ectopic pregnancy, Obstetrics & Gynecology 1981; 58:156-161.
TG Stovall, FW Ling, LA Gray, SA Carson, and JE Buster, Methotrexate treatment of unruptured ectopic pregnancy: a report of 100 cases, Obstetrics & Gynecology 1991; 77:749-753.