Ectopic Pregnancy

What is an Ectopic pregnancy?

An ectopic pregnancy is one that has implanted outside the cavity of the womb. The most common site is in a fallopian tube but the pregnancy can implant on other structures including the bowel.

How prevalent are ectopic pregnancies?

It is estimated that one pregnancy in a hundred will be ectopic? It is becoming more frequent. Twenty years ago the incidence was one in two hundred pregnancies.

What is the Cause of ectopic pregnancy?

It is thought that the majority of ectopic pregnancies occur as a result of inflammation in the pelvis. Pelvic inflammatory disease and pelvic surgery are the most common antecedents.

How can an ectopic pregnancy be diagnosed – Symptoms, Signs and Tests?

An indication of pregnancy, usually a period is late, together with a symptom of pain on one side of the pelvis followed by some the symptopm of bleeding suggests the possibility of an ectopic pregnancy. On examination the physical sign of pain to the side of the uterus might be found. When a possible diagnosis of ectopic pregnancy is suggested from the symptoms, bimanual pelvic examination should not be performed as it could inadvertently lead to rupture of the pregnancy and potentially catastrophic internal bleeding. In contrast, a miscarriage tends to start with bleeding and the symptom of pain may then develops after the bleeding and tends to be more central rather on one side. The combination of pregnancy tests and ultrasound examination may assist gynaecologists to make the diagnosis. Sometimes laparoscopy may be required.

The diagnosis of ectopic pregnancy can still occasionally be difficult. One reason for this may be that a bleed during the pregnancy may have seemed like a period and the woman is unaware that she is pregnant.

An Ultrasound Picture Showing An Ectopic Pregnancy. To the left, the picture shows a pregnancy in a fallopian tube. The uterus is to the right and includes a pseudosac and this may be misread as a sign of early intrauterine pregnancy.

What is the treatment of an ectopic pregnancy?

At one time, when an ectopic pregnancy was suspected, a laparotomy (open operation into the abdomen) was required and the Fallopian tube with the ectopic pregnancy was removed (salpingectomy). It was thought that it was inappropriate to conserve the damaged tube as another ectopic pregnancy was likely to be the result. We have learned that if the diagnosis is made relatively early, it may be possible to open the tube and remove the ectopic pregnancy (salpingostomy) with a reasonable chance that the conserved tube will function correctly in the future. The latest advice is that salpingostomy should be used if the other tube has been removed or is unhealthy.

Some gynaecologists are able to undertake these operations at laparoscopy (minimally invasive surgery). Several incisions to insert the instruments are required.

There is currently interest in treating ectopic pregnancies medically rather than surgically. Drugs such as methotrexate are administered, which stop the pregnancy from developing further and then nature takes over. This may prove effective in some situations but the exact place of this approach has not yet been defined.

A thirty-three year old lady presented with lower abdominal pain. She had a slightly irregular menstrual cycle and had been trying to conceive for a few months. Two weeks before consultation she had a normal period. She was prone to constipation for which she was taking lactulose. She had recently commenced a course of antibiotics. Her BMI (Q9.8 ) was 32. She was experiencing hirsutism and difficulty keeping her weight down. There were no problems on pelvic examination. Investigations were initiated. Ultrasound showed a 5cm cyst in the left ovary and a 5.5 cm cyst on the right. One week later she felt unwell and a pregnancy test proved positive. The patient had not been sexually active since the last period. A further ultrasound showed no change in the cyst on the right but adjacent to it was another structure measuring 4.6 x 1.9 cm. The cyst on the left was no longer present. There was no sign of a pregnancy in the uterus. We proceeded to mini-laparotomy and confirmed a right-sided ectopic pregnancy. The left ovary appeared polycystic and we took the opportunity of ovarian drilling. This case is interesting for several reasons. It shows that a period-like bleed can occur in early pregnancy. The 5cm cyst on the left disappeared spontaneously. The patient was home on the third post-operative day and within three weeks she had made a complete recovery. Within a short time she reported that her weight problem and excess hair production were improving following surgery with ovarian drilling (ovarian drilling ).