The most dangerous of these are probably ectopics in the interstitial portion of the tube (2.5%) which account for a fifth of all deaths from ectopic pregnancy.
With very rare exceptions, these pregnancies are not viable. UK NHS statistics state that one pregnancy in 80 is an ectopic, equating to roughly 12,000 a year. Although the chances of having an ectopic pregnancy are relatively low, the seriousness must not be under estimated. If it is left untreated, an ectopic pregnancy can be fatal, and the condition remains the leading cause of maternal mortality in the first three months of pregnancy. Serious outcomes usually result as a consequence of delayed treatment.
Any condition which delays the passage of the fertilised egg down the fallopian tube may cause an ectopic pregnancy.
There are risk factors the most common of which are; increasing maternal age, tubal damage as a result of surgery or infection (particularly Chlamydia), and in-vitro fertilisation (IVF).
Contraception reduces the risk of ectopic pregnancy. However, if a pregnancy does occur in women after female sterilisation or insertion of an intrauterine contraception device then the chance that it is an ectopic is increased.
The first symptoms of an ectopic pregnancy are usually seen between 5 to 12 weeks after the last normal menstrual period. These include, but are not limited to:
Symptoms of pregnancy; nausea, breast tenderness and urinary frequency.
Pain in the lower abdomen, particularly on one side, pain can be persistent and severe but is not present in about 10% of women.
Vaginal bleeding. This may present simply as a brown discharge but may also be heavy.
Feeling faint and dizzy due to internal bleeding.
Shoulder tip pain, due to irritation caused by blood under the diaphragm.
At this early stage, the differential diagnosis is between miscarriage, ectopic pregnancy, pregnancy of unknown location (PUL) and early normal pregnancy.
If women are worried that they may have an ectopic pregnancy, they shouldn’t hesitate to contact their gynaecologist and arrange for the necessary testing.
The current diagnosis of ectopic pregnancy is by a combination of ultrasound, serum and Progesterone measurement is the marker used to test for a positive pregnancy. If levels are low and falling then most cases can be managed conservatively. Most units will use serial measurements of hormones to make the diagnosis.
An ultrasound can then be performed to locate where the pregnancy has implanted. If on ultrasound the pregnancy is not seen in the womb then this points towards either an ectopic pregnancy or a PUL is above 2000 IU/ ml and rising and the progesterone is above 10nmol/l (in the absence of an intrauterine pregnancy) then it must be assumed that there is an ectopic and either medical or surgical treatment is required. If these criteria are not met then it is safe to wait 48hrs to repeat the blood tests and the scan.
Unfortunately, if an ectopic pregnancy exists the pregnancy cannot continue to a live birth. Most parents therefore face not only the loss of a pregnancy but also the need for an operation with the possible loss of a Fallopian tube and a reduction in future fertility. It is therefore essential that all treatment options include counselling for both parents.
Treatment is either surgical or medication based, the choice depending very much on the individual circumstances and the results of the investigations. It is important that women are able to discuss the different options open to them.
Medical treatment involves careful observation with or without treatment using Methotrexate. This type of treatment is only suitable if the pregnancy is small, the hormone levels are low and there has not been significant intra-abdominal bleeding as seen on scan.
Methotrexate is a drug used in the treatment of cancer. It is given by injection and acts on the placental tissue, causing the pregnancy to fail. This drug stops the growth of the embryo, which is then either reabsorbed by the mother, or passed with a menstrual period. As with all chemotherapy it is essential that the drug is given in accordance with very strict guidelines, for this reason Methotrexate treatment of ectopic pregnancy is not available in the private sector. Sometimes the dose of Methotrexate needs to be repeated as b-HCG hormone levels are not falling adequately and some women still require surgery.
Keyhole surgery (operative laparoscopy) to locate and remove ectopic pregnancies with minimal damage to the Fallopian tubes and with minimal scarring, is the preferred course of action for the majority of cases. Keyhole surgery offers clear advantages as the operating time, hospital stay and convalescence are all shorter and there is less blood loss.
There remains controversy as to the best approach to the ectopic and Fallopian tube during the surgery. Clearly women want the option which best maintains their fertility prospects. The evidence base for the best course of action is weak. It is generally accepted that a damaged fallopian tube will be further damaged by the ectopic pregnancy and that retaining the tube also increases the possibility of a continuing ectopic.
As a result women undergoing conservative surgery need much more follow up, a future successful pregnancy via the affected tube is unlikely and the risk of another ectopic pregnancy in the retained tube remains high. Many surgeons will therefore favour removing the damaged tube as long as the remaining fallopian tube looks normal. This hypothesis is currently being investigated by a large multi centre trial.
Before surgery women should be made aware of the fact that there is always a possibility that their Fallopian tube may have to be removed.
Most women are able to go home on the day of surgery or the following morning. It takes a few days to get over the surgery but the psychological impact can take much longer.
Fertility after ectopic pregnancy
The reported rates of spontaneous, intra-uterine pregnancy vary between 38 – 66% in women who have the tube removed and may be as high as 79% where the tube is conserved. However, the rate of another ectopic is also higher, up to 18% in women where the tube is conserved; so it would seem that conserving the damaged tube has both advantages and disadvantages.
It does not appear that medical management using Methotrexate further increases future pregnancy rates or reduces the risk of a future ectopic.
Women having an ectopic, have a life threatening condition, often need to undergo surgery, loose a pregnancy, may loose a Fallopian tube and have reduced future fertility. In addition there is often difficulty and delay in making the diagnosis which can lead to further distress.
It is crucial that women are given good quality information and that they are dealt with in a kind and sympathetic manner. If women feel they need additional help then the UK charity, the Ectopic Pregnancy Trust, is an excellent place to start.
Women who are concerned can be seen the same day. Blood tests and high quality ultrasound scans are available on site so there is no delay in diagnosis. The modern operating theatres at the Portland hospital have all the state of the art facilities for first class Keyhole (“laparoscopic”) surgery.
Chris Barnick is regarded as one of the best in London Gynaecology
. He has delivered babies and performed gynaecological operations for more than 25 years.
A specialist Private Obstetrician at OBGYN Matters in central London he qualified at Guys Hospital in 1984. He has trained and worked ever since in top London teaching hospitals
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