ectopic pregnancyAn ectopic pregnancy occurs when the embryo attaches to a site outside the uterine cavity. Greater than 90% of ectopic pregnancies are located in one of the fallopian tubes. Other sites are rare and include the cervix, ovary and the abdominal cavity.
Incidence
The incidence of ectopic pregnancy is increasing. This is probably due to improvements in diagnosis, increased tubal damage due to sexually transmitted disease, eg Chlamydia, assisted reproductive technology programs (ART) and tubal microsurgery.
Symptoms
The classic group of symptoms of a tubal ectopic is missed period, lower abdominal pain and vaginal bleeding, occurring within the first 6-8 weeks of pregnancy, however symptoms do vary and patients may have no symptoms and the diagnosis made on routine vaginal ultrasound scan, eg patients on the ART program. Because of earlier diagnosis, patients presenting in shock due to acute abdominal haemorrhage from a ruptured ectopic are now seen much less commonly.
 Investigations
In patients in whom an ectopic pregnancy is suspected, a pregnancy test in the blood, combined with a high resolution vaginal ultrasound scan are the primary investigations.
Remember, a blood level of hCG greater than 2000 IU/L, and an empty uterus on vaginal ultrasound scan, raises a serious suspicion of ectopic pregnancy. Diagnostic laparoscopy may be required for diagnosis if a vaginal ultrasound does not help.
Treatment
Treatment may be medical or surgical.
Medical treatment of an unruptured ectopic involves the use of a drug called Methotrexate which kills off the rapidly dividing cells in an early pregnancy. This drug may be injected directly into the ectopic pregnancy sac under ultrasound guidance or administered by injection.
Traditional surgical treatment can involve either laparoscopy or laparotomy. The trend to earlier diagnosis allows a more conservative approach to treatment with removal of the ectopic pregnancy from the tube through a small cut over the pregnancy (salpingostomy). Removal of the tube containing the ectopic may be required particularly if the ectopic is ruptured (salpingectomy). With increasing frequency the surgical approach to management is via laparoscopy.
Follow-Up
Treatment, either medical or surgical, will require follow-up with blood tests, to ensure that there is no viable remaining pregnancy tissue.
Outlook
Patients in whom an ectopic pregnancy has occurred, but not associated with ART programs, have a higher incidence of infertility and are at increased risk of a subsequent ectopic pregnancy and must have a vaginal ultrasound at 6-7 weeks gestation in any subsequent pregnancy to accurately localise the position of the gestation sac.
|
