Ectopic pregnancy management

The modern management of ectopic pregnancy is arguably one of medicine’s greatest success stories. In medieval times, ectopic implantation was viewed as the consequence of violent emotion, usually fright or surprise, during intercourse in the cycle of conception. Early treatments were designed to kill the ectopic conceptus and included starvation, purging, bleeding, and even treatment with strychnine poisoning. There were even attempts to pass electrical current into the ectopic pregnancy which obviously then resulted in the mother dying herself. Ironically till almost the beginning of the 19th century , more women were dying out of the surgery for treatment of ectopic than by untreated ectopic itself. 

Before I start to talk more about ectopic pregnancy let me take a few moments to explain what happens in a natural pregnancy inside the human body. An egg is picked up by one end of the fallopian tube inside the tummy. The other end of the tube is attached to the uterus or the womb from where it allows the sperms to ascend. The fallopian tube is the place where the sperms and the egg meet, fertilization happens and an embryo forms. This embryo now starts to grow slightly bigger in size and travels slowly through the fallopian tube for 4 more days before slipping into the womb on the 5th day. The other thing that you must know is that while the sperms are capable of swimming and moving on their own, the egg or the embryo can’t move by itself. The fallopian tube has fine tiny hair like projections which sweep the egg or the embryo in the right direction. 

What is an Ectopic pregnancy?

It is merely the implantation or attachment of the embryo outside of the uterus. Although from my narrative it seems that the fallopian tube is the only place it would attach, it is not so. In about 95% it attaches to the fallopian tube but ion the other cases, it may be present on the ovary or in the tummy itself.

Since the fallopian tube is the most common site, lets understand why ectopic happens there. Because of an infection or a kink in the tube, the internal space of the tube narrows down. The egg being smaller would reach the right place e but the fertilized embryo being bigger, would get stuck. Sometimes the tiny hairs that I described in the fallopian tube get damaged and they fail to push the embryo to the womb and thus it remains stuck there. Thus, we understand that the most common reason for ectopic pregnancies happening is damaged tubes. There are of course other less common reasons where the natural contractions inside the tube get dysfunctional.

About 1 % of all pregnancies might land up with an ectopic pregnancy. What are the factors that increase the risk of having an ectopic though ironically, 50% of the ectopic occur in women who don’t have any risk factors.

  1. PID or pelvic inflammatory disease would be the most common cause of tubal damage and thus ectopic pregnancy. Most commonly it happens because of infections with Chlamydia Trachomatis or Mycobacterium Tuberculosis. The scary bit is that in 50% of cases there are no symptoms so we don’t even come to know that an infection is there but the chances of tubal damage is as high as 13% after a single act of infection, 35% after 2 episodes and 75% after 3 episodes. There is a way we can take smears from the mouth of the womb to figure out if you have Chlamydia infection. This is part of standard preconception care. 
  2. The chances of having an ectopic increase with age and is maximum after age 35
  3. Smoking is a major cause at least in the western world. 
  4. For those attending infertility clinics, a higher rate of ectopic pregnancy is seen. It is not very clear if these women are inherently at higher risk or does the treatment process increase the risk. This leads to a Catch 22 situation because for those who have damaged tubes for any reason, IVF or invitro fertilization is the way forward but the risk of ectopic increases in those who have IVF. Scientists across the world are working towards reducing this risk by modifying the IVF process. The sceptics may argue saying then why get an IVF done, for someone who had a previous ectopic. The answer is that IVF might be the only way that, that woman may conceive so there isn’t much choice. 
  5. If one has had one ectopic pregnancy the chances are 3 to 8 times higher of a repeat ectopic pregnancy. Thus, one must carefully weigh one’s choices before getting pregnant a 2nd time. 
  6. Some types of contraception, like the Progesterone only pill or even the Copper T provides excellent contraception but if one does still get pregnant on them, the possibility of having an ectopic would be higher.
  7. Last but not the least, having any kind of surgery done on the tubes also increases their chances. Some patients request for their tube affected by the ectopic pregnancy to be saved not realising that ectopic happened in that tube only because it was damaged, and the surgery needed to save that tube would only increase the chances of repeat ectopic only higher.

How do we diagnose an Ectopic pregnancy?

Normally in early pregnancy the beta hCG levels double or increase by 60% every 48 hrs. If it fails to do so or if we fail to see a pregnancy inside the uterine cavity, we suspect an ectopic and then try and locate it on ultrasound outside the uterus for e.g. the fallopian tube or ovary etc and that’s when the clinching diagnosis is made. From the patient’s perspective, if one is having lower abdominal pain or vaginal bleeding or feels faint, one should get in touch with their doctor urgently especially when the first ultrasound has not been done in pregnancy to establish that the pregnancy is inside the uterus.

As far as the treatment is concerned, there are two ways of going about it. in very early cases, before the ectopic has ruptured, it can be managed by giving an injection of an anti-cancer drug. Its perfectly safe to give, provided certain conditions are fulfilled. In more advanced cases or if the ectopic is ruptured, urgent surgery is needed. The surgery should be mostly done laparoscopically, there is no need for an open surgery in majority of the cases.

As you may realise, I am not dwelling much on the diagnosis or treatment much or elaborating in detail as I always do. The problem is ectopic pregnancy is so serious and life threatening that I don’t want anyone to waste time trying to understand it themselves or being at logger heads with their doctor. Incase you experience any of the symptoms that I have mentioned earlier, speak to you doctor urgently, be it day or night and LISTEN to whatever advise they must give.

Why is ectopic so serious?

The walls of the fallopian tube are not designed to hold and grow the pregnancy beyond a point as its walls are very thin. After a point as the pregnancy grows, the walls rupture leading to profuse bleeding. There is a potential risk of bleeding to death. That is why it is imperative that one reaches out to a doctor whenever someone feels faint or has lower abdominal pain or bleeding. This of course is relevant only till the first ultrasound is done. Once on scan we have figured that the pregnancy is inside the uterus, then we usually nothing to worry. Why did I say usually…because in rare cases there might be 2 pregnancies, one inside the uterus and one outside as ectopic? 

I have patients who have arrived pale white in clinic, devoid of practically any blood and we have had to rush them to hospital and operate on them practically on a war footing. Laparoscopy really works wonders and the moment the internal bleeding is stopped, and blood is replaced from outside, the patient is rosy pink again. 

I have some commonly asked questions which I would like to address here:

  • Should I get an open surgery done or laparoscopy

Let your doctor decide. I can tell you from my end, laparoscopy is very safe, quicker than open surgery and gives far better vision inside and thus the bleeding can be controlled much faster.

  • Should I ask my doctor to conserve the tube which is affected by ectopic

I see no reason why one should try and do that. Ectopic happened because the tube is damaged and if you try to have conservative surgery done on the tube, some part of the ectopic pregnancy might get left behind requiring further treatment later on and also as I said earlier, the chances of future ectopic only become higher.

  • What will happen to my other tube?

Since ectopic happened to only one tube, there is no need to remove or do anything to the other tube.

  • Can tubal patency be tested for the other tube while I am undergoing surgery for an ectopic on one tube?

No, it can’t be done. Fallopian tube patency testing involves flushing some dye through the tubes. During the surgery we can’t risk the ectopic side wound opening again or the ectopic pregnancy tissue being washed away into the tummy.

  • When can I undergo a tubal patency test to know if the other side tube is open?

I would recommend 2 months from the surgery; you can safely undergo the test.

  • Lastly how do I go about pregnancy in future

Now this deserves a longer answer. If one side tube is damaged by ectopic, then there are 3 possibilities

The other side tube maybe worse, equally damaged or perfectly normal

  • If its worse then pregnancy itself won’t happen naturally anymore and you would need an IVF
  • If its equally bad, there is a possibility pregnancy happens but the chances of a repeat ectopic is quite high
  • If its fantastic then a natural pregnancy can easily occur without any complications.

How do we determine where we stand? We can easily find out if the other side tube is open by doing a tubal test. If closed, then we know the option is IVF

The confusion arises if its open because beyond stating that the tube is open, there is no way to guarantee if the tube is functional and whether a repeat ectopic might happen. This then depends on the risk-taking ability of the couple as to which path they wish to traverse. Having said that, the chances of conceiving naturally are pretty good with reports saying up to 65% of women who had an ectopic, will conceive naturally and have a safe intra uterine pregnancy within the next 18 months and about 80% in the next 2 years. 

Alls well thyat ends well they say and in modern day science, all women who reach healthcare in time, will be saved for sure and out of them a great many will conceive naturally too a few months later. 

Also read: First Trimester Investigations – Why are they essential ?

This brings me to the end of yet another discussion. This discussion is also available as a podcast – check out here.

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