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ectopic pregnancy

ECTOPIC PREGNANCY

 STORY

In January 2021, Nina suffered an ectopic pregnancy, where instead of implanting into the womb as in normal pregnancy, the embryo was implanted in her right fallopian tube.

Since an embryo can’t survive and grow outside the womb, her pregnancy was not viable. This was complicated by a rupture inside her body. And because of this, she had emergency surgery to remove it.

If it hadn’t been detected early, Nina’s ectopic pregnancy would have resulted in the removal of part of her reproductive system, shock, or even worse, her death.

WHAT IS AN ECTOPIC PREGNANCY?

Ectopic pregnancy also called extrauterine pregnancy, is when a fertilised egg grows outside a woman’s womb. It can cause fatal bleeding and needs urgent medical care. In a normal pregnancy, fertilisation occurs in the fallopian tubes, where an egg, or ovum, meets a sperm cell. The fertilised egg then travels into the womb and becomes implanted in the womb lining. The embryo develops into a fetus and remains in the uterus until birth. Ectopic pregnancies are uncommon — it happens in about 2% of all pregnancies.

WHERE CAN IT OCCUR?

In greater than 90% of cases, the fertilised implants in a fallopian tube. This is called a tubal pregnancy. Unlike the womb, the fallopian tube cannot stretch, hence it is not made to hold a growing embryo. They can break if stretched too much by the growing pregnancy — this is sometimes called a ruptured ectopic pregnancy. This can cause internal bleeding, infection, and in some cases lead to death.

Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary, abdominal cavity, or the lower part of the uterus (cervix), which connects to the vagina. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation. A woman having an ectopic pregnancy may or may not know she’s pregnant.

 

**Sites and frequencies of ectopic pregnancy. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; and (G) Cervical, 0.2%.

CAUSES OF ECTOPIC PREGNANCY

Ectopic pregnancy is the result of a defect in the female reproductive function that allows the fertilised egg to implant and mature outside the womb, which eventually ends in the death of the fetus. Two events must occur for there to be an ectopic pregnancy. First, fertilization of the egg, secondly, abnormal Implantation. Many risk factors have been shown to affect both events, they include;

  • Fallopian tube damage – women with damaged fallopian tubes are more likely to develop an ectopic pregnancy. 50% of ectopic pregnancies are associated with some degree of tubal disease. A fertilized egg may have trouble passing through a damaged tube, causing the egg to implant and grow in the tube.
  • History of a previous ectopic pregnancy
  • Smoking – can damage the ciliated cells of the fallopian tube, resulting in decreased tubal motility.
  • Pelvic inflammatory disease (PID): This is often the result of an infection such as chlamydia, gonorrhoea, or other sexually transmitted infections (STIs).
  • Age – 35 years or older
  • History of pelvic surgery, abdominal surgery, or multiple abortions
  • Endometriosis, which can cause scar tissue in or around the fallopian tubes.
  • Exposure to diethylstilbestrol (DES) before birth.
  • Fertility treatments such as in vitro fertilisation.

WHAT ARE THE SYMPTOMS?

The signs and symptoms of an ectopic pregnancy typically occur six to eight weeks after the last normal menstrual period, but they may occur later if the ectopic pregnancy is not located in the Fallopian tube. There are three classical symptoms of ectopic pregnancy; they include:

1. Abdominal pain

2. Absence of menstrual periods (amenorrhea)

3. Vaginal bleeding or intermittent bleeding (spotting).

However, about 50% of females with an ectopic pregnancy will not have all three signs. These characteristic symptoms occur in ruptured ectopic pregnancies (those accompanied by severe internal bleeding). However, while these symptoms are typical for an ectopic pregnancy, they do not mean an ectopic pregnancy is necessarily present and could represent other conditions. These symptoms also occur with a threatened abortion (miscarriage).

Other symptoms of ectopic pregnancy are

1. Light vaginal bleeding

2. Stomach upset and vomiting

3. Sharp abdominal cramps

4. Pain on one side of the body

5. Dizziness or weakness

6. Pain in the shoulder, neck, or rectum

It is worthy of note that symptoms of pregnancy such as nausea and breast discomfort, may also be present in ectopic pregnancy.

COMPLICATIONS

Complications of ectopic pregnancy can arise from wrong diagnosis, late diagnosis, or the treatment approach.

  • Damage to fallopian tubes: delay and incurred diagnosis can result in tubal damage, significantly increasing the risk of future ectopic pregnancies.
  • Internal bleeding: delaying diagnosis and treatment may lead to massive bleeding, shock, and death.
  • Complications from surgery: bleeding, infections, and damage to surrounding organs. Infertility may result from the loss of reproductive organs after surgery.
  • Depression

HOW IS ECTOPIC PREGNANCY DIAGNOSED?

Diagnostic tests for ectopic pregnancy include a urine pregnancy test; ultrasonography; beta-hCG measurement; and, occasionally, diagnostic curettage.

• A urine test can show if you are pregnant. To find out if you have an ectopic pregnancy, your doctor will likely do:

• A pelvic exam to check the size of your uterus and feel for growths or tenderness in your belly.

• A blood test that checks the level of the human chorionic gonadotrophin (hCG). This test is repeated 2 days later. During early pregnancy, the level of this hormone doubles every 2 days. Low levels suggest a problem, such as ectopic pregnancy.

• Ultrasonography: This test can show pictures of what is inside your belly. With ultrasound, a doctor can usually see a pregnancy in the uterus 6 weeks after your last menstrual period.

TREATMENT FOR ECTOPIC PREGNANCY

Unfortunately, the fetus (the developing embryo) cannot be saved in an ectopic pregnancy. Treatment is usually needed to remove the pregnancy before it grows too large. The main treatment options for ectopic pregnancy are:

1. Expectant management – your condition is carefully monitored to see whether treatment is necessary

2. Medication – a medicine called methotrexate is used to stop pregnancy growth.

3. Surgery – surgery is used to remove the pregnancy, usually along with the affected fallopian tube.

The treatment options depend on the symptoms, fetus size, and the level of HCG in the woman’s blood.

Expectant management 

Patients for successful expectant management should be asymptomatic and have no evidence of rupture or bleeding. They should also demonstrate declining HCG levels.

Close follow-up and patient compliance are of utmost importance, as tubal rupture may occur despite low and declining levels of HCG.

Medication – Methotrexate therapy

Methotrexate is the standard medical treatment for unruptured ectopic pregnancy. The ideal candidate should have the following: no bleeding, normal functioning liver and kidneys, no severe or Persistent abdominal pain. However breastfeeding, anaemic, and patients who are sensitive to methotrexate are not advised to take this therapy.

Surgery

Laparoscopy is the recommended surgical approach in most cases. Laparotomy is usually reserved for patients who are massively bleeding or for patients with cornual ectopic pregnancies.

WHAT TO EXPECT AFTER AN ECTOPIC PREGNANCY

Losing a pregnancy is always hard, no matter When it occurred. Take time to grieve and get the support you need to make it through this time. There is an increased risk for depression after an ectopic pregnancy. If you have symptoms of depression that last for more than a couple of weeks, be sure to get the help needed. It is common to worry about fertility after an ectopic pregnancy. Having an ectopic pregnancy does not mean a woman can’t have a normal pregnancy in the future, but it does mean that:

• There may be trouble getting pregnant.

• Increased chances of having another ectopic pregnancy.

Also after either type of surgery (laparoscopy and laparotomy), a treatment called anti-D rhesus prophylaxis will be given if the woman’s blood type is RhD negative. This is often given in form of an injection to help prevent rhesus disease in future pregnancies.

E. Ayala, PharmD in view, member YALI Network, Executive member at Impact Africa Initiative, member at LEAD (Living Everyday Above Depression) and member Wrighters Community.

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