Safia had missed her period. A pregnancy test done at home came back as positive. With great excitement, she and her husband fixed up an appointment with their obstetrician for confirmation of the pregnancy. On the day of the appointment, she developed slight spotting and also a cramping pain in the lower part of her abdomen. When her doctor did an ultrasound scan to find out why she was bleeding, there was no pregnancy found inside the uterus. A detailed scan showed that the pregnancy was in the Fallopian tube. Safia has an ectopic pregnancy.
What is an ectopic pregnancy?
In the normal course of events, fertilisation of the egg occurs in the Fallopian tube. The fertilised egg then moves into the cavity of the uterus over the next 5-7 days. It then implants into the wall of the cavity and starts growing. Sometimes this process does not go so smoothly. An ectopic pregnancy occurs when a fertilised egg does not reach the uterus and starts growing outside the uterus. Since it is in an abnormal location, it can cause complications.
Why must an ectopic pregnancy be treated?
The majority of ectopic pregnancies occur in a Fallopian tube. When the diagnosis is made at an early stage, before there is danger of the tube bursting, it is called an unruptured ectopic. An unruptured ectopic pregnancy can be treated with medication.
As the pregnancy grows, it can cause the tube to burst. This is called a ruptured ectopic. If this occurs, it can result in life-threatening bleeding inside the abdomen. Emergency surgery may then be required.
Symptoms and diagnosis
An ectopic pregnancy may or may not have the usual symptoms of pregnancy. Some women may not even know they are pregnant. An obstetrician will usually suspect an ectopic pregnancy if there is:
Abnormal vaginal bleeding which may be light or heavy.
Abdominal or pelvic pain which can be sudden, sharp and continuous or seem to come and go. It may be present only on one side.
Weakness, dizziness, or fainting can occur when the ectopic pregnancy has started bleeding inside.
Shoulder pain, which is a late sign and occurs after the ectopic has ruptured, leading to a large amount of blood in the abdomen.
Once your doctor suspects that you may have an ectopic pregnancy, she will perform a pelvic examination and check your blood pressure and pulse. An ultrasound scan will be done to identify the location of the pregnancy. A blood test will be done for the presence of the pregnancy hormone, human chorionic gonadotropin (hCG).
Identifying an ectopic pregnancy before it has ruptured may not always be easy. If the pregnancy hormone is raised but a pregnancy is not identified inside the uterine cavity, an ectopic pregnancy may be suspected. Sometimes a laparoscopy (inserting a thin lighted telescope into the abdomen) may be required to confirm the presence of an unruptured ectopic pregnancy.
Treatment
A small, unruptured ectopic pregnancy, which has not started bleeding, can be treated with medication. Usually a single injection of methotrexate is given and the blood levels of the pregnancy hormone (hCG) are monitored. Methotrexate stops the growth of the pregnancy and permits the body to absorb it. This is conservative management and avoids removal of the tube. This is successful in 85 per cent of unruptured ectopic pregnancies. If during the course of this treatment, rupture of the ectopic pregnancy is suspected, surgery will be performed.
In certain cases, if the ectopic pregnancy has not responded to conservative management, is large, has started bleeding or has ruptured, surgery will be required. Under general anaesthesia, laparoscopic surgery is performed. Depending on the situation, the obstetrician will either remove the pregnancy alone or remove the tube completely. If the bleeding is profuse because the ectopic pregnancy has ruptured, open surgery may be performed and the tube will be removed.
After surgery, if one tube has been removed, there is still a good chance for future pregnancy. It is prudent to give a gap before trying for the next pregnancy. Women who have had a previous ectopic pregnancy should have early confirmation of pregnancy to ensure that it is in the right location.
(The author is a Chennai-based obstetrician and gynaecologist with a special interest in women’s health issues.)
