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07-SEPTEMBER-2008 03:17:44 - Ectopic pregnancy Ectopic pregnancy Classification and external resources Ectopic by Reinier de Graaf ICD-10 O00. ICD-9 633 DiseasesDB 4089 MedlinePlus 000895 eMedicine med/3212 emerg/478 radio/231 MeSH D011271 An ectopic pregnancy is a complication of pregnancy in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube so-called tubal pregnancies, but implantation can also occur in the cervix, ovaries, and abdomen. The fetus produces enzymes that allow it to implant in varied types of tissues, and thus an embryo implanted elsewhere than the uterus can cause great tissue damage in its efforts to reach a sufficient supply of blood. Contents 1 Overview 2 Causes 2.1 Cilial damage and tube occlusion 2.2 Hysterectomy 2.3 Other 3 Symptoms 4 Diagnosis 5 Nontubal ectopic pregnancy 6 Treatment 6.1 Nonsurgical treatment 6.2 Surgical treatment 6.3 Chances of future pregnancy 7 Complications 8 References 9 External links Overview Oviduct with an ectopic pregnancy tubal pregnancy showing a 1 month embryo Oviduct with an ectopic pregnancy tubal pregnancy showing a 1 month embryo Another example of a tubal pregnancy 6 week old embryo Another example of a tubal pregnancy 6 week old embryo In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.1 In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end as a tubal abortion. Some women thinking they are having a miscarriage are actually having a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube just before it enters the uterus, it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy. Causes The causes of ectopic pregnancy are unknown. After fertilization of the oocyte in the peritoneal cavity, the egg takes about nine days to migrate down the tube to the uterine cavity at which time it implants. Wherever the embryo finds itself at that time, it will begin to implant. There are some speculative specific causes or associations. Smoking, advanced maternal age and prior tubal damage of any origin are well known risk factors for ectopic pregnancycitation needed. Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Damage to the cilia or blockage of the Fallopian tubes is likely to lead to an ectopic pregnancy. Women with pelvic inflammatory disease PID have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia. If however both tubes were occluded by PID, pregnancy would not occur and this would be protective against ectopic pregnancy. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy. Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine. Reversal of tubal sterilization Tubal reversal carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation tubal cautery, partial removal of the tubes have been used than less destructive methods tubal clipping. A history of ectopic pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound. Hysterectomy Ectopic pregnancy occasionally occurs in women who have had a hysterectomy. Rather than implanting in the absent uterus, the embryo implants in the abdomen, and must be removed via caesarean section.1 2 Other Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies; this is speculative. Women exposed to diethylstilbestrol DES in utero aka DES Daughters also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women. Symptoms Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability. The early signs are: Pain in the lower abdomen, and inflammation Pain may be confused with a strong stomach pain, it may also feel like a strong cramp Pain while urinating Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. Pain while having a bowel movement Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms. External bleeding is due to the falling progesterone levels. Internal bleeding hematoperitoneum is due to hemorrhage from the affected tube. The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease PID. The most common misdiagnosis assigned to early ectopic pregnancy is PID. More severe internal bleeding may cause: Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse. Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems. Diagnosis An ectopic pregnancy has to be suspected in any woman with lower abdominal pain or unusual bleeding who is or might be sexually active and whose pregnancy test is positive. An abnormal rise in blood βhCG levels may also indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy today is around 1500 IU/ml of β-human chorionic gonadotropin βhCG. A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for βhCG has been reached. An empty uterus with levels lower than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work and ultrasound. If the βhCG falls on repeat examination, this strongly suggests an abortion or rupture. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. Free fluid which is non-echogenic is a normal finding in the late menstrual cycle and early normal pregnancy. This is a transudate and is not presumptive evidence of bleeding. Echogenic free fluid suggests the presence of blood clot and is suggestive of free blood in the peritoneum. A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion has occurred, or a tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. A less commonly performed test, a culdocentesis, may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found there likely comes from a ruptured ectopic pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy. Nontubal ectopic pregnancy 2% of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.3 While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been salvaged from an abdominal pregnancy. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal kidney, liver or hepatic liver artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports. 45 However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of hemorrhage. On May 29, 2008 an Australian woman, Meera Thangarajah age 34, who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce 2.8 kg baby girl, Durga, via Caesarean section, according to a manager at Darwin Private Hospital and to the obstetrician. She had no problems or complications during the 38 week pregnancy.67 Treatment Nonsurgical treatment Early treatment of an ectopic pregnancy with the antimetabolite methotrexate has proven to be a viable alternative to surgical treatment8 since 1993citation needed though the literature dates back to at least 1989.9 If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy. Surgical treatment If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy salpingostomy or remove the affected tube with the pregnancy salpingectomy. The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.10 Chances of future pregnancy The chance of future pregnancy depends on the status of the adnexa left behind. The chance of recurrent ectopic pregnancy is about 10% and depends on whether the affected tube was repaired salpingostomy or removed salpingectomy. Successful pregnancy rates vary widely between different centries, and appear to be operator dependent. Pregnancy rates with successful methotrexate treatment compare favorably with the highest reported pregnancy rates. Often, patients may have to resort to in vitro fertilisation to achieve a successful pregnancy. The use of in vitro fertilisation does not preclude further ectopic pregnancies, but the likelihood is reduced. Complications The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare in women who have access to modern medical facilities. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy. References ^ Serdar Ural May 2004. Ectopic pregnancy. KidsHealth. Retrieved on 2006-11-26. ^ SA Carson, JE Buster, Ectopic Pregnancy. New Engl J Med 329:1174-1181 ^ Spiegelberg's criteria at Who Named It ^ 'Special' baby grew outside womb, BBC news 2005-08-30. Retrieved on 2006-07-14. ^ Bowel baby born safely, BBC news 2005-03-09. Retrieved on 2006-11-10. ^ Baby Born After Rare Ovarian Pregnancy, Associated Press 2008-05-30. Retrieved on 2008-05-30. ^ Cavanagh, Rebekah 2008-05-30. Miracle baby may be a world first. Retrieved on 2008-05-30. ^ Mahboob U, Mazhar SB 2006. Management of ectopic pregnancy: a two-year study. Journal of Ayub Medical College, Abbottabad : JAMC 18 4: 34-7. PMID 17591007. ^ Clark L, Raymond S, Stanger J, Jackel G 1989. Treatment of ectopic pregnancy with intraamniotic methotrexate--a case report. The Australian New Zealand journal of obstetrics gynaecology 29 1: 84-5. PMID 2562613. ^ eMedicine - Surgical Management of Ectopic Pregnancy : Article Excerpt by R Daniel Braun. Retrieved on 2007-09-17. External links The Ectopic Pregnancy Trust - Information and support for those who have suffered the condition by a medically overseen and moderated, UK based charity, recognised by the National Health Service UK Department of Health UK and The Royal College of Obstetricians and Gynaecologists v d e Pregnancy Conception Assisted reproductive technology ZIFT, GIFT In vitro fertilisation Detection HCG pregnancy strip test Obstetric ultrasonography Pregnancy test Prenatal diagnosis 3D ultrasound During pregnancy Amniotic fluid Amniotic sac Amniocentesis Chorionic villus sampling Pregnancy complications Diabetes mellitus and pregnancy Ectopic pregnancy Miscarriage Molar pregnancy Birth preparation Lamaze Bradley Method Childbirth Midwifery Doula Home birth Labor and Delivery v d e Pathology of pregnancy, childbirth and the puerperium O, 630-676 Pregnancy with abortive outcome Ectopic pregnancy - Hydatidiform mole - Miscarriage Oedema, proteinuria and hypertensive disorders Pregnancy-induced hypertension - Pre-eclampsia - Eclampsia - Gestational diabetes Other, predominantly related to pregnancy Hyperemesis gravidarum - Gestational pemphigoid - Intrahepatic cholestasis of pregnancy Maternal care related to the fetus and amniotic cavity and possible delivery problems Polyhydramnios - Oligohydramnios - Chorioamnionitis - Premature rupture of membranes - Amniotic band syndrome - Placenta praevia - Braxton Hicks contractions - Antepartum haemorrhage - Placental abruption Complications of labour and delivery Premature birth - Postmature birth - Cephalopelvic disproportion - Dystocia Shoulder dystocia - Fetal distress - Vasa praevia - Uterine rupture - hemorrhage - Placenta accreta - Umbilical cord prolapse - Amniotic fluid embolism Maternal complications in the weeks after childbirth Puerperal fever - Peripartum cardiomyopathy - Postpartum thyroiditis - Galactorrhea - Postpartum depression Complications related to the fetus Fetal intervention - Fetal surgery Other Maternal death v d e Sexually transmitted diseases and infections STD/STI primarily A50-A64, 090-099 Bacterial Chancroid Haemophilus ducreyi Chlamydia Chlamydia trachomatis Donovanosis Granuloma Inguinale Lymphogranuloma venereum LGV Gonorrhea Neisseria gonorrhoeae Syphilis Treponema pallidum Ureaplasma urealyticum Protozoal Trichomoniasis Trichomonas vaginalis Parasitic Crab louse/crabs Scabies Viral AIDS HIV-1/HIV-2 Cervical cancer Genital warts condyloma Human papillomavirus HPV Hepatitis B Herpes simplex virus HSV1/HSV2 Molluscum contagiosum MCV General inflammation female: Cervicitis Pelvic inflammatory disease PID male: Epididymitis Prostatitis either: Proctitis Urethritis/Non-gonococcal urethritis NGU Other Ectopic pregnancy Premature birth Infertility Reactive arthritis Retrieved from http://en..org/wiki/Ectopic_pregnancy Categories: Sexually transmitted diseases and infections | Medical emergencies | Obstetrics | PregnancyHidden categories: All articles with statements | Articles with statements since August 2007 | Articles with statements since September 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية Bosanski БългарÑ?ки Català Deutsch Español Français Hrvatski Bahasa Indonesia Ã?slenska Italiano Lietuvių Nederlands 日本語 Polski Português РуÑ?Ñ?кий SlovenÅ¡Ä?ina СрпÑ?ки / Srpski Svenska ä¸æ–‡ This page was last modified on 25 August 2008, at 04:39
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