Ectopic pregnancy

• Ectopic pregnancy is a medical condition where the fertilised egg implants and grows outside the uterine cavity, most commonly in the fallopian tubes (tubal pregnancy).
• It can also occur in other locations, such as the ovary, abdominal cavity, or the cervix, but these are less common.

• Ectopic pregnancy accounts for 1-2% of all pregnancies.
• The incidence has increased over the past decades, partly due to improved diagnostic techniques and also due to factors that increase risk.

• The fertilised egg’s implantation outside the uterine cavity disrupts normal embryonic development.
• If the embryo implants in the fallopian tube, its growth can cause tubal rupture, leading to internal bleeding, a situation that can become life-threatening.

• Pelvic inflammatory disease (PID), often due to Chlamydia trachomatis.
• Previous ectopic pregnancy.
• Previous tubal surgery, including tubal sterilisation.
• Infertility.
• In vitro fertilisation (IVF) or other assisted reproductive technologies (ART).
• Endometriosis.
• Smoking.
• Advanced maternal age (>35 years).
• History of pelvic or abdominal surgery.
• Intrauterine device (IUD), especially if pregnancy occurs with IUD in place.
• Tubal ligation – rare but possible.

• Abdominal pain, often unilateral.
• Vaginal bleeding, which may be light or heavy.
• Amenorrhea (missing one or more menstrual periods).
• Signs of pregnancy: breast tenderness, nausea.
• Symptoms of acute abdomen (severe abdominal pain, tenderness) if rupture occurs.
• Shoulder tip pain (referred pain due to diaphragmatic irritation by blood in the peritoneal cavity).
• Signs of shock: tachycardia, hypotension, especially if tube ruptures.
• Dizziness or fainting (syncope), indicating possible internal bleeding.

• Clinical examination and history taking are crucial.
• Transvaginal ultrasound is the most effective diagnostic tool, used to visualise the location of the pregnancy.
• Quantitative blood tests to measure human chorionic gonadotropin (hCG) levels. Ectopic pregnancies often have lower and more slowly rising hCG levels compared to normal pregnancies.
• Laparoscopy may be used as a diagnostic and sometimes therapeutic procedure if the diagnosis is unclear.

Medical:

• Methotrexate is a medication used to treat unruptured ectopic pregnancy in patients who are haemodynamically stable, with no significant pain, and where the ectopic mass is small (<3.5 cm).
• It works by inhibiting cell division, thereby stopping the growth of the embryo.

Surgical:

• Laparoscopic surgery is the preferred method for surgical management, especially in cases of tubal rupture or when the patient is haemodynamically unstable.
• The affected tube can be removed (salpingectomy) or the ectopic pregnancy can be removed while preserving the tube (salpingostomy), depending on the situation and future fertility desires.
• Laparotomy may be required in cases of severe internal bleeding or when laparoscopy is not available.

• Rupture: Leading to haemorrhage, shock, and, if not treated immediately, death.
• Infertility: Resulting from damage to the fallopian tubes (especially if a tube is removed).
• Recurrence: Risk of another ectopic pregnancy.

• With prompt diagnosis and treatment, the prognosis is generally good.
• Fertility outcomes vary depending on the extent of the damage to the fallopian tubes and the type of treatment received.

• Reducing the risk factors where possible, such as quitting smoking and screening for and treating sexually transmitted infections (STIs) to prevent PID.
• Early detection of risk factors and close monitoring of pregnancies in women at high risk.

• Ectopic pregnancy is a significant gynaecological emergency and a leading cause of maternal mortality in the first trimester.
• Any woman of reproductive age with abdominal pain and/or vaginal bleeding should be evaluated for ectopic pregnancy.
• Early diagnosis and management can help in preserving future fertility.
• Understanding the risk factors, clinical presentation, diagnostic approaches, and management strategies is crucial for medical students.
• It highlights the importance of early intervention and the role of both medical and surgical treatments in managing this potentially life-threatening condition.