Ectopic pregnancy

Definition:

Ectopic Pregnancy is a medical condition where the fertilized 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.

Epidemiology:

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.

Risk Factors:

Previous ectopic pregnancy
History of pelvic inflammatory disease (PID)
Surgery on the fallopian tubes, including tubal sterilization
In vitro fertilization (IVF) or other assisted reproductive technologies (ART)
Smoking
Age over 35 years
Endometriosis

Pathophysiology:

The fertilized 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.

Clinical Features

Signs and Symptoms:

Abdominal pain, often unilateral
Vaginal bleeding, which may be light or heavy
Amenorrhea (missing one or more menstrual periods)
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)
Dizziness or fainting (syncope), indicating possible internal bleeding

Diagnosis:

Clinical examination and history taking are crucial.
Transvaginal ultrasound is the most effective diagnostic tool, used to visualize 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.

Management

Medical:

Methotrexate is a medication used to treat unruptured ectopic pregnancy in patients who are hemodynamically 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 hemodynamically 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.

Prognosis

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.

Complications

Rupture of the ectopic pregnancy can lead to severe internal bleeding, shock, and, if not treated immediately, death.
Infertility can result from damage to the fallopian tubes.

Prevention

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.

Summary

Ectopic pregnancy is a significant gynecological emergency that requires prompt diagnosis and management to prevent serious complications. 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.