Ectopic pregnancy

Overview

• Definition: A pregnancy that occurs outside the uterine cavity, most commonly in the fallopian tube.

Etiology/ Risk Factors

• Pelvic inflammatory disease (PID), often due to Chlamydia trachomatis.
• Previous ectopic pregnancy.
• Previous tubal surgery.
• Infertility and its treatments.
• Endometriosis.
• Smoking.
• Advanced maternal age.
• History of pelvic or abdominal surgery.
• Intrauterine device (IUD), especially if pregnancy occurs with IUD in place.
• Tubal ligation – rare but possible.

Clinical Features

• Amenorrhoea: Absent menstrual periods.
• Vaginal bleeding: often darker and less than a normal period.
• Unilateral pelvic pain.
• Shoulder tip pain due to blood irritating the diaphragm (Kehr’s sign).
• Signs of pregnancy: breast tenderness, nausea.
• Signs of shock: tachycardia, hypotension, especially if tube ruptures.

Investigations

• Beta-hCG: Serial measurements. Levels may rise slower than expected or decline abnormally.
• Transvaginal ultrasound: To identify location of pregnancy.
• Laparoscopy: Diagnostic and potentially therapeutic.
• Culdocentesis: Aspiration of blood from the pouch of Douglas.

Management

• Methotrexate: For unruptured ectopic pregnancy, used to inhibit growth of the embryo.
• Laparoscopic surgery: Salpingostomy or salpingectomy.
• Laparotomy: For unstable patients or where laparoscopic expertise is not available.
• Rh(D) immune globulin: Given to Rh-negative women to prevent Rh sensitisation.

Complications

• Rupture: Leading to haemorrhage and shock.
• Infertility: Especially if a tube is removed.
• Recurrence: Risk of another ectopic pregnancy.

Key Points

• Ectopic pregnancy is a life-threatening condition 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.