Ectopic pregnancy – still a pregnancy or already an illness?

What is an ectopic pregnancy?

Ectopic pregnancy , also known as ectopic pregnancy , is a fairly common complication of pregnancy in which a fertilized egg implants and develops outside the uterine cavity.

In approximately 95% of cases of ectopic pregnancy, the fertilized egg implants in one of the fallopian tubes (usually due to obstruction of its patency), and less frequently in the ovary , peritoneum or cervix .

Possible Solutions to Tubal Ectopic Pregnancy Without Treatment

If left untreated, there are two possible outcomes for an ectopic tubal pregnancy:

• The release of the egg into the peritoneal cavity , the so-called tubal abortion (Latin: abortus tubarius ).
• Rupture of the fallopian tube (Latin: ruptura tubae uterinae ), which occurs with symptoms of shock.

Is it possible to maintain an ectopic pregnancy?

Unfortunately, there is no such possibility. It cannot be transferred to the uterus to grow normally - it is therefore a pregnancy that has no chance of ending in childbirth . In addition, it can cause specific health complications, and in the case of a ruptured fallopian tube - it can pose a direct threat to the life of the pregnant person .

Prognosis

In the case of surgical or pharmacological treatment of ectopic pregnancy, most people recover completely. However, we must remember that if left untreated, it is a condition of direct threat to life.

Studies say that ectopic pregnancy is the cause of 9 to 13% of deaths in pregnancy. It often ends in a tubal miscarriage, but it can also cause rupture of the fallopian tube and fatal hemorrhage into the peritoneal cavity.

Fortunately, in the vast majority of cases the course is mild, and ectopic pregnancy is diagnosed before serious health complications occur. Regular gynecological check-ups and consulting all worrying symptoms play an important role.

Symptoms of ectopic pregnancy

If symptoms of ectopic pregnancy appear at all, they usually occur at a very early stage and are very non-specific (they may just as well indicate other diseases).

The main symptoms of an ectopic pregnancy include:

• cessation of menstruation,
• bleeding or spotting from the genital tract (after a few weeks, usually in the 2nd month after the period stops),
• abdominal pain (acute or smoldering and chronic, usually one-sided),
• symptoms of pregnancy, such as breast tenderness, frequent urination , or nausea.

Less common symptoms include:

• bowel and bladder problems , such as diarrhea and pain during defecation or urination,
• feeling of fullness when lying down (unrelated to eating),
• back pain , mainly in the sacrolumbar section.

Risk factors

• Previous pelvic inflammatory disease , i.e. serious bacterial infections of the reproductive organs, such as chlamydia , ureoplasmosis or tuberculosis . These diseases can damage the fallopian tubes, causing, for example, post-inflammatory adhesions.
• Previous fallopian tube surgery.
• Previous ectopic pregnancy – If a person has already had an ectopic pregnancy, they are at increased risk of having another one.
• Endometriosis .
• Infertility – two to three times greater risk of ectopic pregnancy (indirect factor, co-occurring with others mentioned).
• Pregnancy after IVF (in vitro fertilization) - Embryo transfer during in vitro fertilization (IVF) can sometimes cause an ectopic pregnancy if, for example, the embryo moves into the fallopian tube. It can increase the risk of unusual types of ectopic pregnancy, such as heterotopic pregnancy , in which intrauterine and tubal pregnancies occur at the same time, and interstitial pregnancy , which occurs in a part of the fallopian tube that is embedded in the wall of the uterus.
• Age – the risk of ectopic pregnancy increases with age.
• Sterilization – People who become pregnant after tubal sterilization (either because it failed or because it was reversed) are at greater risk.
• Caesarean section – the embryo may implant in the scar tissue of the uterine lining caused by the cesarean section.
• Copper Contraceptive Device (IUD) – Using an IUD provides a very low risk of pregnancy, both intrauterine and ectopic. However, if a woman does become pregnant, her chances of ectopic pregnancy are higher than those who do not use an IUD. The IUD still provides better protection against ectopic pregnancy than not using contraception.

You can read more about the IUD in the article on contraception:here .

• Smoking – This can make it harder for the egg to travel into the uterus by reducing the ability of the muscles in the walls of the fallopian tubes to contract.
• Diethylstilbestrol (DES) exposure – DES is a synthetic estrogen that was used from the 1940s to the 1970s (mostly in the US) to treat threatened miscarriage in early pregnancy. It has been associated with severe reproductive system defects in children with uteruses. Prenatal exposure to DES has been found to increase the risk of ectopic pregnancy by about 4 times.

Other types of ectopic pregnancy

Besides tubal pregnancies, there are other (rare) types of ectopic pregnancies:

• Interstitial pregnancy – occurs in the part of the fallopian tube embedded in the uterine wall. It is usually difficult to diagnose and therefore particularly dangerous because it can continue to progress and later rupture, damaging both the fallopian tube and the uterine wall.
• Ectopic pregnancy of the cervix is ​​one of the rarest forms of pregnancy outside the uterine cavity.
• Ovarian Ectopic Pregnancy – This is usually difficult to diagnose because it can look very similar to a tubal ectopic pregnancy attached to the ovary. It is usually not recognized until surgery, when it is necessary to partially or completely remove the ovary.
• Ectopic pregnancies in the cesarean scar – this happens when a pregnancy implants in the surgical scar in the lower part of the uterus. It usually leads to the uterus rupturing because the scar tissue is unable to support it.
• Intramural pregnancy – This is a difficult-to-diagnose pregnancy that implants outside the uterine cavity but in the muscular wall of the uterus. It can occur if the uterus has scar tissue from surgery or if there is a condition called adenomyosis, in which the inner lining of the uterus tears through the muscular wall of the uterus.
• Abdominal Pregnancy – Abdominal pregnancies are thought to start out as tubal pregnancies before separating from the fallopian tube wall and moving into the abdomen where they reattach. It can take many weeks for symptoms to appear.
• Heterotopic pregnancy – This term describes the coexistence of an intrauterine and ectopic pregnancy. The intrauterine twin is able to survive to birth in about one third of cases after surgical treatment of the ectopic pregnancy.

Diagnosis

Diagnosis of ectopic pregnancy usually begins with a gynecological examination and taking the medical history of the person. This pregnancy is diagnosed by ultrasound or laparoscopy when the laboratory results (beta-hCG) indicate pregnancy, but the fetus is not visible in the uterine cavity.

Once diagnosed, any ectopic pregnancy must be removed. This is done surgically or with the use of pharmacological agents, depending on the case.

Ectopic pregnancies are most often diagnosed using a combination of tests:

• Ultrasound examination (USG) – a painless and non-invasive examination performed transvaginally or transabdominally, in which sound waves allow for the creation of an image of the developing pregnancy.
• Determination of the level of chorionic gonadotropin (hCG) – a hormone produced by the trophoblast (a layer that develops in the early developmental stage of the embryo). The test can be repeated at intervals to measure changes in hCG levels. A drop in hCG levels may indicate that the ectopic pregnancy has ended and will resolve spontaneously or will be miscarried in the coming days or weeks. If hCG increases more slowly than in a normal pregnancy, it is probably an ectopic pregnancy (although an ectopic pregnancy is possible even with normal growth).

In a healthy pregnancy, the normal increase in hCG in the blood is approximately 63% over 48 hours.

Laparoscopy , if previous test results are still inconclusive - to perform the test, a laparoscopic camera and instruments are inserted into the abdominal cavity through small incisions under general anesthesia. If an ectopic pregnancy is detected, treatment to remove it can take place during the same operation.

Treatment of ectopic pregnancy

• Expectant management (when hCG levels drop) – an ectopic pregnancy can be life-threatening if left untreated and usually requires medical or surgical intervention to remove it. In some cases, if diagnosed early, it can be monitored to see if it resolves on its own (observation of the pregnancy during hospital stay or during gynecological check-ups every 2 to 3 days).
• Drug treatment with methotrexate – methotrexate stops the growth of the embryo and usually allows you to avoid surgery. Medical treatment may be appropriate if the diagnosis is made very early and specific conditions are met. Methotrexate treatment of ectopic pregnancy is effective, especially for pregnancy located in the horn, cervix or intramural part of the fallopian tube.

Methotrexate is administered by injection into the buttock muscle (less often intravenously), necessarily in a hospital setting. Single-dose or multi-dose regimens are available.

Follow-up visits are held for several weeks to monitor hCG levels until they return to normal. Very rarely, surgery will still be required.

Good to know: Methotrexate is also used in chemotherapy and suppresses the immune system, which is why it is used as a drug to treat many other conditions. It can cause serious side effects. Sometimes folinic acid is necessary. However, the dose for treating ectopic pregnancy is much lower and there is a small risk of serious complications.

• Surgical treatment - There are two possible goals of surgical treatment , which will be determined depending on the damage to the affected fallopian tube and the condition of the other fallopian tube . These are:

– Total salpingectomy – a surgery to remove the fallopian tube containing the ectopic pregnancy. It is usually recommended for people who do not want to have children in the future, who have had another ectopic pregnancy in the same fallopian tube, or those whose pregnancy has severely damaged the fallopian tube.

– Linear salpingotomy – This is an approach that involves surgically incising the fallopian tube to remove an ectopic pregnancy without removing the entire fallopian tube. This carries a higher risk of recurrent ectopic pregnancy, but still leaves the possibility of a uterine pregnancy developing. However, salpingotomy is not always possible.

• Surgical treatment (laparotomy or laparoscopy).

Fertility problems after ectopic pregnancy

Most people recover completely from an ectopic pregnancy and can have a normal pregnancy in the future. Fertility is affected if the ectopic pregnancy ruptures or the fallopian tube is removed during treatment.

Emotions in the event of an ectopic pregnancy

Many people experience emotional stress after an ectopic pregnancy, especially if the ectopic pregnancy occurred while trying to conceive. In addition to the sadness associated with losing the pregnancy, there is the shock of the diagnosis, and ultimately the fear for one's own life and the success of the treatment.

It is also natural to feel frustrated at having to wait a certain amount of time before trying to get pregnant again, and having to undergo follow-up blood and urine tests.

An ectopic pregnancy is a difficult experience. Not only medical care is very important, but also therapeutic care and participation in support groups.