Ectopic pregnancy

An ectopic pregnancy occurs when the fertilized egg does not normally nest inside the uterus, but settles in a different location. In most cases, implantation occurs in the fallopian tubes and, for this reason, these pregnancies are called tubal.

In 16 cases out of 1,000 pregnancies, an ectopic pregnancy occurs.

The fallopian tubes (also called oviducts, or uterine tubes) are a part of the genital apparatus, they are two symmetrical organs that connect the ovary to the uterine cavity.

These tubes are not suitable for the growth of the embryo, and therefore the tubal pregnancy can not be carried out in any way and must be treated accordingly.

Since it is a potentially dangerous condition for women, the fact that immediately recognizing the first signs of an (possible) ectopic pregnancy is important to be able to contact the doctor as soon as possible.

Heterotopic pregnancy

There is also the possibility that one embryo implants normally in the uterus and, at the same time, that another embryo implants in a tube or other location.

This condition, in which a normal pregnancy and an abnormal pregnancy coexist inside the uterus, is extremely rare, and is called heterotopic pregnancy.

Experts estimate that it occurs in one pregnancy every 4,000 -10,000.

The causes of an ectopic pregnancy

The causes of an ectopic pregnancy may be due,

  • an infection, or inflammation of the fallopian tubes (typically caused by chlamydia) that causes partial or total blockage;
  • smoking: there are some experts who hypothesize that cigarette smoke can compromise the normal functioning of the fallopian tubes;
  • scar tissue derived from tubal surgery (such as failed tubal sterilization) which could hinder egg movement;
  • previous interventionsto the pelvic area or tubes that may have caused adhesions: may increase the risk of having an ectopic pregnancyprevious surgical operations to correct problems related to the fallopian tubes;
  • an abnormal shape of the fallopian tubes due to abnormal tubal growth or birth defects;
  • to a previous ectopic pregnancy: some researchers (examining studies done on the subject) have found that, as regards women who have already had an ectopic pregnancy, the risk of having another one ranges from 5 to 25%, depending on how the first was treated;
  • the fact that you have had fertility treatments or used fertility medicines;
  • endometriosis (it is a chronic and complex disease due to the abnormal presence of tissue that lines the inner wall of the uterus). In this case, the tissue that normally lines the inside of the uterus, grows outside the uterine cavity invading the ovaries, intestines or fallopian tubes. When the endometrium grows inside the fallopian tubes, it can cause inflammation and tissue scarring, thus increasing the risks of an ectopic pregnancy;
  • repeated induced abortions;
  • at the advanced age of the mother (35-44 years): if you are over 35, you may have accumulated over time a number of risk factors, such as pelvic infections or changes in tubal function;
  • to the fact of having taken hormonal contraceptives based only on progestin: some scholars hypothesize that these may increase the risks of an ectopic pregnancy.

Symptoms of an ectopic pregnancy

Not always an ectopic pregnancy is accompanied by obvious symptoms. It could therefore only be recognised during routine checks. Many women do not experience any symptoms until the tube ruptures.

When present, symptoms tend to appear between the  4th  and  12th  week of pregnancy, and include a combination of the following conditions.

  • Vaginal bleeding or watery brown discharge: may resemble the start of your period; the blood may be red or brown (like the color of dried blood), and the bleeding may be continuous or intermittent, heavy or light. 
  • Pain in the apical part of the shoulder : their cause internal bleeding that irritates the nerves that pass in the shoulder area. 
  • Absent period, and symptoms typical of the initial phase of pregnancy , such as sore breasts, fatigue, nausea in the presence of a positive pregnancy test .
  • A pain in the lower abdomen, on one side only. It could be intermittent or sudden pain, persistent and severe, mild or sharp; you may also experience nausea and vomiting; you may notice the pain gets worse with bowel movements or when you cough. If your fallopian tube has ruptured, your abdomen may feel distended and swollen. 
  • Discomfort with urination or defecation.
  • Signs of hemorrhagic shock . If the fallopian tube ruptures, the blood loss can cause shock. Its hallmarks are: weak and very fast pulse, lightheadedness, tendency to faint, and pale, clammy skin.

However, these symptoms are not necessarily indicative of a serious problem, as they could also be caused by other types of problems, such as stomach flu. 

The diagnosis of ectopic pregnancy

Ectopic pregnancies are diagnosed by your doctor. Your doctor will (likely) first examine your pelvis for tender spots, swelling, or a mass.

Subsequently, you can use ultrasound to check for the presence of the fetus inside the uterus.

In these circumstances it is also very important to measure the levels of chorionic gonadotropin (hGC) as its lower than normal level could lead to suspicion of ectopic pregnancy.

How it is treated

The cure of an ectopic pregnancy depends on a series of elements such as,

  • the possibility of having a definitive diagnosis,
  • the size of the embryo,
  • the presence or absence of painful symptoms,
  • the presence of internal bleeding and other related symptoms.

If the pregnancy is clearly ectopic, and if the embryo is still relatively small, your doctor may decide to prescribe a medication called methotrexate or methotrexate.

This intramuscularly injected drug reaches the embryo through the bloodstream, causes an interruption of pregnancy as it stops the growth of placenta cells. (The embryo will be reabsorbed by the body after some time). 

If the tube is pulled, or has ruptured and started to bleed, it may need to be removed all or part of the tube. In this case, the bleeding must be stopped promptly by emergency surgery.

Another possibility  could be given by  laparoscopic surgery done under general anesthesia. This type of surgery requires the surgeon to use a laparoscope to remove the embryo in addition to repairing or removing the affected tube.

If the ectopic pregnancy cannot be terminated by laparoscopy, another type of surgery called laparotomy is performed. 

The possible consequences

Experiencing an ectopic pregnancy may make you feel distraught.

Not only because you had to terminate the pregnancy, but also because it will be more difficult for you to conceive a child again: if the fallopian tubes have not been removed, you have about a 60% chance of carrying on a regular pregnancy in the future. 

It is usually recommended to wait at least 2 menstrual cycles before trying to get pregnant again, as this way the tubes will have time to recover (if you have taken methotrexate, it will take you at least 3 months).

Before even trying to get pregnant, you need time to recover your strength, both emotionally and physically: when you’re ready, ask your doctor for advice on the best time to try to conceive. 

Then consider that your partner may also feel sad or helpless in this situation and, while trying to be supportive, it may be difficult for him to express these emotions.

However, this experience could bring you even more together, but it could also put your relationship in difficulty. Therefore, consider the possibility of psychological support to help your partner recover; your doctor will be able to advise you on suitable professionals.

Katherine Johnson, M.D., is a board-certified obstetrician-gynecologist with clinical expertise in general obstetrics and gynecology, family planning, women’s health, and gynecology.

She is affiliated with the Obstetrics and Gynecology division at an undisclosed healthcare institution and the online platform,

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