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Ectopic pregnancy is a common pregnancy complication that can lead to high morbidity and mortality rates if not promptly treated. Providers must maintain a high index of suspicion for ectopics, as they may present with pain, vaginal bleeding, or vague complaints like nausea and vomiting. Let us gain a better understanding of ectopic pregnancies and critical information related to the same.

WHAT EXACTLY IS AN ECTOPIC PREGNANCY?

Fertilization and embryo implantation involve chemical, hormonal, and anatomical interactions. Ovaries in the lower pelvic region release an egg each month for fertilization. Fallopian tubes transport the egg to the uterus, where sperm fertilizes the egg, forming an embryo. The embryo implants into endometrial tissue within the uterus. An ectopic pregnancy occurs when the fetal tissue implants outside the uterus or attaches to an abnormal or scarred part of the uterus.

In a normal pregnancy, a fertilized egg implants and grows in the uterus (also called the womb). From fertilization to delivery, pregnancy requires several steps in a woman’s body. One of these steps is when a fertilized egg travels to the uterus to attach itself.

In the case of an ectopic pregnancy occurs when a fertilized egg grows outside of the uterus. Almost all ectopic pregnancies, more than 90%, appear in a fallopian tube. As the pregnancy develops, it can cause the tube to burst (rupture). A rupture can cause major internal bleeding. This can be a life-threatening emergency that needs immediate surgery. Only 1%–2% of pregnancies are ectopic, according to a reliable source. Three to four percent of pregnancy-related fatalities are the result of this problem.

CAUSES OF ECTOPIC PREGNANCY

Ectopic pregnancy occurs when an embryo is implanted outside the uterus, typically in the fallopian tube, due to inflammation caused by toxins, viral infections, immunological issues, or hormonal changes. This can lead to increased pro-inflammatory cytokines and embryo implantation. Interleukin 1 is an essential marker for endometrial implantation, and fallopian tube injury can also result.

Smoking, illness, and hormonal fluctuations during the menstrual cycle can also affect cilia beat frequency. Ectopic implantation can occur in various bodily sites, including the cervix, uterine cornea, myometrium, ovaries, and abdominal cavity.

Women who have had their fallopian tubes surgically altered or ligated may also have ectopic pregnancies. The cause of an ectopic pregnancy is not always clear. Still, some conditions have been linked to it, including inflammation, scarring, hormonal factors, genetic abnormalities, congenital disabilities, and medical conditions affecting the fallopian tube and reproductive organs.

Ectopic implantation can also occur in various body parts, including the cervix, uterine cornea, myometrium, ovaries, and abdominal cavity. Women with tubal ligation or other fallopian tube alterations are at risk for ectopic pregnancies, which can also occur concurrently with an intrauterine pregnancy.

SYMPTOMS

The onset of ectopic pregnancy symptoms can occur as early as week four and as late as week 12, but they are more prevalent in weeks 6–9.

An ectopic pregnancy may initially appear similar to a typical pregnancy, with signs like missed menstrual periods, tender breasts, and upset stomach. Still, more severe symptoms might appear as an ectopic pregnancy progresses, particularly if a fallopian tube bursts. They are:

Abdominal pain: This usually affects the lower part of the pelvis.

Vaginal bleeding: Compared to the fluid of a menstrual cycle, the blood may be lighter or darker. It might also have reduced viscosity.

Pain in the shoulders: This may indicate internal bleeding. The bleeding may be irritating the phrenic nerve, which results in discomfort.

Stealth or collapse: Severe bleeding may cause this medical emergency

It’s better to contact the doctor if you experience any of these symptoms.

EPIDEMIOLOGY

In the general population, ectopic pregnancy is a prevalent problem, with rates between 1% and 2% and between 2% and 5% among individuals utilizing assisted reproductive technologies. While 4% of all ectopic pregnancies result in a cesarean scar, less than 10% of ectopic pregnancies occur outside the fallopian tube. Because of their more significant rates of bleeding, interstitial ectopic pregnancies account for up to 4% of all ectopic implantation sites and are associated with higher rates of morbidity and death. A report of 1% of ectopic pregnancies involved intramural ectopic pregnancies when the embryo was implanted in the myometrium. 1.3% of ectopic implantation sites are in the abdominal cavity; the pouches anterior and posterior to the uterus, the serosa of the adnexa, and the uterus are the most often used locations.

Advanced maternal age, smoking, ectopic pregnancy history, tubal injury or surgery, previous pelvic infections, exposure to DES, use of an IUD, and assisted reproductive technologies are risk factors. The risk is up to 10 times higher for older women with a history of ectopic pregnancies than for the general population. With an estimated probability of 1:100, women pursuing in vitro fertilization are more likely to experience an ectopic pregnancy along with a contemporary intrauterine pregnancy, a condition known as heterotypic pregnancy.

FOR WHOM IS AN ECTOPIC PREGNANCY RISKY?

Every sexually active woman has a chance of becoming pregnant unexpectedly. If any of the following apply, risk factors will rise:

35 years of age or older; previous history of numerous abortions, abdominal surgery, or pelvic surgery

pelvic inflammatory disease (PID) history

history of endometriosis, despite having an intrauterine device (IUD) or tubal ligation, pregnancy took place

fertilization assisted by fertility medications or treatments

cigarette use

ectopic pregnancy history

history of STDs, such as chlamydia or gonorrhea, or structural abnormalities in the fallopian tubes that impede the ability of the egg to move.

DIAGNOSIS:

Vaginal ultrasound: Ectopic pregnancy is diagnosed through a transvaginal ultrasound scan, which uses a small probe to insert into the vagina. The probe emits sound waves that bounce back, creating a close-up image of the reproductive system on a monitor. This often shows whether a fertilized egg has been implanted in one of the fallopian tubes, although it may be difficult to spot.

Blood test: Blood tests measuring the pregnancy hormone human chorionic gonadotropin (HCG) can be conducted twice, 48 hours apart, to observe changes over time. This method can identify ectopic pregnancies not detected during an ultrasound scan, as HCG levels tend to be lower and rise more slowly over time. The test results can also aid in determining the best treatment for an ectopic pregnancy.

Keyhole surgery: A laparoscopy is a keyhole surgery performed under general anesthesia to determine if an ectopic pregnancy is present or its location is unknown. It involves making a small incision in the tummy and inserting a laparoscope to examine the womb and fallopian tubes directly. If an ectopic pregnancy is found during the procedure, small surgical instruments may be used to remove it, avoiding the need for a second operation.

TREATMENT:

Ectopic pregnancies are unsafe for the mother and the embryo, and it is crucial to remove the embryo as soon as possible for her immediate health and long-term fertility. Treatment options vary depending on the location of the pregnancy and its development.

Medication, such as methotrexate (Rheumatrex), can help prevent immediate complications and prevent the ectopic mass from bursting. Methotrexate is an injection that stops the growth of rapidly dividing cells, such as the ectopic mass cells. It causes symptoms similar to a miscarriage, such as cramping, bleeding, and tissue passing.

Surgery, such as a laparotomy, is often recommended to remove the embryo and repair internal damage. If the surgery is unsuccessful, the surgeon may repeat the procedure through a larger incision. If the fallopian tube is damaged, the doctor may need to remove it during surgery.

Home care after surgery involves keeping the incisions clean and dry, checking them daily for infection signs, and avoiding lifting anything heavier than 10 pounds. Self-care measures include drinking plenty of fluids, pelvic rest, resting as much as possible the first week of post-surgery, and increasing activity as tolerated. Always notify your doctor if pain increases or something is out of the ordinary.

PREVENTION:

Although they cannot be prevented, ectopic pregnancies (EP) can be avoided with prompt diagnosis and care. Pregnant women who have risk factors for EP should keep a watchful eye on their doctors. Preventing STIs such as chlamydia and gonorrhea might raise the risk of an ectopic pregnancy. Treatment for STIs is essential to avoid inflammation, which can harm the reproductive system and increase the chance of EP. STIs frequently cause discomfort during intercourse, vaginal discharge, abnormal bleeding, stomach pain, difficulty urination, and vaginal odor. Women who smoke should give it up before attempting to get pregnant since smoking raises the chance of EP.

For women who have unilaterally damaged Fallopian tubes, salpingectomy is the recommended surgical procedure to reduce the possibility of an ectopic tubal pregnancy.

CONCLUSION:

In conclusion, ectopic pregnancy is a severe problem that leads to high morbidity and mortality rates. It initially appears as a typical pregnancy, but it cannot be noticed. Still, if more severe symptoms like abdominal pain, vaginal bleeding, pain in the shoulders, or dizziness occur, it is better to consult the doctor.

It can’t be prevented, but precautions from our side can avoid ectopic pregnancy. Preventing STIs, quitting smoking, or performing salpingectomy for those who have damaged fallopian tubes can prevent ectopic pregnancy to an extent.