Ectopic Pregnancy

Maternal mortality in the United States fell dramatically during the last century. Over the last 20 years the maternal mortality rate has been approximately 7.5 deaths per 100,000 live births. Ectopic pregnancy has and continues to account for a significant percent of these deaths. Some pregnancy complications with adverse outcomes are unavoidable, however death from ectopic pregnancy should rarely if ever occur with access to modern medical care.

Approximately 100,000 ectopic pregnancies occur each year in the United States. An ectopic pregnancy (sometimes called a tubal pregnancy) occurs when a fertilized egg implants somewhere outside of the uterus. The majority of ectopic pregnancies are found in the fallopian tubes but abnormal implantation can also occur on the ovaries, in the abdominal cavity or in the cervix. The most feared complication of an ectopic pregnancy is rupture of the tube, which can result in life threatening hemorrhage.

Symptoms from an ectopic pregnancy can be severe or mild. Most commonly a woman with an ectopic pregnancy will present with abnormal bleeding with or without abdominal pain. Sometimes pregnancy symptoms will be present (such as nausea or breast tenderness) but many women don’t realize that they are pregnant. If left untreated the pregnancy will continue to grow until the tube ruptures at which point severe pelvic pain which may be accompanied by shoulder pain, lightheadedness and fainting will occur. To prevent rupture of the tube it is imperative that women with abnormal bleeding and pelvic pain consult a physician so the appropriate diagnosis can be made.

When a woman presents with pain or abnormal bleeding and a pregnancy test is positive there are four possible diagnoses…a normal pregnancy, a pregnancy that is likely or has resulted in a miscarriage, a molar pregnancy or an ectopic pregnancy. A molar pregnancy is an uncommon cause of bleeding, it occurs when the early placenta develops into a mass of cysts and there is no or a very abnormal embryo. To differentiate between a normal early pregnancy, a miscarriage or ectopic various tests are used. First a thorough history of the woman’s bleeding, past history and an exam is performed. This is then correlated with the results of a quantitative pregnancy test (HCG) and pelvic ultrasound. Sometimes in early pregnancies it is impossible to differentiate between the three possibilities. Thus the blood level of HCG is repeated in 48-72 hours. In a normal pregnancy the level will double in that time. When it reaches 2000 an ultrasound can confirm a pregnancy in the uterus. An abnormal rise in the level may indicate an ectopic pregnancy or a miscarriage. To distinguish between these two possibilities a D and C or laparoscopy may be recommended. If the suspicion of an ectopic is high treatment with a medication called methotrexate may be offered without any surgical evaluation.

Anything that can cause scarring of the fallopian tubes increases the risk of an ectopic pregnancy. The incidence of ectopic pregnancy has significantly increased over the past 20 years in large part due to the increase in sexually transmitted diseases such as Chlamydia. Infections of the fallopian tubes (which may not be recognized by the affected woman) are a result of chlamydial and gonnoccal infections. Other risk factors for an ectopic pregnancy include endometriosis, prior pelvic surgery (including sterilization) and infertility.

A recent study of sterilized women found a risk of 7 ectopic pregnancies per 1000 procedures. This is more likely to occur in women sterilized before the age of 30. Although an uncommon event it should never be assumed by women or their health care providers that a history of sterilization rules out the possibility of an ectopic pregnancy.

Once diagnosed the treatment for an ectopic pregnancy is either surgical where the pregnancy is removed from the fallopian tube or medical with the drug methotrexate.

It is not possible to put the pregnancy into the uterus. If the ectopic is large or the tube has been ruptured then removal of the tube may be necessary.

Once a woman has had an ectopic pregnancy she is always at risk for another ectopic pregnancy. Fortunately the majority of women who have had an ectopic pregnancy are ultimately able to have a child.