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What is ectopic pregnancy?

A normal pregnancy grows inside the uterus. If the embryo implants outside the uterus, the pregnancy is known as ‘ectopic pregnancy’. The incidence of ectopic pregnancy is about 1-2% of all pregnancies.

Where exactly does an ectopic pregnancy occur outside the uterus?

The pregnancy may implant at any of the following sites:

  • Inside the fallopian tube (tubal ectopic pregnancy)- commonest (98% cases)
  • Inside the ovary (ovarian ectopic pregnancy)
  • Inside the cervix (cervical ectopic pregnancy)
  • Inside the abdominal cavity (abdominal ectopic pregnancy)

What happens if I have a ectopic pregnancy? What happens to my baby? Will it be fine?

Unfortunately, the fetus cannot survive outside the uterus as it cannot get the nourishment and space to grow. Normally, the baby’s blood vessels grow deep into the muscles of the mother’s uterus to form the placenta which gives it blood supply. However, when the pregnancy is in the fallopian tube, the muscles of the tube are very thin and the blood vessels erode the wall of the tube, leading to bleeding, causing an emergency situation.
In an emergency situation, doctors have to operate and remove the pregnancy surgically.

Will I get any symptoms if I have ectopic pregnancy?

If you have ectopic pregnancy, you may experience the following symptoms:

  • Missed periods
  • Bleeding from vagina (mild, moderate or severe)
  • Lower abdominal pain (usually on one side or in the centre- may be mild, moderate or severe
  • Giddiness
  • Fainting (usually indicates internal bleeding)
Since most women undergo an early sonography in pregnancy, ectopic pregnancies are getting diagnosed very early before symptoms can develop.

Can ultrasound diagnose ectopic pregnancy?

Since the incidence of ectopic pregnancy is on the rise, it is advisable to undergo an early ultrasound examination (baseline check) at about 6 weeks pregnancy (2 weeks after a missed period) to confirm that the pregnancy is within the uterus. Transvaginal ultrasound (internal ultrasound) is the preferred method as it gives much better information at an early stage of pregnancy.
If the sonologist does not find the pregnancy inside the uterus, he/she will look for it in the tubes. It looks like an abnormal mass outside the uterus in the region of the tubes. But ectopic pregnancy may not always show up on sonography, especially in the early stages. In such cases, doctors will look for other signs suggestive of ectopic pregnancy such as free fluid inside the pelvis and abdomen (suggestive of internal bleeding). In very early cases, there may be no indication even on sonography.

What if ultrasonography does not diagnose ectopic pregnancy? Is there any other way?

If your gynaeocologist is suspicious, he/she will advise a blood test – beta HCG level. This level is higher in normal pregnancies than in ectopic pregnancy. Also, if you do HCG level twice (at 48-72 hours interval), the rate of rise of HCG hormone gives us a clue whether the pregnancy is ectopic or not.

So how can I be sure whether it is ectopic or not?

If sonography can clearly see the ectopic pregnancy, the diagnosis is easy. Otherwise, a simple indicator is this: If the beta HCG value is more than 1500 and no pregnancy is seen inside the uterus on INTERNAL sonography, it is diagnostic of an ectopic pregnancy. Sometimes you may need to undergo serial (repeated) beta HCG levels and sonographies to arrive at a diagnosis.

I have been bleeding heavily since 2 days. Does that mean that the ectopic pregnancy has been thrown out of my system? Or that it has ruptured?

No. The ectopic pregnancy is located inside the abdominal cavity. It cannot bleed outside. If you are having vaginal bleeding, it means that the inner lining of the uterus is shedding. That can happen due to low hormonal levels.

If I have a tubal ectopic pregnancy, is it necessary that I have to undergo surgery? Can I take medicine to dissolve the pregnancy?

Fortunately, there are treatments available which can avoid surgery.
The commonest and time-tested treatment is giving Inj Methotrexate (an anti-cancer drug) to dissolve the pregnancy. It is given in a small dose and thus, it harms only the growing embryo and is quite safe for the mother. This regimen is about 80% effective for well-selected cases.

How can I decide whether to undergo surgery or to take the injection? What would be best for me?

This is a technical issue and should be decided by your doctor. However, there are certain indicators which can guide you. Inj Methotrexate should be used under the following conditions:
You are not bleeding internally
Your tube has not ruptured
Your ectopic pregnancy is less than 3 cm in size and the embryo does not show heart beat
Your beta HCG level is low (preferably less than 5000 IU/ml)
If the mass is big or HCG is high or you have begun to bleed internally, the risk of rupture of the fallopian tube is high. Therefore it is better to undergo surgery.

If I am given injections, am I assured that the ectopic pregnancy will dissolve? And I will be cured?

If you are given Inj Methotrexate (single dose in the muscle), you would need to be under observation, preferably in the hospital. You may experience the following symptoms: Abdominal pain (mostly cramp-like) usually happens about 3 days after the injection; occasionally, you may get nausea, vomiting, loose motions or ulcers in the mouth. The doctor will do your beta HCG on the 4th and 7th day after the injection. The levels should drop by 15% of the initial value on 7th day. That indicates good response to the injection. The fourth day Beta HCG may rise. Do not panic. There is a chance that your tube might rupture inspite of Methotrexate injection and that would require immediate surgery.

How do I know if my tube has ruptured? Is it dangerous?

When your tube ruptures, you get intense pain in the lower abdomen. You may even faint or feel giddy or may vomit. This happens because of sudden bleeding inside the abdomen. This is a critical situation because blood loss may be sudden and massive. If your tube has ruptured and you are bleeding profusely, you may need to undergo emergency laparotomy (open surgery). You may need blood transfusions to save your life (depending on the amount of blood loss).

Why does one get ectopic pregnancy?

Ectopic pregnancy occurs more commonly in the following group of women:

  • Women with diseased fallopian tubes. This may be due to infection (pelvic inflammatory disease) endometriosis or post-operative adhesions.
  • Women undergoing fertility treatments
  • Women who have had ectopic pregnancy in the past
  • Women with IUD in place and women who have undergone tubal sterilisation or tubal repair surgery may rarely find themselves with pregnant inside the tubes
  • Smokers may have a slightly increased risk depending on the number of cigarettes per day smoked
  • I have had ectopic pregnancy in the past. Will I get it again?

    The risk of getting a repeat ectopic pregnancy on the same side or the opposite side is 15% after one episode of ectopic pregnancy and 30% after two episodes of ectopic pregnancy.