Everything you need to know about an ectopic pregnancy

An ectopic pregnancy is a pregnancy that occurs in other sites other than the inner lining of the womb. If you have had an ectopic pregnancy in the past, it is important that you do a prompt pregnancy test and ultrasound scan to confirm the position of a new pregnancy — in the event that you miss your period or suspect you could be pregnant. 
Here’s what you need to know
What are some of the sites for ectopic pregnancy?
Fallopian tubes, ovaries, abdominal cavity, cervix and caesarean scar.
What are the risk factors for an ectopic pregnancy?
Previous ectopic pregnancy. Having a history of an ectopic pregnancy puts one at a higher risk of another one. This is because the problems that led to the initial ectopic pregnancy are likely to be persistent and lead to a recurrence of such a pregnancy.

Abnormalities of the fallopian tubes: Damage on the fallopian tubes can lead to an ectopic pregnancy. The following are some of the causes of fallopian tube damage: Infection (mostly sexually transmitted infections like chlamydia and gonorrhoea); previous surgery of the fallopian tubes in an attempt to treat infertility due to blocked tubes; disease processes such as endometriosis and cancer. 

Infertility: The risk of ectopic pregnancy is higher among women with infertility problems. Tubal blockage is a common cause of infertility. This, as well as attempts to surgically unblock the fallopian tubes, can increase chances of an ectopic pregnancy. Fertility drugs and IVF (in vitro fertilisation) may also increase the risk of an ectopic pregnancy. 

Multiple sexual partners increase risk of acquiring pelvic sexually transmitted infections, which in turn increase the risk of an ectopic pregnancy.

Contraception methods.:Tubal ligation - having the fallopian tubes surgically tied or cut, as a form of permanent birth control- can rarely fail and if this happens, it can result in an ectopic pregnancy.Women who use an intrauterine contraceptive device (IUD) are less likely to have an ectopic pregnancy because the IUD is effective at preventing all types of pregnancy. However, if a pregnancy occurs in a woman using an IUD, there’s a high chance that it may be an ectopic pregnancy.

How does an ectopic pregnancy present?

If you have an ectopic pregnancy, you are likely to miss your menstrual period, have symptoms of early pregnancy such as breast tenderness and nausea, vaginal spotting or bleeding, lower abdominal pains which can be one sided depending on the site of the ectopic pregnancy, generalised abdominal pains, abdominal distension and shoulder pains in case of ruptured ectopic pregnancy.

You can also experience symptoms of severe bleeding in cases of ruptured ectopic pregnancy such as dizziness, headache, easy fatigability, awareness of one’s own heartbeats, fainting and shock.

How is an ectopic pregnancy diagnosed?

Diagnosis is based on symptoms described above. A positive pregnancy test and an ultrasound scan that confirms the location of the pregnancy to be outside the womb. 

Often, the ultrasound will confirm absence of an intrauterine pregnancy in the presence of a positive pregnancy test. It may also show the exact location of the ectopic pregnancy or blood in the abdominal cavity.

How is an ectopic pregnancy treated?

Treatment should be urgent due to the risk posed by a ruptured pregnancy. When a pregnancy grows in a site outside the inner lining of the womb, the site is incapable of accommodating the rapidly growing embryo, resulting in its rupture and consequent bleeding. The bleeding is often heavy and life-threatening, making most ectopic pregnancies a medical emergency. If not caught and treated in time, it may result in death of a woman. 

The other consequence of an ectopic pregnancy is loss of the fallopian pain, that is if it is a tubal pregnancy. This leaves the woman with one fallopian tube. There is a high chance that an ectopic pregnancy may recur in the remaining fallopian tube with a potential loss of the tube, rendering the woman infertile. Most times however, if left with one fallopian tube, a woman’s fertility is well preserved and they can have children afterwards.

It is therefore important that an ectopic pregnancy is caught early enough, when the fallopian tube can be spared through non-surgical treatment options.

Treatment options include:

Medical management: Approximately one-third of women with ectopic pregnancies can be treated with a medication called methotrexate, which stops the growth of the embryo. It is given as an injection. After the injection, the woman may experience abdominal pain or cramps, which can be managed by painkillers. 

The pregnancy hormone known as BHCG levels is monitored after treatment, on specific days, until the level has fallen to negative. Some women may need additional methotrexate injections. 

Surgical management: Surgery is indicated if the ectopic pregnancy is ruptured, if the patient does not meet the set criteria for medical treatment, in the rare situations of a heterotopic pregnancy, if the patient is unable or unwilling to return for monitoring after methotrexate treatment and in case of a failed medical treatment. 

During surgery, the pregnancy is removed alongside the fallopian tube. Sometimes it might be possible to remove the ectopic pregnancy alone and spare the fallopian tube, but this is rare.

Occasionally, the patient may need additional methotrexate injection, even after the surgery, if some remnants of the pregnancy could not be fully removed surgically.

How do I prevent an ectopic pregnancy?

If you have had an ectopic pregnancy in the past, it is important that you do a prompt pregnancy test and ultrasound scan to confirm the position of a new pregnancy. 

If you have had medical treatment, pregnancy must be avoided for at least three months due to the dangerous effects methotrexate has on a growing foetus. 

Avoiding high risk sexual partners or multiple sex partners in order to prevent sexually transmitted infections. 

Prompt treatment of sexually transmitted infections is also important. Unfortunately, STIs are asymptomatic/quiet and may go unnoticed for a long time, hence a delay in diagnosis and treatment, resulting in complications such as tubal blockage.

Dr Okemo is a consultant obstetrician Gynaecologist at Aga Khan University Hospital, Nairobi