Definition: The implantation and development of pregnancy at a site other than the lining of the uterus is called ectopic pregnancy. The most common site of ectopic pregnancy is the fallopian tube but the cervix, ovary or abdominal cavity can also be involved. Such a pregnancy cannot developed normally and leads to potentially serious or life threatening complications, unless diagnosed and treated well in time.

Cause

There are many predisposing risk factors for ectopic pregnancy:-

• Previous infection of the tubes due to any cause e.g. Chlamydia, tuberculosis, sexually transmitted diseases etc.
• Peritubal adhesions due to post-abortal or post-partum infection, appendicitis, endometriosis or any surgery.
• Previous surgery on the fallopian tubes.
• Use of intra uterine contraceptive devices e.g. CuT, progestin only contraceptive pills, morning after emergency contraceptive pill.
• There is 7-15 % chance of repeat ectopic in patients with history of previous ectopic pregnancy.
• Increased incidence can be seen after assisted reproductive techniques and ovulation induction.
• Ectopic pregnancy can also occur in the absence of known predisposing factors.

Symptoms

Patient with ectopic pregnancy have stoppage of menses, a positive urine pregnancy test and early symptoms of pregnancy. Vaginal bleeding is seen in most cases varying from spotting to moderate bleeding.
In initial cases there may be mild dull lower abdominal pain. However, if the pregnancy leads to rupture of the tube, there is rapid collection of blood in the abdomen causing sudden severe pain and fainting. If untreated it leads to severe internal bleeding and shock with a severe fall in blood pressure which can even prove fatal.

Diagnosis

In a women with suspicious history of irregular bleeding and pain abdomen, diagnosis can be made by clinical / gynaecological examination combined with urine pregnancy test, blood test (b-hCG) and careful ultrasound evaluation.
A routine ultrasound done in early pregnancy in some patients can give a clue to diagnosis as there is absence of the early pregnancy sac in uterine cavity. Pregnancy in the tube can only be seen on ultrasound if it has grown big or has partially ruptured to form a mass.

Treatment

If the patient presents at a stage when bleeding from the ectopic pregnancy sac has started, treatment requires urgent hospitalization, intravenous fluids and surgical treatment. Most often surgery can be done by laparoscopy. During surgery, salpingectomy i.e. removal of the tube along with the pregnancy has to be done in cases of severe tubal damage or rupture. In early cases it is sometimes possible to remove the pregnancy through an incision in the tube and save the tube for future reproductive function.

In case the diagnosis is made at an early stage when symptoms have not started medical management can be tried. An injectable cytotoxic drug Methotrexate is given, which destroys the pregnancy which is eventually absorbed. The patient requires strict follow up with blood b-hCG levels and ultrasound examination till all evidence of pregnancy disappears.

Prevention

Prompt detection and early treatment of genital tract infections.
Early consultation with the gynecologist in cases of known risk factor history of ectopic pregnancy.