Normally fertilized egg implants in the lining of uterus but if implantation occurs anywhere else, it is called an ectopic pregnancy. Almost one in 50 pregnancies is an ectopic pregnancy. The most common site for an ectopic pregnancy is the fallopian tube, in rare cases ectopic pregnancy can occur in ovary, abdomen or cervix
Risk factors for ectopic pregnancy:
There are a number of risk factors for tubal damage and dysfunction
Previous tubal surgery
Previous Ectopic Pregnancy
Pelvic inflammatory diseases
Peritubal adhesions subsequent to post abortal infection or peripheral infection.
Rates of ectopic pregnancy increase following invitrofertilization. Ectopic Pregnancy accounts for 10% of pregnancy related deaths and it is the most common cause of maternal mortality in the first trimester. Fallopian tubes cannot sustain pregnancy like the uterus, if it is not diagnosed in early stages it can lead to tubal rupture.
How to detect an ectopic pregnancy?
If any patient presents with pain, bleeding and positive pregnancy test, vaginal sonography is a logical first step. If an intra uterine gestation sac is present, ectopic pregnancy is extremely unlikely, heterotypic pregnancy (both uterine and extra uterine pregnancy) is the rare exception. Presence of an empty uterus and visualization of an adrenal mass separate from ovaries and the presence of free fluid in pelvis is suggestive of an Ectopic pregnancy. An empty uterus with BHCG>1500 miu/ml is 100% accurate excluding intrauterine pregnancy.
Management of ectopic pregnancy can be based upon BHCg level and vaginal sonography. If patient is diagnosed with ruptured ectopic pregnancy and also if woman is hemodynamically unstable, patient should undergo prompt surgical therapy. Surgical management includes salpingostomy if ectopic pregnancy is small ( <2cm in length) and is located in distal third of fallopian tube.
What is Salpingectomy and how can ectopic pregnancies be medically managed ?
It is the removal of fallopian tubes. It is the treatment of choice when there are no chances of tube salvage. Medical management of ectopic pregnancy with methotrexate has 90% success rate in the treatment of unruptured ectopic pregnancy .Methotrexate is highly effective against rapidly proliferating trophoblast. . Acute intraabdominal hemorrhage is a contraindication for medical management.
Success with medical management is greatest if:
Gestation is less than 6 weeks
Tubal mass not more than 3.5 cm in diameter
Fetus is dead
BHCg less than 15000 IU/ml
Methotrexate injection can be given in single dose of 50 mg/m2 (body surface) or in multiple dosage regimes – methotrexate alternate with folinic acid with maximum of 4 doses.
Contraindications of Methotrexate include – breast feeding, immunodeficiency, liver or renal disease, blood dyscrasias, active pulmonary disease and peptic ulcer. Complete hemoglobin count, liver function test, renal function test should be done before starting medical management.
Efficacy of medical management is monitored by declining serum BHCg levels. Average time taken to resolution is around 30 days .Failure is judged when BHCg levels plateau or rises or tubal rupture occurs. Approximately 5 to 15% of women treated with systemic Methotrexate required surgery. Patients chosen for Methotrexate injection should be instructed to report hospital immediately if they experience any sign and symptoms of tubal rupture such as abdominal pain, dizziness and syncope.