Luna explains : What Is An Ectopic Pregnancy ?

An ectopic pregnancy (EP) is defined as implantation of the fertilised egg outside the uterine cavity.

In a normal situation, during fertilisation, the sperm and egg meet in the fallopian tube and the fertilised egg then settles in the lining of the uterus (endometrium). In the case of an ectopic pregnancy, the fertilised egg will implant itself abnormally: either on the fallopian tube, and sometimes on the ovary or in the abdominal cavity or the cervix.

An ectopic pregnancy should be diagnosed as early as possible, as it cannot be carried to term and the egg grows rapidly. It represents a danger to the woman’s health.

The pregnancy must then be terminated and the egg removed as there is a risk that the fallopian tube will become distended and rupture, leading to bleeding into the abdominal cavity, which can lead to complications and/or subsequent infertility.

Sometimes ectopic pregnancies are unexplained. However, the risk of ectopic pregnancy may be increased in the following cases :

• Congenital anomaly of the fallopian tubes
• Fallopian tube abnormality due to a history of STIs, PID, or endometritis. PID is an infection of the fallopian tubes that may be caused by Chlamydia (the most common germ). This type of infection can damage the fallopian tubes, and in some cases obstruct them, preventing the passage of the fertilised egg into the uterine cavity.
• History of gynaecological surgery, such as tubal ligation (sterilisation technique), or tubal or abdominal-pelvic surgery (e.g. removal of the appendix)
• Endometriosis and other conditions that can affect the fallopian tubes
• Pregnancy with an IUD (the IUD does not prevent ovulation, so fertilisation is possible in rare cases) or microprogesterone contraception
• Pregnancy obtained by In Vitro Fertilisation (so-called “ectopic” pregnancies or pregnancies with anomalies occur in 4.5% of pregnancies obtained by In Vitro Fertilisation). In this particular case, it is also possible to evoke a heterotopic pregnancy, i.e. two pregnancies developing simultaneously: an intrauterine pregnancy and an ectopic, extrauterine pregnancy.
• Smoking
• High age of the patient

The symptoms of an ectopic pregnancy are similar to those of a “normal” pregnancy :

• Delayed or no menstruation
• Nausea
• Bloating
• Breast pain
• However, there are specific symptoms of an ectopic pregnancy that should raise a red flag:
• Irregularities in the last period
• Vaginal bleeding outside the menstrual period (metrorrhagia), generally not very abundant and dark in colour
• Abdominal pain, more pronounced on one side than the other
• Pain in the shoulder blades
• Agitation, stress, anxiety

If the fallopian tube ruptures, the symptoms are more serious: heavy bleeding, intense abdominal pain, fainting, loss of consciousness…

If these symptoms occur, you should seek urgent medical attention, because without early treatment, the risk of a rupture of the fallopian tube with intraperitoneal bleeding is increased.

A gynaecological examination is necessary in the first instance to suggest a diagnosis of uterine pregnancy. The midwife or gynaecologist will look for :

• A uterus that is less voluminous than the age of the pregnancy would suggest
• Localized pelvic pain on the side of the ectopic pregnancy
• Tenderness in the cul-de-sac of Douglas (peritoneal membrane lining the abdominal cavity between the rectum and the uterus)
• The endo-uterine origin of the bleeding (if metrorrhagia)

The diagnosis is then confirmed by two examinations to be carried out urgently :

• An endovaginal abdominal-pelvic ultrasound to observe the uterine cavity, and determine whether it is empty, and to detect the presence of a mass in one of the tubes and the uterus.
• A blood test for the beta HCG hormone is necessary in addition to the ultrasound to make the diagnosis of an ectopic pregnancy.

If the beta HCG hormone is more than 1500 IU/L, and the uterus is empty, an EP is very likely.

If the level is below 1,500 IU/L and there are no serious signs, the test should be repeated 48 hours after the first test. In a “normal” pregnancy, the beta HCG hormone level should double in this time. In the case of a spontaneous miscarriage, however, it decreases. In the case of an EP, the beta HCG hormone level stagnates or does not increase significantly.

If there is any doubt about the diagnosis, and if the patient has severe clinical symptoms and signs, the doctor may consider laparoscopy to confirm or rule out an ectopic pregnancy.

The treatment of an ectopic pregnancy consists of removing the implanted egg.

Two methods can be used, depending on the age of the pregnancy:

1. If the pregnancy is early (beta HCG hormone level below 5000 IU/L) and the patient has no signs of severity and/or few symptoms, termination of the pregnancy can be considered by drug treatment: methotrexate. This treatment option requires extensive information to the patient regarding precautions and side effects, and if there are no medical contraindications and/or patient refusal.

2. If the pregnancy is advanced and/or the patient has severe clinical signs, the procedure is performed surgically. A laparoscopy is carried out, allowing not only the location of the pregnancy and the removal of the abnormally implanted egg, but also the identification of risk factors (adhesions, after-effects of IGH) for the EP.

• In all cases where this is possible, so-called conservative surgery is preferred: the uterine tube is incised (salpingotomy), and the egg aspirated allowing the tube to be preserved. If there is a desire for future pregnancy, this conservative treatment is preferred.
• In the event of excessive bleeding and/or if the fallopian tube is too damaged, the surgeon will remove the fallopian tube (salpingectomy). This operation is more common in older patients and/or those who no longer wish to have children. Any patient who is to undergo an operation for an EP should be informed of the risk of removal of the fallopian tube and its potential consequences before the operation.

An ectopic pregnancy (EP) may be responsible for a subsequent decrease in fertility, particularly if the patient is over 35 years old, and/or has a history of infertility, and/or factors that increase the risk (smoking, STIs).