ectopic pregnancy

Ectopic Pregnancy

Definition

In an ectopic pregnancy, the fertilized egg implants in a location outside the uterus and tries to develop there. The word ectopic means "in an abnormal place or position." The most common site is the fallopian tube, the tube that normally carries eggs from the ovary to the uterus. However, ectopic pregnancy can also occur in the ovary, the abdomen, and the cervical canal (the opening from the uterus to the vaginal canal). The phrases tubal pregnancy, ovarian pregnancy, cervical pregnancy, and abdominal pregnancy refer to the specific area of an ectopic pregnancy.

Description

Once a month, an egg is produced in a woman's ovary and travels down the fallopian tube where it meets the male's sperm and is fertilized. In a normal pregnancy the fertilized egg, or zygote, continues on its passage down the fallopian tube and enters the uterus in three to five days. The zygote continues to grow, implanting itself securely in the wall of the uterus. The zygote's cells develop into the embryo (the organism in its first two months of development) and placenta (a spongy structure that lines the uterus and nourishes the developing organism).In a tubal ectopic pregnancy, the fertilized egg cannot make it all the way down the tube because of scarring or obstruction. The fallopian tube is too narrow for the growing zygote. Eventually the thin walls of the tube stretch and may burst (rupture), resulting in severe bleeding and possibly the death of the mother. More than 95% percent of all ectopic pregnancies occur in the fallopian tube. Only 1.5% develop in the abdomen; less than 1% develop in the ovary or the cervix.

Causes and symptoms

As many as 50% of women with ectopic pregnancies have a history of pelvic inflammatory disease (PID). This is an infection of the fallopian tubes (salpingitis) that can spread to the uterus or ovaries. It is most commonly caused by the organisms Gonorrhea and Chlamydia and is usually transmitted by sexual intercourse.Other conditions also increase the risk of ectopic pregnancy. They include:

Endometriosis. A condition in which the tissue that normally lines the uterus is found outside the uterus, and can block a fallopian tube.

Exposure to diethylsilbestrol (DES) as a fetus. If a woman's mother took DES (a synthetic version of the hormone estrogen) during pregnancy, the woman may have abnormalities in her fallopian tubes that can make ectopic pregnancy more likely.
Taking hormones. Estrogen and progesterone are hormones that regulate the menstrual cycle and may be in medications prescribed by a doctor for birth control or other reasons. Taking these hormones can affect the interior lining of the fallopian tubes and slow the movement of the fertilized egg down the tube. Women who become pregnant in spite of taking some progesterone-only contraceptives have a greater chance of an ectopic pregnancy. Ectopic pregnancy is also more likely when the ovaries are artificially stimulated with hormones to produce eggs for in vitro fertilization (a procedure in which eggs are taken from a woman's body, fertilized, and then placed in the uterus in an attempt to conceive a child).
Use of an intrauterine device (IUD). These contraceptive devices are designed to prevent fertilized eggs from becoming implanted in the uterus, but they have only a minimal effect on preventing ectopic pregnancies. Therefore, if a woman becomes pregnant while using an IUD for contraception, the fertilized egg is more likely to be implanted someplace other than the uterus. For example, among women who become pregnant while using a progesterone-bearing IUD, about 15% have ectopic pregnancies.
Surgery on a fallopian tube. The risk of ectopic pregnancy can be as high as 60% after undergoing elective tubal sterilization, a procedure in which the fallopian tubes are severed to prevent pregnancy. Women who have successful surgery to reverse the procedure are also more likely to have an ectopic pregnancy.

Early symptoms

In an ectopic pregnancy all the hormonal changes associated with a normal pregnancy may occur. The early symptoms include: fatigue; nausea; a missed period; breast tenderness; low back pain; mild cramping on one side of the pelvis; and abnormal vaginal bleeding, usually spotting.

Later symptoms

As the embryo grows too large for the confined space in the tube, the first sign that something is wrong may be a stabbing pain in the pelvis or abdomen. If the tube has ruptured, blood may irritate the diaphragm and cause shoulder pain. Other warning signs are lightheadedness and fainting.

Diagnosis

To confirm an early diagnosis of ectopic pregnancy, the doctor must determine first that the patient is pregnant and that the location of the embryo is outside the uterus. If an ectopic pregnancy is suspected, the doctor will perform a pelvic examination to locate the source of pain and to detect a mass in the abdomen.Several laboratory tests of the patient's blood provide information for diagnosis. Measurement of the human chorionic gonadotropin (hCG) level in the patient's blood serum is the most useful laboratory test in the early stages. In a normal pregnancy, the level of this hormone doubles about every two days during the first 10 weeks. In an ectopic pregnancy, the rate of the increase is much slower and the low hCG for the stage of the pregnancy is a strong indication that the pregnancy is abnormal. (It could also represent a miscarriage in progress.) The level is usually tested several times over a period of days to determine whether or not it is increasing at a normal rate.Progesterone levels in the blood are also measured. Lower than expected levels can indicate that the pregnancy is not normal.An ultrasound examination may provide information about whether or not the pregnancy is ectopic. A device called a transducer, which emits high frequency sound waves, is moved over the surface of the patient's abdomen or inserted into the vagina. The sound waves bounce off of the internal organs and create an image on a screen. The doctor should be able to see whether or not there is a fetus developing in the uterus after at least five weeks of gestation. Before that point, a normal pregnancy is too small to see.A culdocentesis may also help confirm a diagnosis. In this procedure a needle is inserted into the space at the top of the vagina, behind the uterus and in front of the rectum. Blood in this area may indicate bleeding from a ruptured fallopian tube.A laparoscopy will enable the doctor to see the patient's reproductive organs and examine an ectopic pregnancy. In this technique, a hollow tube with a light on one end is inserted through a small incision in the abdomen. Through this instrument the internal organs can be observed.

Treatment

Ectopic pregnancy requires immediate treatment. The earlier the condition is treated, the better the chance to preserve the fallopian tube intact for future normal pregnancies.

In an ectopic pregnancy, the fertilized egg implants in a location outside the uterus and attempts to develop at that site. The most common site of an ectopic pregnancy is the fallopian tube, but it can occur in the ovary, the abdomen, and the cervical wall. More than 95% of all ectopic pregnancies occur in the fallopian tube. (Illustration by Electronic Illustrators Group.)

Medical

If the ectopic pregnancy is discovered in a very early stage of development, the drug methotrexate may be given. The best results are obtained when the pregnancy is less than six weeks old and the tubal mass is no more than 1.4 in (3.5 cm) in diameter. Methotrexate, which has been used successfully since 1987, works by inhibiting the growth of rapidly growing cells. (It is also used to treat some cancers.) Most side effects are mild and temporary, but the patient must be monitored after treatment. Usually the medication is injected into the muscle in a single dose, but may also be given intravenously or injected directly into the fallopian tube to dissolve the embryonic tissue. Methotrexate has also been used to treat ovarian, abdominal, and cervical pregnancies that are discovered in the early stages.

Surgical

When a laparoscopy is done to visualize the ectopic pregnancy, the scope can be fitted with surgical tools and used to remove the ectopic mass immediately after it is identified. The affected fallopian tube can be repaired or removed as necessary. This procedure can be done without requiring the patient to stay in the hospital overnight.When the pregnancy has ruptured, a surgical incision into the abdomen, or laparotomy, is performed to stop the immediate loss of blood and to remove the embryo. This usually requires general anesthesia and a hospital stay. Every effort is made to preserve and repair the injured fallopian tube. However, if the fallopian tube has already ruptured, repair is extremely difficult and the tube is usually removed.

Alternative treatment

Ectopic pregnancy was first described in the eleventh century and was a potentially fatal condition until the advent of surgery and blood transfusions in the early twentieth century. The sophisticated diagnostic tools and surgical procedures developed since the 1970s have equipped modern medicine with the tools to not only save a woman's life, but also to preserve her future fertility.

Key terms

Embryo — In humans, the developing organism from conception until approximately the end of the second month.Fallopian tube — The tube that carries the egg from the ovary to the uterus.Human chorionic gonadotropin (hCG) — A hormone excreted during the development of an embryo or fetus.Laparoscopy — Examination of the contents of the abdominal cavity with a fiberoptic tube inserted through a small incision.Laparotomy — Surgical incision into the abdomen to locate, repair, and/or remove injured or diseased tissues.Pelvic inflammatory disease (PID) — Acute or chronic inflammation in the pelvic cavity, particularly inflammation of the fallopian tubes (salpingitis) and its complications.Rupture — A breaking apart of an organ or tissue.Salpingitis — Inflammation of the fallopian tube.Tubal pregnancy — Pregnancy in one of the fallopian tubes.Zygote — The fertilized egg.Although there are herbal remedies for the temporary relief of the common symptoms of anxiety and abdominal discomfort, prompt medical treatment is the only sure remedy for ectopic pregnancy.

Prognosis

Ectopic pregnancies are the leading cause of pregnancy-related deaths in the first trimester and account for 9% of all pregnancy-related deaths in the United States. More than 1% of pregnancies are ectopic, and they are becoming more common. The reason for this increase is not clearly understood, though it is thought that the dramatic increase in sexually transmitted diseases (STD) is at least partly responsible.The earlier an ectopic pregnancy is diagnosed and treated, the better the outcome. The chances of having a successful pregnancy are lower after an ectopic pregnancy, but depend on the extent of permanent fallopian tube damage. If the tube has been spared, chances are as high as 60%. The chances of a successful pregnancy after the removal of one tube are 40%.

Prevention

Many forms of ectopic pregnancy cannot be prevented. However, tubal pregnancies, which make up the majority of ectopic pregnancies, may be prevented by avoiding conditions that cause damage to the fallopian tubes. Since half of all women who experience ectopic pregnancy have a history of PID, avoiding this infection or getting early diagnosis and treatment for sexually transmitted diseases will decrease the risk of a future problem.

Resources

Organizations

Resolve. 1310 Broadway, Somerville, MA 02144-1731. (617) 623-0744. http://www.resolve.org.

pregnancy

[preg´nan-se] the condition of having a developing embryo or fetus in the body, after union of an oocyte (ovum) and spermatozoon" >spermatozoon. The average gestation period" >gestation period for a human pregnancy is 10 lunar months (280 days) from the first day of the last menstrual period.Conception. Once a month an ovum (secondary oocyte) matures in one of the ovaries" >ovaries and travels down the nearby fallopian tube" >fallopian tube to the uterus" >uterus; this process is called ovulation" >ovulation. Fertilization" >At Fertilization, which must take place within a day or two of ovulation, one of the spermatozoa unites with the ovum to form a zygote. The zygote then implants itself in the wall of the uterus, which is richly supplied with blood, and begins to grow. (See also reproduction.)Signs of Pregnancy. Usually the first indication of pregnancy is a missed menstrual period. Unless the period is more than 10 days late, however, this is not a definite indication, since many factors, including a strong fear of pregnancy, can delay menstruation. Nausea, or morning sickness, usually begins in the fifth or sixth week of pregnancy. About 4 weeks after conception, changes in the breasts become noticeable: there may be a tingling sensation in the breasts, the nipples enlarge, and the areolae (dark areas around nipples) may become darker. Frequent urination, another early sign, is the result of expansion of the uterus, which presses on the bladder.
Other signs of pregnancy include softening of the cervix and filling of the cervical canal with a plug of mucus. Early in labor this plug is expelled and there is slight bleeding; expulsion of the mucous plug is known as show" >show and indicates the beginning of cervical dilatation. chadwick's sign" >chadwick's sign of pregnancy refers to a bluish color of the vagina which is a result of increased blood supply to the area.
When the abdominal wall becomes stretched there may be a breaking down of elastic tissues, resulting in depressed areas in the skin which are smooth and reddened. These markings are called striae gravidarum" >striae gravidarum. In subsequent pregnancies the old striae appear as whitish streaks and frequently do not disappear completely.
There are several fairly accurate laboratory tests for pregnancy; all are designed to detect human gonadotropin" >chorionic gonadotropin (hCG), a hormone produced by living chorionic placental tissue and evident in the blood and urine of pregnant women. See also pregnancy tests.Growth of the Fetus. The average pregnancy lasts about 280 days, or 40 weeks, from the date of conception to childbirth. Since the exact date of conception usually is not known, the estimated date of delivery can be calculated using nägele's rule. This is approximate, since pregnancy may be shorter than the average or can last as long as 300 days. (For stages of growth of the fetus, see fetus.)Care of the Fetus. A host of influences can adversely affect the growth and development of the fetus and his or her chances for survival and good health after birth. The diet of the mother should be nutritious and well-balanced so that the fetus receives the necessary food elements for development and maturity of body structures. It is especially important that the mother receive adequate protein in her diet, because a protein deficiency can hamper fetal intellectual development. Supplemental iron and vitamins usually are recommended during pregnancy.
There is now less emphasis on severe restriction of the mother's dietary intake to maintain a limited weight gain. The average gain is about 28 lb during pregnancy, and either starvation diets or forced feedings can be unhealthy for the mother and hazardous for the fetus. Ideally, the mother should achieve normal weight before she becomes pregnant because obesity increases the possibility of eclampsia and other serious complications of pregnancy. Mothers who are underweight are more likely to deliver immature babies who, by virtue of their physiologic immaturity, are more likely to suffer from birth defects, hyaline membrane disease, and other developmental disorders of the newborn.
Other factors affecting the fetus include certain drugs taken by the mother during pregnancy. A well-known example is thalidomide, which inhibits the growth of the extremities of the fetus, resulting in gross deformities. Many drugs, including prescription as well as nonprescription medications, are now believed to be capable of causing fetal abnormalities. In addition, consumption of alcohol during pregnancy may result in fetal alcohol syndrome. Most health care providers recommend that all drugs be avoided during pregnancy except those essential to the control of disease in the mother.
Diseases that increase the risk of obstetrical complications include diabetes, heart disease, hypertension, kidney disease, and anemia. rubella" >rubella (German measles) can be responsible for many types of birth defects, particularly if the mother contracts it in the first 3 months of pregnancy. Sexually transmitted diseases can have tragic effects on the baby, even though the symptoms in the mother are minor at the time of pregnancy. syphilis is particularly dangerous because it is one of the few diseases that can be transmitted to the fetus in utero. The baby is either stillborn or born infected, and rarely escapes physical or mental defects or both. Successful treatment of the mother before the fifth month of pregnancy will prevent infection in the infant.
During the birth process the infant may be infected with gonorrhea as it passes through the birth canal. Gonorrheal infection of the eyes can cause blindness. herpes simplex Type II involving the genitals of the mother can also be transmitted to the infant at birth. The mortality and morbidity rates for such infected infants are high.
The age of the mother is also an important factor in the well-being of the fetus. The mortality and morbidity rate for infants born of mothers below age 15 and above 40 are higher than for those of mothers between these ages.
Recently developed tests to monitor fetal health have taken much of the guesswork out of predicting the chances of survival and health status of the fetus after birth. Such tests and evaluation techniques include amniocentesis, chemical and hormonal assays, biophysical profiles, testing for alpha-fetoprotein, ultrasound examinations, electronic surveillance of fetal vital signs and reaction to uterine contractions, and analyses of the infant's blood during labor.Prenatal Care. The care of the mother during her entire pregnancy is important to her well-being and that of the fetus she is carrying. It will help provide ease and safety during pregnancy and childbirth. The health care provider learns about the patient's physical condition and medical history, and can detect possible complications before they become serious.
On the first prenatal visit the patient's medical history is taken in considerable detail, including any diseases or operations she has had, the course of previous pregnancies, if any, and whether there is a family history of multiple births or of diabetes mellitus or other chronic diseases. The first visit also includes a thorough physical examination and measurement of the pelvis. Blood samples are taken for screening for rubella and sexually transmitted diseases such as syphilis, hepatitis B, chlamydiosis, infection by the human immunodeficiency virus, and other conditions. A complete blood count is also needed. Urine is tested for albumin and sugar and examined microscopically. On subsequent visits the patient brings a urine specimen, collected upon arising that morning, to be tested for albumin and glucose. At each prenatal visit her blood pressure is taken and recorded and she is weighed. In the second trimester, when the uterus becomes an abdominal organ, the height of the fundus is measured at each visit. After the sixth month a rule such as mcdonald's rule can be applied to assess fetal growth.
Patients who are considered high-risk mothers usually are sent to a specialist and the infant is delivered at a regional hospital where sophisticated monitoring equipment and laboratory tests are available, and specially trained personnel can attend to the needs of the mother and her infant.Discomforts and Complications.morning sickness usually appears in the early months of pregnancy and rarely lasts beyond the third month. Often it requires no treatment or can be relieved by such simple measures as eating dry crackers and tea before rising. Indigestion and heartburn are best prevented by avoiding foods that are difficult to digest, such as cucumbers, cabbage, cauliflower, spinach, onions, and rich foods. Constipation usually can be corrected by diet or a mild laxative; strong laxatives should not be used unless prescribed by the health care provider.
A visit to a dentist early in pregnancy is a good idea to forestall any possibility of infection arising from tooth decay. Pregnancy does not encourage tooth decay. Hemorrhoids sometimes occur in pregnancy because of pressure from the enlarged uterus on the veins in the rectum. The health care provider should be consulted for treatment. varicose veins also result from pressure of the uterus, which restricts the flow of blood from the legs and feet. Lying flat with the feet raised on a pillow several times a day will help relieve swelling and pain in the legs. In more difficult cases the health care provider may prescribe an elastic bandage or support stockings.
Backache during pregnancy is caused by the heavy abdomen pulling on muscles that are not normally used, and can be relieved by rest, sensible shoes, and good posture. Swelling of the feet and ankles usually is relieved by rest and by remaining off the feet for a day or two. If the swelling does not disappear, the health care provider should be informed since it may be an indication of a more serious complication.
Shortness of breath is common in the later stages of pregnancy. If at any time it becomes so extreme that the woman cannot climb a short flight of stairs without discomfort, the health care provider should be consulted. If a mild shortness of breath interferes with sleep, lying in a half-sitting position, supported by several pillows, may help.
The more serious complications of pregnancy include pyelitis, hyperemesis gravidarum, eclampsia, and placenta previa and abruptio placentae.

Uterine levels in pregnancy.abdominal pregnancy ectopic pregnancy within the peritoneal cavity.ampullar pregnancy ectopic pregnancy in the ampulla of the fallopian tube.cervical pregnancy ectopic pregnancy within the cervical canal.combined pregnancy simultaneous intrauterine and extrauterine pregnancies.cornual pregnancy pregnancy in a horn of the uterus.ectopic pregnancy pregnancy in which the fertilized ovum becomes implanted outside the uterus instead of in the wall of the uterus; this is almost always in a fallopian tube (tubal pregnancy), although occasionally the ovum develops in the abdominal cavity, ovary, or cervix uteri. Called also extrauterine pregnancy.
In a tubal pregnancy a spontaneous abortion may occur, but more often the fetus will grow to a size large enough to rupture the tube. This is an emergency situation requiring immediate treatment. The symptoms of such a tubal rupture are vaginal bleeding and severe pain in one side of the abdomen. Prompt surgery is necessary to remove the damaged tube and the fetus, and to stop the bleeding. Fortunately, the removal of one tube usually leaves the other one intact, so that future pregnancy is possible. Patients who are Rh-negative should be given Rh₀ (D) immune globulin (RhoGAM) after ectopic pregnancy for isoimmunization protection in future pregnancies.

Ectopic pregnancy. The fallopian tube is the most common site for ectopic pregnancies but they can also occur on the ovary or the peritoneal surface of the abdominal cavity. From Damjanov, 2000.extrauterine pregnancy ectopic pregnancy.false pregnancy development of all the signs of pregnancy without the presence of an embryo; called also pseudocyesis and pseudopregnancy.interstitial pregnancy pregnancy in that part of the fallopian tube within the wall of the uterus.intraligamentary pregnancy (intraligamentous pregnancy) ectopic pregnancy within the broad ligament.molar pregnancy conversion of the fertilized ovum into a mole.multiple pregnancy the presence of more than one fetus in the uterus at the same time.mural pregnancy interstitial pregnancy.ovarian pregnancy pregnancy occurring in an ovary.phantom pregnancy false pregnancy due to psychogenic factors.surrogate pregnancy one in which a woman other than the female partner is artificially impregnated with the male partner's sperm. The resultant child represents only the male of the marital unit, and may be adopted by the female.pregnancy tests procedures for early determination of pregnancy. By the first missed menstrual period or shortly thereafter, human chorionic gonadotropin (hCG), a hormone secreted by the placenta, is present in the blood and urine of a pregnant woman. It was formerly determined by bioassay in which a urine or serum specimen was injected into a laboratory animal and the response of ovarian tissue was noted. All testing now uses immunologic techniques based on antigen-antibody binding between hCG and anti-hCG antibody. There are several commercial kits available (see early pregnancy tests), based on the agglutination of hCG-coated latex particles by anti-hCG serum, which is inhibited if the urine specimen added to the serum contains hCG. Clinical laboratories generally use radioimmunoassay or radioreceptor assay to determine serum hCG levels. These methods are more accurate and less likely to produce false-positive results.tubal pregnancy the most common type of pregnancy" >ectopic pregnancy, occurring within a fallopian tube" >fallopian tube.tuboabdominal pregnancy ectopic pregnancy occurring partly in the fimbriated end of the fallopian tube and partly in the abdominal cavity.tubo-ovarian pregnancy pregnancy at the fimbriae of the fallopian tube.

ec·top·ic preg·nan·cy

the implantation and development of a blastocyst outside the cavity of the uterus. Synonym(s): eccyesis, extrauterine pregnancy, heterotopic pregnancy, paracyesis

ectopic pregnancy

n. Implantation and subsequent development of a fertilized ovum outside the uterus, as in a fallopian tube.

ectopic pregnancy

Ectopic gestation Obstetrics The implantation of a fertilized outside of the uterus–eg, fallopian tube, ovary, peritoneum, and other tissues not designed to accommodate the vasculature required by a growing fetus Clinical Lower abdominal pain, vomiting, amenorrhea Management Surgery

ec·top·ic preg·nan·cy

(ek-top'ik preg'năn-sē) The development of an impregnated oocyte outside the cavity of the uterus.
Synonym(s): eccyesis.

SITES FOR ECTOPIC PREGNANCY

ectopic pregnancy

Extrauterine implantation of a fertilized ovum, usually in the fallopian tubes, but occasionally in the peritoneum, ovary, or other locations. Ectopic implantation occurs in about 1 of every 150 pregnancies. Symptoms usually occur between 6 and 12 weeks after conception. Synonym: extrauterine pregnancy See: illustration; pregnancy

Symptoms

Early complaints are consistent with those of a normal pregnancy (i.e., amenorrhea, breast tenderness, nausea). Pregnancy test results are positive owing to the presence of human chorionic gonadotropin (hCG) in blood and urine. Signs and symptoms arise as the growing embryo distends the fallopian tube; associated complaints include intermittent, unilateral, colicky abdominal pain. Complaints associated with tubal rupture include sharp unilateral pelvic or lower abdominal pain; orthostatic dizziness and vertigo or syncope; and referred shoulder pain related to peritoneal irritation from abdominal bleeding (hemoperitoneum). Signs of hypovolemic shock may indicate extensive abdominal bleeding. Vaginal bleeding, typically occurring after the onset of pain, is the result of decidual sloughing.

Locations

Abdominal: The incidence of pregnancy in the abdominal cavity with the conceptus attached to an abdominal organ is between 1:3000 and 1:4000 births. Ovarian: Conception and implantation within the ovary itself occurs in approximately 1 in 7,000 to 1 in 50,000 pregnancies. Tubal: Ninety to 95% of ectopic pregnancies occur in the fallopian tube; of these, 78% become implanted in the uterine ampulla, 12% in the isthmus, and 2% to 3% in the interstices.

Diagnosis

Transabdominal or transvaginal pelvic ultrasonography is used to identify the location of the pregnancy. It has also largely replaced culdocentesis for confirmation of hemoperitoneum.

Treatment

An operative approach is most common. Laparoscopy and linear laser salpingostomy can be used to excise early ectopic implantations; healing is by secondary intention. Segmental resection allows salvage and later reconstruction of the affected tube. Salpingectomy is reserved for cases in which tubal damage is so extensive that reanastomosis is not possible. Methotrexate has been used successfully to induce dissolution of unruptured tubal masses less than 3.5 cm. Posttreatment monitoring includes serial quantitative b-hCG levels, to be certain that the pregnancy has ended.

Patient care

Preoperative: The patient is assessed for pain and shock. Vital signs are monitored and oxygen administration by nonrebreather mask is started. An IV fluid infusion via a large-bore cannula is started and blood is drawn to type and cross (including Rh-compatibility) for potential transfusion. Medications (including RhoGAM if the patient is Rh negative) may be prescribed and administered and the patient's response evaluated. The patient's and family's wishes regarding religious rites for the products of conception are determined. Both patient and family are encouraged to express their feelings of fear, loss, and grief. Information regarding the condition and the need for surgical intervention is clarified.

Postoperative: Vital signs are monitored until stable, incisional dressings are inspected, vaginal bleeding is assessed, and the patient's physical and emotional reactions to the surgery are evaluated. Prescribed analgesics and other medications are administered, and the patient evaluated for desired and adverse effects. The grieving process is anticipated, and both the patient and family are referred for further counseling as needed.

ectopic pregnancy

A dangerous complication of pregnancy in which the fertilized egg (ovum) becomes implanted in an abnormal site, such as the FALLOPIAN TUBE or in the pelvis or abdomen, instead of in the womb lining. The great danger is severe, and sometimes life-threatening, bleeding (haemorrhage). Treatment is by urgent operation to remove the growing embryo. This is now mainly done by laparoscopic surgery.

Ectopic Pregnancy

DRG Category:	777
Mean LOS:	2.3 days
Description:	MEDICAL: Ectopic Pregnancy

An ectopic pregnancy is an implantation of the blastocyst (a solid mass of cells formed by rapid mitotic division of the zygote that eventually form the embryo) in a site other than the endometrial lining of the uterus. It is the leading cause of maternal death in the first trimester of pregnancy. In more than 95% of ectopic pregnancies, this implantation occurs somewhere in the fallopian tubes, hence the term “tubal pregnancy.” The fallopian tube lacks a submucosal layer, which allows the ovum to burrow through the epithelium. Fertilization occurs, and the zygote lies within the muscular wall of the tube, drawing its blood supply from maternal vessels. The ampullary portion of the tube is the most common site (80%), followed by the isthmic portion (12%) and the fimbria (5%). The cornual and interstitial regions of the tube have lower (2%) prevalence but a higher risk of mortality. Nontubal sites are more rare and include abdominal, ovarian, and cervical locations.

After the blastocyst implants in the tube, it begins to grow and can cause bleeding into the abdominal cavity. Eventually, the ovum becomes too large and the tube can rupture, causing further bleeding that can lead to shock and maternal death. Ectopic pregnancies occur in approximately 25 per 1,000 pregnancies, and non-European Americans have a 1.4 times increased risk over European Americans. Heterotopic pregnancies, in which there is an ectopic and a uterine pregnancy at the same time, occur at a rate of 1:10,000. The frequency of ectopic pregnancy has increased four-fold since 1970, owing to the increase in sexually transmitted infections (STIs), better diagnostic techniques, increased use of artificial reproductive technology, and increased use of tubal surgeries to treat infertility. Ectopic pregnancy accounts for 3% to 4% of all pregnancy-related deaths and reduces a woman’s chance of future pregnancy because of tubal damage; approximately one-third of women who experience an ectopic pregnancy subsequently give birth to a live infant. Hemorrhage, peritonitis, and infertility are the main complications.

Causes

The major cause of ectopic pregnancy is tubal damage, which can result from pelvic inflammatory disease, previous pelvic or tubal surgery, or endometriosis. Other causes may be hormonal factors that impede ovum transport and mechanically stop the forward movement of the egg in the tube, congenital anomalies of the tube, and a blighted ovum. Pelvic infections and STIs, specifically chlamydia and gonorrhea, are often involved. Other risk factors include smoking, diethylbestrol exposure, T-shaped uterus, certain intrauterine devices (IUDs), and a ruptured appendix.

Genetic considerations

No clear genetic contributions to susceptibility have been defined.

Gender, ethnic/racial, and life span considerations

In the United States, ectopic pregnancy is most often seen in non-European American women over age 35. Women of all ancestries over 40 have three times the likelihood of ectopic pregnancy as compared to their younger counterparts. Aging may result in progressive loss of myoelectrical activity responsible for moving the egg through the fallopian tube. Also, ectopic pregnancy often occurs in teens who have engaged in high-risk sexual practices that have resulted in frequent pelvic infections. African American teenagers and teenagers of other minority races have a mortality rate almost five times higher from ectopic pregnancy than white teenagers.

Global health considerations

In developing countries, deaths from ectopic pregnancy are 10 times higher than those reported in developed countries. Several reasons may contribute to this disparity, including increased prevalence due to untreated sexual transmitted infections and lack of prompt identification and intervention when an ectopic pregnancy occurs.

Assessment

History

Women in their childbearing years, including teens, should be evaluated for an ectopic pregnancy any time they are evaluated for abdominal pain, cramping, or vaginal bleeding. Elicit a history about the onset of menses, gynecological disorders, pattern of sexual practices and birth control, and past pregnancies. Patients with an ectopic pregnancy often have some history of tubular damage as a result of infections or endometriosis. They may also have had tubal surgeries. Often, patients describe a history of using an IUD, and some may report a history of infertility. Question the patient about her last menstrual period to determine the onset, duration, amount of bleeding, and whether it was a “normal” period for her. This description is important because although amenorrhea may be present in many cases of ectopic pregnancy, uterine bleeding that occurs with ectopic pregnancy may be mistaken for a menstrual period. In addition to amenorrhea, the patient may exhibit other signs of pregnancy, such as breast tenderness, nausea, and fatigue.

Physical examination

The most common symptoms include abdominal pain, amenorrhea, and vaginal bleeding. An undocumented ectopic pregnancy is a life-threatening emergency. Assess vaginal bleeding for the amount, color, and odor; if none is noted, bleeding may be concealed. Bleeding can occur as vaginal spotting, as a “slow leak,” or as a massive hemorrhage depending on the gestational age and whether the tube has ruptured. Usually, the bleeding is slow, and the abdomen can become rigid and tender. Sometimes, vaginal bleeding is present with the death of the embryo. If internal hemorrhage is profuse, the woman experiences signs and symptoms of hypovolemic shock (restlessness, agitation, confusion, cold and clammy skin, increased respirations and heart rate, delayed capillary blanching, hypotension).

Evaluate the patient’s pain; it can range from a feeling of fullness in the rectal area and abdominal cramping to excruciating pain. Often, the pain is one-sided and increases when the cervix is moved during a vaginal examination. Some women do not feel any pain until the tube is about to rupture, usually at the third month of gestation. If the tube ruptures, the woman experiences sharp, one-sided, lower abdominal pain and syncope. The pain may radiate to the shoulders and neck and is aggravated by situations that cause increased abdominal pressure, such as lifting or having a bowel movement.

Psychosocial

Often, the patient experiences anger, grief, guilt, and self-blame over the loss of the fetus. She may also be anxious about her ability to conceive in the future. Because much of her anxiety may stem from lack of information about her condition, assess her learning needs. Determine the ability of the father and other family members to cope and support the patient.

Diagnostic highlights

General Comments: Diagnosis is based on a positive pregnancy and inability to visualize the embryo in the uterus. Have a high index of suspicion for any female patient in her reproductive years who reports abdominal pain, cramping, or vaginal bleeding. All these females should be screened for ectopic pregnancy.

Test	Normal Result	Abnormality With Condition	Explanation
Transvaginal ultrasonography	Intrauterine gestational sac is visualized	Unable to visualize intrauterine sac	This result, combined with a positive pregnancy test (elevated hCG), confirms the diagnosis
Human chorionic gonadotropin (hCG)	Normally is not present in nonpregnant women	The level is above the discriminatory zone of 1,500 mIU	hCG doubles every 2 days during the first 40 days of pregnancy; failure to do so is evidence of abnormality
Progesterone level (not accurate if fertility drugs were used)	> 25 ng/L	< 5 ng/L (values between 5 and 25 are inconclusive)	Progesterone increases with normal pregnancy

Other Tests: Laparoscopic examination of the abdominal cavity (used only in confusing cases), color flow Doppler ultrasound (used in cases when the gestational sac is questionably empty), Rh antibody screen and blood type, complete blood count and coagulation studies, culdocentesis

Primary nursing diagnosis

Diagnosis

Anticipatory grieving related to the loss of a pregnancy

Outcomes

Coping; Family coping; Grief resolution

Interventions

Grief work facilitation; Perinatal death; Active listening; Presence

Planning and implementation

Collaborative

medical.

Medical management of a tubal pregnancy depends on the patient’s condition, fetus’s gestational age and size, and whether the fallopian tube has ruptured. If the tube is intact, the gestation is less than 6 weeks, the fertilized mass is less than 3.5 cm in diameter, and the patient is hemodynamically stable with normal liver and renal function, methotrexate, a chemotherapeutic agent that inhibits cell division, may be ordered. The patient must also be committed to coming in for follow-up appointments, which are critical to maternal well-being and assessing the effectiveness of treatment. Human chorionic gonadotropin (hCG) levels and fetal cardiac activity are monitored with methotrexate therapy; success of treatment is based on these two assessments (hCG should decrease 15% by day 4, and fetal cardiac activity should cease by day 7). If the tube is damaged or ruptured, surgical management is indicated immediately.

surgical.

Laparoscopic laser surgery is usually performed, but if the tube has already ruptured, a laparotomy may be indicated. A salpingectomy (removal of the tube), salpingostomy (incision and evacuation of tubal contents), salpingotomy (incision and closure of the tube), or segmental resection and anastomosis can be performed. The goal is to salvage the tube, especially in women who desire future pregnancy.

Postoperative care includes monitoring vital signs and observing for other signs of shock. Monitor the fluid intake and output as well and note the color and amount of vaginal bleeding. Observe the incision for any signs and symptoms of infection. Administer analgesics and assess the patient’s level of pain relief from the medication.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Methotrexate sodium (Folex) (leucovorin is also given with methotrexate if given over 4 days)	50 mg/m2 IM or 1 mg/kg IM days 1, 3, 5, 7	Antineoplastic, acts a folic acid antagonist	Inhibits the growth of the pregnancy by interfering with DNA, RNA, and protein synthesis
Analgesics	Varies by drug	Narcotics, NSAIDs; drug used depends on the level of pain	Relieve pain
RhoD immunoglobulin (RhoGAM)	120–300 μg IM one time	Immune serum	Given only if mother is Rh-negative and father is Rh-positive; prevents the antigen-antibody response leading to Rh isoimmunization in future pregnancies

Independent

Provide emotional support, using therapeutic communication techniques to relieve the patient’s anxiety. Emotional support of this patient is important because the termination of any pregnancy causes a host of psychological and physiological changes. Inform the patient of perinatal grief support groups.

The patient may be concerned about infertility. Provide information and clarify the physician’s explanations if needed. If necessary, provide a referral for a clinical nurse specialist or counselor.

Evidence-Based Practice and Health Policy

Karhus, L.L., Egerup, P., Skovlund, C.W., & Lidegaard, O. (2013). Long-term reproductive outcomes in women whose first pregnancy is ectopic: A national controlled follow-up study. Human Reproduction, 28(1), 241–246.

Future fertility may be compromised in women who have ectopic pregnancies.
Investigators conducted a retrospective study among a sample of 2,917 women whose first pregnancies were ectopic and compared them to a cohort of age-matched women who had first pregnancies within the same year. Findings revealed that women with ectopic pregnancies had a lower long-term rate of successful delivery (69 per 100 pregnancies) over a mean follow-up period of 23.2 years.
Women whose first pregnancy was ectopic were 4.7 times more likely (95% CI, 3.8 to 5.8) to have future ectopic pregnancies and 45% less likely (95% CI, 0.52 to 0.58) to deliver future pregnancies successfully than the comparison cohort.

Documentation guidelines

Physical responses: Amount and character of blood loss, vital signs, abdominal assessment (presence and description of pain, response to analgesics)
Serial laboratory values: Hemoglobin and hematocrit, coagulation profile, white blood cell count; results of Rh test
Response to treatments: Surgery, laparoscopy, fluid or blood replacement, medications
Emotional status and coping abilities, partner’s response
Presence of complications: Hemorrhage, hypovolemic shock, infection

Discharge and home healthcare guidelines

patient teaching.

If the patient is receiving methotrexate on an outpatient basis, teach her that more severe pain may indicate treatment failure and that she needs to notify the physician. She should not drink alcohol or take vitamins containing folic acid. She may experience anorexia, nausea and vomiting, mouth ulcers, and sensitivity to sunlight as side effects of methotrexate. She also needs to follow up with scheduled hCG testing.

If a salpingectomy was done, explain to the patient that becoming pregnant again may be difficult. Fertilization takes place only on the side of the remaining tube after ovulation of the ovary on the same side. If a tubal repair was done, the patient is at a higher risk for a subsequent ectopic pregnancy as well as infertility. Educate the patient to recognize the signs and symptoms of ectopic pregnancy and to notify the doctor immediately if these should occur.

To prevent recurrence, advise the patient to engage in safe sexual practices. Teach her strategies to avoid STIs and pelvic infections that could cause further damage to the fallopian tubes.

postoperative instructions.

Give the patient the following instructions: Limit activity and get plenty of rest. Increase fluid intake. Keep the incision clean. Refrain from sexual intercourse for 2 weeks until the follow-up appointment with the physician occurs. Delay pregnancy for at least 3 months to allow for tubal healing. Determine that she has a method of birth control prior to leaving the hospital.

referral.

If the patient is having difficulty dealing with the perinatal loss, referring her to a support group is appropriate. Often, follow-up by the hospital perinatal grief counselor is done. Referral to a fertility specialist is indicated if she is having difficulty conceiving for 6 months after tubal surgery.

Patient discussion about ectopic pregnancy

Q. What is an Ectopic Pregnancy? I've heard that an ectopic pregnancy can be very dangerous. What is exactly an ectopic pregnancy?A. Thanks Ridings and Conger..
for easier understanding, ectopic pregnancy means a pregnancy that occurs not in the normal place (uterus/womb). It talks about the implantation of the zygote (embryo).
If it is implanted in uterus wall then it is normal, if it is not in uterus wall (endometrium) then it is called ectopic pregnancy.
So ectopic pregnancy includes :
- extra-uterine pregnancy (including tuba, abdomen, ovarium)
- abnormal intra-uterine pregnancy (some doctors include : cervix, muscular wall of uterine)

Q. Do doctors normally do ultrasounds to prove you have mis carried?? 2 weeks ago i found out i was pregnant, i started spottion so we went to the hospital where they toldl me i miscarried, but they did not do any alternative tests to prove it not even check my Hcg levels. Im wandering if i should get a second opinion to make sure.A. Congratulations on the new pregnancy - that's wonderful news!

More discussions about ectopic pregnancy

ectopic pregnancy

ectopic pregnancy

ectopic pregnancy

ectop′ic preg′nancy

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ectopic pregnancy

ectopic pregnancy

Ectopic Pregnancy

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ec·top·ic preg·nan·cy

ectopic pregnancy

ectopic pregnancy

ec·top·ic preg·nan·cy

ectopic pregnancy

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ectopic pregnancy

Ectopic Pregnancy

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Collaborative

medical.

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Evidence-Based Practice and Health Policy

Documentation guidelines

Discharge and home healthcare guidelines

patient teaching.

postoperative instructions.

referral.

Patient discussion about ectopic pregnancy

ectopic pregnancy

Synonyms for ectopic pregnancy

noun pregnancy resulting from gestation elsewhere than in the uterus

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