January 25, 2024 Author : Ana Filipa Brás In a normal pregnancy, after fertilization, which occurs in the fallopian tubes, the fertilized egg begins a journey through to the uterine cavity and implantation occurs in the endometrium (inner layer of the uterine wall). An ectopic pregnancy occurs when the embryo does not reach the uterus , and implantation is done elsewhere than the uterine cavity, making embryo and/or fetal development unfeasible. In most cases (96%) implantation occurs in the Fallopian tubes and is called a tubal ectopic pregnancy. Other possibilities for incorrect implantation are, for example, the ovaries (1%-3% of cases), the cervix, the abdominal wall or even a scar from a previous cesarean section. Rarely, in a twin pregnancy, a normal uterine implantation and an ectopic implantation may occur simultaneously, and this situation is called a heterotopic pregnancy. Ectopic pregnancy can be a serious clinical situation : The ectopic tissue where the fertilized egg implants is not prepared for this function and as the pregnancy progresses the risk of organ rupture increases with internal bleeding, which can be fatal; Hemorrhage from ectopic pregnancy accounts for 3%-4% of pregnancy-related mortality. Who can have an ectopic pregnancy? Any woman of childbearing age can have an ectopic pregnancy , although this is not common. Studies carried out in the USA reveal an incidence varying between 6.4 and 20.7 cases per 1000 pregnancies. There appears to be an increase in the incidence of ectopic pregnancy with age. A decrease in incidence has been seen over the last few decades. On the other hand, there are women who are more likely to have an ectopic pregnancy: Among the most important risk factors are a previous ectopic pregnancy, previous tubal disease or surgery, use of an intrauterine device and in vitro fertilization; History of sexually transmitted infections or pelvic inflammatory disease, previous abdominal or pelvic surgery, use of oral contraceptives and tobacco consumption are among the risk factors with moderate importance; Less important risk factors include, for example, being over 40 years of age, having previously terminated pregnancy with medicines and starting sexual life at a young age. Symptoms In most cases, ectopic pregnancies end early, either naturally or through medical intervention, as they are not viable. The clinical presentation varies from perfectly asymptomatic to the extreme situation of hypovolemic shock with syncope, hypotension, and tachycardia. The classic triad, present in up to 50% of cases, consists of: menstrual delay, scant vaginal bleeding and abdominal pain. In the absence of complications, an ectopic pregnancy should be suspected when: In a woman of childbearing age, with no known pregnancy but being pregnancy), there is abdominal pain with no other identifiable cause; In the presence of a known pregnancy (positive test) there is unexplained abdominal pain with or without vaginal bleeding. Abdominal pain is in general unilateral, but can be diffuse, with an intensity depending on the problem evolution. If there is significant internal bleeding, the patient may report pain radiating to the shoulder or intense urge and pain when evacuating. Diagnosis and treatment Diagnosing an ectopic pregnancy based only on symptoms is not always easy. In general, t he diagnosis is obtained after a gynecological exam, a transvaginal ultrasound and blood measurement of human chorionic gonadotropin (HCG), the pregnancy hormone. A positive HCG, but with values increasing with a slower pattern than usual, associated with the absence of visualization of an intra- or extra-uterine embryo raise high suspicious and require investigation. In a very early pregnancy, it is not always easy to identify the ectopic location of the embryo. Therefore, and if there are no other issues, the exams are repeated every 48 hours until a definitive diagnosis and subsequent therapeutic approach are reached. Depending on the particularities of each case, an ectopic pregnancy may resolve spontaneously, without medical intervention. When medical treatment is needed it can be done: With drugs, if inclusion criteria are met (namely clinical and hemodynamic stability of the patient, mass size and HCG value) that prevent embryonic evolution; By surgery, preferably laparoscopic (minimally invasive) or by laparotomy, most of the time it is necessary to remove the fallopian tube where the embryo was implanted. An ectopic pregnancy does not necessarily prevent a future pregnancy, but it is an important risk factor for recurrence of a new ectopic pregnancy. Therefore, women in these circumstances usually undergo reinforced gynecological and obstetric follow-up. Sources Tulandi T. Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. (www.uptodate.com) Meet the Gynecology-Obstetrics clinical team at the Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
