Understanding ectopic pregnancy, causes, signs, symptoms and management.
– An ectopic pregnancy is a condition where the uterus is not properly positioned or positioned to allow for the delivery of the baby.

– Ectopic pregnancy occurs when fertilized egg is caught or delayed in Fallopian tube, potentially causing tube burst, internal bleeding, pain, and medical attention.

– UK ectopic pregnancies diagnose nearly 12,000 women annually, with an estimated 30,000 cases in the country alone, according to anecdotal evidence.

– The 2019 MBRRACE Maternal Deaths and Morbidity Report 2015-17 revealed that all but one of six women who died from early pregnancy problems had ectopic pregnancies, with 50% of them from Black or ethnic minority backgrounds. The 2022 MBRRACE Report 2018-20 shows an increase in ectopic pregnancy deaths. Understanding ectopic pregnancy, causes, signs, symptoms and management.

– Ectopic pregnancy causes three deaths annually in the UK and Ireland. The Ectopic Pregnancy Trust aims to prevent deaths and trauma, relieve distress, and provide ongoing support through treatment and beyond.

1. Tubal ectopic pregnancy – ampullary, isthmic and fimbrial
2. Interstitial pregnancy
3. Caesarean scar pregnancy
4. Cervical pregnancy
5. Cornual or Rudimentary horn pregnancy
6. Ovarian pregnancy
7. Intramural pregnancy
8. Abdominal pregnancy
9. Heterotopic pregnancy

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1. Tubal ectopic pregnancy – ampullary, isthmic and fimbrial
– Fallopian tubes are small, hollow muscular tubes about ten centimetres long, with a delicate mucous membrane lining. As they near the ovary, fimbriae form, creating a suction effect. The lining contains mucus-secreting cells and cilia, propelling secretions towards the uterus. The tubes have natural peristaltic action for mucus movement.
– The Fallopian tube picks up an egg during ovulation, which is transported to the uterus by the follicles. If a pregnancy occurs, the embryo implants six to seven days after ovulation, forming a placenta. However, if the uterus is not reached, the delicate linings may be damaged, and the embryo can implant, potentially leading to an ectopic pregnancy. Understanding ectopic pregnancy, causes, signs, symptoms and management.

2. Interstitial pregnancy
– Interstitial pregnancy is a rare ectopic pregnancy where the fertilized egg implants in the Fallopian tube, making it difficult to diagnose. These pregnancies can be dangerous if growing and can rupture later, damaging both the uterus wall and the Fallopian tube.
– Doctors may recommend methotrexate treatment for interstitial ectopic pregnancies if diagnosed early. Surgery may weaken the uterus, and some may resolve without treatment. Successful uterine pregnancies can occur after an interstitial pregnancy, with the preferred delivery method based on surgery extent.

3. Caesarean scar pregnancy
– Caesarean scar ectopic pregnancies occur when an egg implants into a uterine muscle gap, causing internal or vaginal bleeding. Some pregnancies may lead to live delivery, but risk significant bleeding and hysterectomy. Treatment is challenging, and management is individualized.
– Caesarean scar pregnancies can be treated with suction or keyhole surgery, but ectopic pregnancy rates are increasing due to elective caesarean section delivery. Some hospitals see few cases, so care is focusing on regional units with experience to optimize care and improve evidence-based treatment decisions.

4. Cervical pregnancy
– Cervical pregnancies are rare and risky due to the risk of vaginal haemorrhage. The highly vascular cervix requires blood transfusions. Emergency hysterectomy is often the only option, but conservative management using suction evacuation or methotrexate can preserve fertility. Gynecological procedures can cause scarring of the passage through the cervix.

5. Cornual or Rudimentary horn pregnancy
– Ectopic pregnancy occurs when a uterus does not form as expected, with one banana-shaped side in contact with the cervix and vagina and the opposite rudimentary horn. Both sides have their own Fallopian tube, allowing sperm to reach deep inside the uterus.
– The rudimentary horn, with a thick muscular wall, can advance into the second or third trimester before rupture. Diagnosis is difficult due to the assumption of a normal uterus during ultrasound scans. Treatment involves surgically removing the rudimentary horn and Fallopian tube. Interstitial pregnancy forms as expected.

6. Ovarian pregnancy
– Ovarian ectopic pregnancies are rare, accounting for less than 1% of all ectopic gestations. They are difficult to diagnose due to their resemblance to tubal ectopic pregnancy or ‘corpus luteum’. Typically, surgery is required for partial or complete ovary removal due to bleeding. If partially removed, the other ovary can continue to produce eggs. Understanding ectopic pregnancy, causes, signs, symptoms and management.

7. Intramural pregnancy
– A ‘in the wall’ pregnancy occurs when the uterus implants outside its cavity, resulting from surgery or adenomyosis. Diagnosis is challenging due to the inaccessibility of the cavity, making treatment difficult, and methotrexate may be recommended.

8. Abdominal pregnancy
– Abdominal pregnancies typically begin in the fallopian tube and separate, reattaching to the abdominal cavity. They can progress undetected until weeks, with rare cases of surviving and requiring abdominal surgery.

9. Heterotopic pregnancy
– Heterotopic pregnancy involves co-existing intrauterine and ectopic pregnancies, with rare cases of twin pregnancy. Survival rates are around 30% in diagnosed cases, even with surgical treatment. Live birth rates may be higher if the pregnancy is in the uterus.

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Symptoms of an Ectopic Pregnancy
1. A missed or late period
2. Vaginal bleeding
3. Pregnancy test
4. Abdominal pain
5. Shoulder tip pain
6. Bladder or bowel problems

1. A missed or late period
Missed periods usually indicate pregnancy progress. However, if symptoms like nausea, pain, or swollen abdomen are present but not bleeding, an ectopic pregnancy is rare. A true period should be normal, while a light period may be abnormal.

2. Vaginal bleeding
Ectopic pregnancy can cause ongoing bleeding, which may be red, brown, black, and watery. Prolonged, heavy bleeding should prompt a pregnancy test and an Early Pregnancy Unit referral. It’s crucial not to confuse abnormal bleeding with a normal period, as healthcare professionals may mistake you for less pregnant.

3. Pregnancy test
Pregnancy test kits are sensitive and can be positive before missed periods. They should be performed in the morning when urine contains the most pregnancy hormone, Human Chorionic Gonadotropin (hCG). If a negative result is found, repeat the test with a different kit. If the test is negative, a blood test can be performed to accurately measure hCG levels. If symptoms persist, see a doctor immediately. Blood tests can identify the exact hCG level in the blood, but results may take a few days.

4. Abdominal pain
Pregnancy often leads to period-like aches in the lower tummy and back. It may involve persistent or intermittent pain, bloating, fullness, and significant abdominal or back pain, especially if the pregnancy has already occurred.

5. Shoulder tip pain
Shoulder tip pain is a distinctive, unusual, and sudden pain that may occur when we are stressed due to rigidity in our back and neck muscles. It often develops alongside other symptoms like abdominal pain, vaginal bleeding, faintness, abdominal bloating, fullness, or pain when opening our bowels. It is caused by internal bleeding irritating the diaphragm muscle during breathing.

6. Bladder or bowel problems
Diarrhea, pain in the bowels, water passing, and sharp vaginal pain are typical pregnancy symptoms. If you present with these symptoms, an early pregnancy assessment is recommended.

7. Collapse
Fever, often accompanied by sickness and paleness, can be accompanied by an increase or slowing pulse rate or falling blood pressure.

Management of ectopic pregnancy?
1. Surgical treatment
2. Medical treatment with methotrexate
3. Expectant management

1. Surgical treatment
– Surgical management is the most common treatment for ectopic pregnancy, typically performed under general anesthesia using laparoscopy or laparotomy. This involves inserting a camera through the navel and instruments through small cuts in the lower abdomen. In cases of high hormone levels, large ectopic pregnancy, or significant internal bleeding, less invasive treatments may be necessary, and surgery may also be performed if expectant or medical management is ineffective.

2. Medical treatment with methotrexate
– Medical management for ectopic pregnancy involves using methotrexate, a drug that stops pregnancy development and gradually resorbs by the body, leaving the Fallopian tube intact. It is most effective in early ectopic pregnancy when beta hCG levels are below 5000 mIU/mL. Methotrexate is given via injection into the bottom muscle, with doses based on height and weight. Regular monitoring and follow-up are required, with hCG levels tested on the day of injection, day four, and day seven.

3. Expectant management
– Expectant management, also known as conservative management, involves watchful waiting by medical professionals instead of immediate treatment for ectopic pregnancies. Research shows that up to 50% of these pregnancies can end naturally, with no need for surgery or drugs. Doctors prioritize the least invasive treatment first, as a proportion of diagnosed or suspected ectopic pregnancies may resolve naturally. This approach can expedite physical recovery.