What is Ectopic Pregnancy?

Ectopic pregnancy is an abnormal pregnancy that occurs as a result of the combination of sperm and oocyte (egg cell) and the development of the pregnancy product in another place and often in the fallopian tube, where it develops.

The embryo, which continues to develop in the tube, “melts” the tissue around it after a while, and after a certain period, one or more of the veins in the region ruptures. The biggest and life-threatening risk of ectopic pregnancy is caused by this bleeding. Surgery is often required to stop this bleeding and eliminate life-threatening.

With the early diagnosis and treatment methods of today, provided that the patient is admitted early, ectopic pregnancy can be recognized and treated without causing internal bleeding. Moreover, it may be possible to preserve the fallopian tube instead of removing the entire fallopian tube in early pregnancy.

The task of you, mothers, on this matter is to go for control from the earliest period of your pregnancy, even if you do not have any risk factors for having an external pregnancy. In this control, it will be possible to detect intrauterine (normal location) pregnancy, or if an ectopic pregnancy is detected, your treatment will be possible at the earliest stages.

Who gets ectopic pregnancy more often?

Ectopic pregnancy is a condition that occurs when the pregnancy product reaches inside the uterus. In order for an ectopic pregnancy to occur, the narrowing of the tubes should be such that the sperm should be able to pass from the vagina to the uterus and from there to fertilize the egg cell, but the embryo formed as a result of fertilization should not reach the uterus by moving through the tube. In other words, partial obstruction should occur in the tube (fertilization cannot occur if full obstruction occurs), or the natural movements of the tubes that take the embryo to the uterus in the form of “waves” have slowed down. All the factors that lead to the formation of these conditions can lead to ectopic pregnancy in the tubes.

However, it should be emphasized that none of the factors listed below exist in many ectopic pregnancy cases.

Previous Salpingitis History

Salpingitis is a condition observed during PID (Pelvic Inflammatory Disease; Pelvic inflammatory disease) in the group of sexually transmitted diseases in women. Depending on various factors (most often chlamydia and gonorrhoea (gonorrhea: gonorrhea in men)), infection in the tubes and around the tubes may cause complete clogging of the tubes, as well as partial clogging of the tubes and / or reduction of the "wave" motion feature in the tubes. Occlusion or partial contraction can be caused both by the deterioration of the inner structure of the tubes, and by the external compression and compression of the tubes by adhesions occurring in the surrounding tissues during salpingitis. When salpingitis clogs both tubes, infertility (infertility) occurs because the egg cell will never encounter sperm. This situation is among the top causes of infertility due to women. When the damage in the tubes does not occur in the form of complete obstruction, previous salpingitis increases the risk of ectopic pregnancy with the mechanism described above. As the number of salpingitis attacks increases, the risk of infertility or ectopic pregnancy increases.

Adhesions around the tubes

Adhesion around the tubes may occur due to previous salpingitis, especially operations performed in this region (cyst operations, previous ectopic surgeries, “opening the tubes” operations for the tubes, connecting the tubes) can increase the risk of ectopic pregnancy by sticking around the tubes. If the previous appendicitis was operated on time (ie if the appendix was just made before the eruption), it is not expected to adhere to a high degree of adhesion. Although caesarean operation causes adhesions, it is not considered as a condition that increases the risk of ectopic pregnancy.

Having an ectopic pregnancy before

Having had an ectopic pregnancy before, also causes pregnancy to develop as ectopic pregnancy with a probability of 10%.

"Infertility" treatment

The risk of ectopic pregnancy, which is “created” with both medicines (spawning drugs) and interventions (operations for tubes, IVF (IVF)), is higher compared to spontaneous pregnancies. The most important reason for this is the increased likelihood of multiple embryos in infertility treatment. Thus, the risk of ectopic pregnancy is folded in line with the number of embryos available, and the probability of statistical ectopic pregnancy is reached more quickly.

The first pregnancy provided by IVF method is an ectopic pregnancy. In IVF, this can also be caused by the embryo being placed "high" in the uterus.

Age factor

Age reduces the mobility of the tubes, thereby increasing the likelihood that the pregnancy product will settle and develop inside the tube before it reaches the uterus.

Having had a lot of abortions

Regardless of the number of optional abortions that have been performed duly and did not have any abnormal conditions afterwards, the risk of ectopic pregnancy is not expected to increase. Having many abortions causes more adhesion to the inner lining of the uterus and, consequently, an increased risk of abortion or pregnancy.

However, the risk of ectopic pregnancy increases in subsequent pregnancies, in cases of evacuation in weeks exceeding the legal limit, or if serious infections develop after any abortion. In countries where abortion is not legal, self-attempted abortion can also cause serious infections.

Pregnancy occurring in some contraception (prevention) methods

Highly effective methods (connecting tubes, birth control pills, "needles", progesterone pills, emergency contraception, and spiral reduce the risk of ectopic pregnancy numerically because it reduces the risk of conception. However, if any of these methods fail, pregnancy occurs The risk is quite high (except for failures in birth control pills.) The most typical example of this is pregnancy, which occurs after the tubes are connected.

Although other methods (spiral, progesterone-weighted "pills" and "needles", emergency contraception) are quite successful in preventing pregnancy, they fail to prevent pregnancy in the tubes, and the "leak" pregnancy that occurs is at high risk of being an external pregnancy.

Smoking

Smoking is a factor that slows down the “wave” movements of the tubes. Therefore, the risk of ectopic pregnancy increases especially in mothers who smoke more than one package a day.

Congenital defects in the tubes

Rarely, this can also be a factor.

Genital masses

Large fibroids or ovarian (ovarian) cysts that can press the tubes from the outside can prepare the ground for ectopic pregnancy.

How Often is Ectopic Pregnancy is Observed?

External pregnancy has been increasing proportionally in the world for 30 years, especially in developed countries. The latest data of America show that 16 of the pregnancies diagnosed have an external pregnancy, and this number has increased five times compared to 1970. The same data show that the prevalence of ectopic pregnancy is 35-44 years old, the contribution of maternal deaths is 15%, and that maternal deaths are the second most common cause of ectopic pregnancy.

Why Ectopic Pregnancy is Increasing?

The most important reasons for the increase in ectopic pregnancy are the increase in the frequency of sexually transmitted diseases, the application of IVF and other infertility treatments more frequently, and the diagnosis of ectopic pregnancy in more patients with advanced technology, and thus the detection of “self-healing” external pregnancy cases that will be described below.

Symptoms of Ectopic Pregnancy?

Symptoms of ectopic pregnancy can be evaluated in stages. In the earliest stages, ectopic pregnancy does not show any symptoms. Like a normal pregnancy, there is a delay in menstruation and there may be other symptoms of pregnancy. However, as soon as the tube starts to stretch with the growth of pregnancy, patients have “ambiguous” pains. These vague pain causes a sensitive patient to consult a doctor and it may be possible to make a diagnosis at the earliest period.

These pains become worse as pregnancy progresses. The reason for this is that the embryo continues to grow inside the tube and causes pain due to stretching. It is possible to diagnose and treat a woman who applies at this stage without tearing the tube.

When the pregnancy progresses further, the tube in which the pregnancy is located cannot remove the tension further and tears. The rupture gradually grows and intra-abdominal bleeding begins in the region. During this period, the patient's complaints also change. Now pain begins to be replaced by symptoms related to blood loss. Depending on the amount of blood loss that occurs, symptoms related to the development of shock due to faint dizziness and development of blood loss in very advanced periods are seen. Since the development of the pregnancy product stops after rupture, pregnancy hormones in the blood decrease rapidly and the endometrium (inner layer of the uterus), which loses hormone support, starts to pour with vaginal bleeding.

Unfortunately all over the world, ectopic pregnancy can be caught at this stage most often because the woman ignores her complaints or her husband does not take her to the doctor.

In some cases, the ectopic pregnancy that starts in the tube proceeds in the opposite direction inside the tube, "falls" from the mouth of the tube into the abdomen, where it "disappears" by itself. Although these kinds of situations are sometimes encountered in our follow-ups, most of these cases watch themselves unconsciously.

How is an Ectopic Pregnancy Diagnosed?

It has come to an advanced stage and it is not difficult to diagnose an ectopic pregnancy ongoing internal bleeding. A positive pregnancy test along with symptoms of blood loss and free blood in the abdomen on examination and ultrasound are sufficient to make a diagnosis.

The diagnosis of ectopic pregnancy, which has not yet reached this stage, is not so easy. It may be necessary to apply to the series for beta HCG In serial measurements made for this purpose, the rate of rise of beta HCG level in blood in a certain time period is examined. In a normal pregnancy, the beta HCG rate increases approximately twice in two measurements performed at 48-hour intervals. This does not increase in ectopic pregnancy. Serial measurements are not a definitive diagnostic tool and although the measurement has reached a certain stage, the absence of intrauterine (intrauterine) signs of pregnancy is a valuable finding that pregnancy is an ectopic pregnancy. When vaginal ultrasound beta HCG level is 2000 (attention: it may change according to the reference values of the laboratory!) And above, when abdominal (made from the abdomen) ultrasound is 6500 and above (attention: it may change according to the reference values of the laboratory!), The gestational sac should be observed within the uterus. If it is not observed, laparoscopy is frequently used after a complete gynecological examination to investigate the location of pregnancy.

In laparoscopy, the pelvis is carefully examined, and it is often seen that the external pregnancy is located in one of the tubes, and a definitive diagnosis of the external pregnancy is made and treatment is started.

In very rare cases, the gestational sac and embryo can be clearly observed outside the uterus. This is another finding that makes a definitive diagnosis of ectopic pregnancy. (The picture below, which has a historical value, explains this situation!)

Another examination used to distinguish whether pregnancy is ectopic or intrauterine pregnancy is blood progesterone level measurement. A level of 25 ng / ml and above at any time is a favor in favor of normal pregnancy, while a lower level is a favor in favor of a non-normal pregnancy.

How is Ectopic Pregnancy Treated?

When the diagnosis of ectopic pregnancy is made early, that is, when the tube is caught without tearing, the chance of treatment with laparoscopic method is quite high before the patient starts to lose blood yet. Moreover, laparoscopic treatment has the advantage of treating the patient by “emptying the tube” without removing the tube, thereby protecting the tube. Where laparoscopy devices are not available, the same procedure can be performed by laparotomy (opening the abdomen).

Another treatment method used in the early period is treatment with a drug called methotrexate. When certain criteria are met, if the general condition of the patient meets the appropriate conditions, ectopic pregnancy can be treated with a single or several doses of methotrexate without requiring surgery.

When the fallopian tube is torn and internal bleeding begins, the only and most appropriate treatment is to open the abdomen by operating the procedure called laparotomy and to stop the bleeding by partially removing the torn tube.  

Other rare forms of ectopic pregnancy

Abdominal pregnancy

It is the situation where the ectopic pregnancy is located in the abdomen. The pregnancy product settles on the outer surface of the bladder, bowel or other organs and lives here. It is a rare form of ectopic pregnancy that is relatively difficult to diagnose and very dangerous.

Cervical pregnancy

It is the situation where the ectopic pregnancy is in the cervix (cervix). This is also very rare.

Heterotopic ectopic pregnancy

It is the case when the pregnancy is plural (the most frequent twin) and one embryo is normal online and the other is ectopic. Although it is a rare form of pregnancy, infertility treatments that have a high probability of multiple pregnancy increase the risk. 

Op. Sibel Malkoç, MD

Gynecology and Obstetrics Specialist

Dr. Sibel Malkoç attended many domestic and international training seminars and congresses during 25 years of specialised physician service.

Pregnancy follow-up, urinary incontinence surgery and laser treatments, genital aesthetic surgery and laser applications and vaginismus treatment are of special interest.

It serves its patients especially in surgical and laser-assisted Vagina aesthetics.

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