Medical Management of Ectopic Pregnancy

Published in Panorama



Medical Management of Ectopic Pregnancy



Six weeks into her pregnancy, Sonia was told that her foetus was developing in the Fallopian Tube when she went for a routine checkup. Fortunately for her, Sonia s Ectopic Pregnancy was discovered early enough for medical intervention to be taken and further complications avoided.

What is Ectopic Pregnancy and who are the women at risk of having it? Dr.Nasser El Beih, Consultant Gynaecologist, Zulekha Hospital, Sharjah explains, ”Ectopic Pregnancy occurs when a fertilized egg becomes implanted in the Fallopian Tube, ovary or even in the abdominal cavity instead of in the uterus. In fact, 95% of Ectopic Pregnancies occur in the tube!”

Dr.Beih continues that Ectopic Pregnancy results due to conditions that obstruct the Fallopian tube or slow the passage of the fertilized egg through it, to the uterus. The tube may be blocked as a result of scarring caused by previous tubal infection or tubal surgery. However, majority of women with ectopic pregnancy have a medical history of Pelvic Inflammatory Disease, says Dr.Beih. Other causes of such pregnancy include congenital tubal abnormalities, endometriosis, tubal scarring due to previous pelvic surgery or a ruptured appendix.

In some instances, reveals Dr.Beih, women who conceive after elective tubal sterilization, are at risk of having ectopic pregnancy. Similarly, the risk of ectopic pregnancy is increased in those women who have had surgery to reverse previous tubal sterilization so as to become pregnant.

According to Dr.Beih, “About one out of twelve thousand women with ectopic pregnancy will die as a result of the condition. In fact, it is the leading cause of deaths in mothers within the first trimester of pregnancy.”

Are there any symptoms associated with Ectopic pregnancy, leading a woman to suspect the condition? “Pain is the most important symptoms and this may be the only symptom in 80-90% of cases,” explains Dr.Beih. “There will be lower abdominal or pelvic pain, mild cramping on one side of the pelvis. The other symptoms include some vaginal bleeding, nausea and low back pain. But sometimes the women with ectopic pregnancy come to the clinic completely without any of these symptoms, not even pain.”

If there are no symptoms, how then is diagnosis reached? Dr.Beih emphasizes the importance of routine checkup by every pregnant woman right from the time she misses her periods by two weeks. “At no point should pregnant women wait for signs and symptoms to appear to have an ectopic pregnancy diagnosed. Because, these symptoms when they start showing up, may already involve the tube which is on the verge of a rupture, if it has not already ruptured. If this has happened, you are not left with any treatment option except to go in for surgery. Hence, it is absolutely important for the early diagnosis of the problem so that it can be effectively managed by medication alone.”

How early can tubal rupture occur in an ectopic pregnancy? “It is very much there in the early stage of pregnancy itself,” reveals Dr.Beih. “It can happen as early as between the 6th 8th weeks. The tube can rupture during this period and put the woman’s life at risk. Hence a routine checkup that would involve an ultrasound scan will pick up the condition in its very early stage itself.”

Speaking of the diagnostic tools, Dr.Beih explains, Ultrasound scaning is the only mode of diagnosing an ectopic pregnancy, especially if the woman has no symptoms. Of course in women who have a history of infertility or tubal surgery, we also do a blood test to check the level of the pregnancy hormone which will also give an indication of an ectopic pregnancy.

Failure to diagnose and treat an ectopic pregnancy on time, may result in rupture and haemorrhage, cautions Dr.Beih. In these cases, the symptoms of pain and cramps may worsen and the woman may feel faint or actually fain. In a vast majority of cases, the first symptom of a pelvic rupture due to ectopic pregnancy, is shock. In such instances, the patient first needs to be treated for the shock by keeping her warm, her legs elevated and giving oxygen.

Intravenous fluid and blood transfusion may be necessary. Surgical intervention with laparotomy may become necessary to arrest the bleeding. Also, it may be necessary to remove the products of conception and repair the surrounding tissues as far as possible. In very serious instances, surgical removal of the Fallopian tube may be necessary. 10-15% of women with ectopic pregnancy, may become infertile.

Emphasizing the medical management of ectopic pregnancy, Dr.Beih explains, First of all it is important to diagnose the condition in early pregnancy. Once diagnosed, the treatment involves injections of Methotrexate, a drug which is basically a folate antagonist. This is administered with careful outpatient monitoring of the woman for ectopic pregnancy, without suspected immediate danger of rupture of the tube.

Can every case of ectopic pregnancy at its early stage be treated with this drug? Dr.Beih cautions, We require to do certain blood tests to make sure the woman is suitable for receiving this treatment. Because the body gets rid of this medicine through the kidneys and liver; hence we need to do a kidney and liver function test to see if these organs are functioning well and are normal. We also need to take a complete blood count to ensure that the patient s bone marrow is functioning well. If there is any abnormality in any of these functions, we don t treat the women with the drug. Surgical treatment, then, remains the only treatment option.

Are there any side effects to this drug? Yes, admits Dr.Beih. But these are not quite bad. Some women may have stomatitis, an inflammation of the gums and teeth. In very rare cases, the woman can have bone marrow depression, that is, her bone marrow cannot make the blood elements effectively.

What is the success rate of treatment of ectopic pregnancy? While the condition itself can be well managed without risk to the women, successfully when diagnosed and treated timely, about 85% of women who ve had one ectopic pregnancy, are likely to have a normal pregnancy later; 10-20% of women with one ectopic pregnancy may have a subsequent ectopic pregnancy. Some women may fail to become pregnant again after one ectopic pregnancy while some may conceive but spontaneously abort during the first trimester.

Can ectopic pregnancy be prevented in the first place? Dr.Beih emphasizes that prevention is only by avoiding or preventing the root causes for ectopic pregnancy. This involves avoiding risk factors for pelvic inflammatory disease and its early diagnosis and treatment if it occurs. However, most forms of ectopic pregnancy other than tubal pregnancy are not really preventable.



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