Surgery for Ectopic Pregnancy but Baby in Uterus

Ectopic Pregnancy (booklet)

A Guide for Patients

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INTRODUCTION

The diagnosis of an ectopic pregnancy is usually unexpected and is often emotionally traumatic. Many women may have only recently discovered they were pregnant when they receive the diagnosis. Some women diagnosed with an ectopic pregnancy do not even know they are meaning and suddenly must think about the possibility of major surgery or medical handling. This booklet is designed to provide information on the diagnosis and treatment of ectopic pregnancy.

Definition

Ectopic pregnancies account for 1% to two% of all conceptions. An ectopic pregnancy is an early on embryo (fertilized egg) that has implanted outside of the uterus (womb), the normal site for implantation. In normal conception, the egg is fertilized past the sperm within the fallopian tube. The resulting embryo travels through the tube and reaches the uterus three to iv days after. However, if the fallopian tube is blocked or damaged and unable to send the embryo to the uterus, the embryo may implant in the lining of the tube, resulting in an ectopic pregnancy. The fallopian tube cannot support the growing embryo. Later on several weeks the tube tin rupture and bleed, resulting in a potentially serious state of affairs.

Ninety-five percentage of ectopic pregnancies implant in the fallopian tube, but they also tin occur in the neck, ovary (Fig. i), or fifty-fifty within the belly (abdominal pregnancy). Intestinal pregnancies are extremely rare and tin can progress quite late into the pregnancy before they are discovered. Fetuses that abound in the abdomen who could survive afterward birth have been delivered, on rare occasions, past laparotomy (abdominal surgery).

Women who have ectopic pregnancies, specially if they have been attempting to excogitate for a long period of time, often inquire whether the pregnancy can exist removed from the tube so transplanted into the uterus where it might grow normally. Unfortunately, this is not possible with present medical science.

Ectopic Pregnancy Figure 1 Image

Causes

Women who already have damaged tubes are more likely to develop an ectopic pregnancy. In fact, 50% of ectopic pregnancies are associated with some degree of tubal affliction. Fallopian tube harm usually results from prior pelvic infection, such equally gonorrhea, chlamydia, or other sexually transmitted infections (STIs). Tubal affliction also may occur as a issue of endometriosis, appendicitis, previous pelvic surgery, or exposure to diethylstilbestrol (DES). The pregnancies of women who conceive with an IUD in identify sometimes occur in the fallopian tube. Women who excogitate after having a tubal ligation for sterilization, reversal of a tubal ligation, or any other type of tubal surgery also take a higher chance of having an ectopic pregnancy. Women who conceive as a effect of fertility drugs or in vitro fertilization (IVF) have a slightly higher risk of having an ectopic pregnancy. For more data on tubal damage and surgery, refer to the ASRM patient data booklet titled, Tubal Factor Infertility.

Sometimes, there is no apparent caption for why an ectopic pregnancy has occurred. However, information technology is known that one time a woman has had an ectopic pregnancy, she has a higher take a chance of having another one and should be monitored carefully if some other pregnancy is attempted or suspected.

Symptoms

Delayed or abnormal bleeding can be an early sign of an ectopic pregnancy. If pregnancy is confirmed, early aberrant levels of homo chorionic gonadotropin (hCG), pelvic hurting, and/or irregular bleeding in the beginning weeks of pregnancy can indicate an ectopic pregnancy. If a woman knows or suspects that she is pregnant and has had pelvic or lower abdominal pain, she should consult her physician, fifty-fifty if the pain decreases in severity or stops birthday. Additionally, if a woman has any risk factors for an ectopic pregnancy, including a previous ectopic pregnancy, she should bank check a home pregnancy exam if her period is delayed and consult her physician as before long as she is pregnant. Early detection of an ectopic pregnancy may aid minimize the complications associated with ectopic pregnancies and offers the opportunity for other treatment options. Sometimes an ectopic pregnancy is suspected when an ultrasound does not testify a pregnancy inside the uterus. Until recently, ectopic pregnancies often were non diagnosed until 6 to 8 weeks into the pregnancy, when a woman was experiencing pelvic pain, irregular vaginal haemorrhage, possible internal bleeding, and a tender feeling in the pelvis. Under these circumstances, this represented a life-threatening emergency, and major surgery (laparotomy) was required to remove the pregnancy and control bleeding. Fortunately, almost ectopic pregnancies are now identified much earlier, often before the woman is fifty-fifty aware of an acute trouble. This is largely due to the availability of sensitive hormone testing and ultrasound examinations.

Diagnosis

The tests that are often used to diagnose an early ectopic pregnancy include the measurement of hCG and/or progesterone levels in the bloodstream, ultrasound, laparoscopy, or dilation and curettage (D&C).

Homo Chorionic Gonadotropin (hCG)

In a normal pregnancy, the blood level of hCG, a hormone produced by the placenta, should double approximately every 48 hours. If this doubling does not occur, this suggests that the pregnancy may non exist healthy. It may hateful a miscarriage or an ectopic pregnancy. Often measurements of hCG blood levels are repeated to assistance make the diagnosis.

Progesterone

Progesterone levels in the bloodstream rising very early in the grade of a pregnancy. Low levels of this hormone are oftentimes associated with an aberrant pregnancy, such as an ectopic pregnancy or an impending miscarriage. Withal, progesterone levels alone do not always predict the location or mean the pregnancy is healthy and are not routinely used to diagnose ectopic pregnancy.

Ultrasound Examinations

Ultrasound can be used in the first iii to 5 weeks after formulation (as early on as 1 to 3 weeks subsequently a missed flow) to decide whether or not a pregnancy is inside the uterine cavity. Transvaginal ultrasound is much more sensitive than intestinal ultrasound for this purpose. Ultrasound scans too tin can show fluid or blood in the abdominal cavity, suggesting haemorrhage from an ectopic pregnancy. Sometimes, the use of ultrasound, combined with hCG and/or progesterone blood level measurements, can confirm the diagnosis of an ectopic pregnancy without the need for a laparoscopy or D&C. Often, it is not possible to see an ectopic pregnancy with ultrasound and the diagnosis is considered when the pregnancy is not seen in the uterus when specific levels of hCG are likewise present.

Laparoscopy

In some cases, a laparoscopy is needed to ostend the diagnosis of an ectopic pregnancy. Sometimes, laparoscopy also can exist used to treat the ectopic pregnancy. Laparoscopy is an outpatient surgical process requiring general anesthesia. A small telescope chosen a laparoscope is placed into the abdominal crenel through a small-scale incision (cut) in the omphalus. If necessary, the doctor usually can remove the ectopic pregnancy past placing special instruments through the laparoscope or through pocket-size incisions above the pubic area. An overnight infirmary stay ordinarily is not necessary following laparoscopy. For more information on laparoscopy, refer to the ASRM patient information booklet titled, Laparoscopy and Hysteroscopy.

Dilation and Curettage (D&C)

If a woman'south blood hormone levels and ultrasounds testify that the pregnancy will terminate in miscarriage or an embryo that has not successfully attached to the uterine wall, the physician may choose to gently scrape out the lining of the uterus. This operation, known as a D&C, can be performed nether anesthesia either in the hospital or every bit an outpatient process. A woman's hCG levels will drop sharply following removal of a miscarriage. The tissues taken from the uterus too are examined advisedly by a pathologist. If pregnancy tissue is seen, an ectopic pregnancy is very unlikely. However, very rarely a double pregnancy can occur, one in the uterus and the other in the fallopian tube (called a heterotopic pregnancy). If there is no testify of pregnancy tissue or the hCG levels practise not drop sharply following a D&C, the presence of an ectopic pregnancy must be considered.

Handling

Prior to sensitive pregnancy tests and modern pelvic ultrasound, ectopic pregnancies were normally diagnosed after they ruptured and had caused internal bleeding. Surgery was the primary handling. At present, doctors can notice pregnancy by the time a women is due for her menstrual period by measuring blood hCG levels, and the location of a pregnancy ordinarily can be determined within 1 to 2 weeks. As a result, ectopic pregnancies oft can be diagnosed very early, even earlier symptoms develop. This allows some ectopic pregnancies to be treated safely without the need for surgery.

Ascertainment Alone

Some ectopic pregnancies resolve without treatment and tin be managed by observation lone. This is referred to as "expectant management" and usually is limited to women with early on ectopic pregnancies with no symptoms and depression serum hCG levels (normally <1,000 IU/L) that decrease without treatment. Treatment of ectopic pregnancy past observation alone can be used only for women who can dependably return for weekly claret hCG levels or sooner if symptoms develop. Women existence treated with observation solitary should avoid intercourse and strenuous exercise.

When hCG levels are <i,000 IU/L and dropping, and pelvic ultrasound is unable to determine the location of the pregnancy, these pregnancies are sometimes referred to every bit "biochemical pregnancies." Approximately half are really ectopic pregnancies, and the rest are intrauterine pregnancies that are destined to end equally miscarriages. Observation alone volition allow the not bad majority of these to resolve without incident within a month. If the woman experiences pain or related symptoms, or the hCG levels do non drop accordingly or ascension, handling with the medicine methotrexate or surgery volition be necessary.

Medical Treatment

With early diagnosis of an ectopic pregnancy, medical (non-surgical) treatment often is possible with the drug methotrexate. To be a candidate for methotrexate handling, a woman needs to be in stable condition with no evidence of internal bleeding or severe hurting. She also needs to maintain communication with her physician during the treatment protocol and exist able to return for follow-up blood tests after treatment.

Methotrexate is a drug that was initially used to treat certain types of cancers, some of which are derived from placental tissue. It is very constructive in destroying ectopic pregnancy tissue and assuasive it to be reabsorbed by the body. Information technology can besides destroy normal pregnancy tissue. Therefore, it is not an option for women with a heterotopic pregnancy. Methotrexate is given every bit a unmarried intramuscular shot or as a serial of shots over several days. Most early on ectopic pregnancies tin be successfully treated with methotrexate. This frequently leaves the tube open up. Success is based largely on the size of the ectopic pregnancy seen on the ultrasound exam and the level of hCG found on the blood test. Women with large ectopic pregnancies or rapidly rising and/or high levels of hCG (>10,000 IU/L) are less likely to respond to single-dose methotrexate therapy. These women may be considered candidates for multiple-dose methotrexate regimens or surgical treatment. If methotrexate is successful, hCG levels should decrease to zero over the adjacent 2 to six weeks. If the hCG levels practise non fall, methotrexate treatment may be repeated or the pregnancy may be removed surgically.

In that location are no known long-term side effects from apply of methotrexate. The short-term side effects are few. The drug tin can cause temporary ulcers in the rima oris and other gastrointestinal areas and tin can cause temporary changes in liver function. Rare complications include pneumonia. Decreased platelet product, another rare complication, tin cause bleeding within ii weeks after the injection. Any woman with changes in liver blood tests, anemia (low claret counts), or platelet disorders cannot take methotrexate. A adult female may have some abdominal pain for a few days due to the resorption of the ectopic pregnancy. Whatsoever severe pain needs to exist reported to her dr.. Women should limit lord's day exposure during treatment, as methotrexate tin can cause sensitivity to sunlight and sunburn may occur. When being treated with methotrexate, women should not drink booze or take vitamins containing folic acrid (folate).

Surgical Treatment

Until the last twenty years, ectopic pregnancies usually were treated by full salpingectomy (removal of the entire tube [Fig. 2]) via laparotomy (major abdominal surgery). Today, most surgeries for ectopic pregnancies are performed by laparoscopy. Laparotomy unremarkably is reserved for those ectopic pregnancies that have ruptured, causing severe internal bleeding, or when there is extensive scar tissue inside the abdomen and pelvis.

If the ectopic pregnancy is diagnosed early, earlier the tube ruptures, a laparoscopic salpingostomy may be performed. In this process, the fallopian tube is opened and the pregnancy tissue is removed while leaving the tube in place (Fig. 3). The tube so heals on its own. In about five% to 15% of cases, some of the ectopic tissue may remain and continue to grow. This may be treated past boosted surgery to remove the tube or by using methotrexate therapy. A fractional salpingectomy (sometimes called a segmental resection, to remove a center segment of the tube [Fig. 2]) may be performed when the ends of the tubes (the fimbriae) appear good for you and the ectopic pregnancy is modest. If but a small portion of the tube is removed, the tube may be rejoined later using microsurgery. If the fallopian tube is extremely damaged, the ectopic pregnancy is large, or the woman is bleeding excessively, a total salpingectomy is performed. In rare cases when the ectopic pregnancy involves the ovary, a portion of the ovary or the unabridged ovary may exist removed.

Ectopic Pregnancy Figure 2 Image

Operative Laparoscopy Versus Laparotomy for Ectopic Pregnancy

Up until the belatedly 20th century, all gynecologic, reproductive, and tubal operations were performed by opening the abdomen (chosen "laparotomy") using either a "bikini" or "up and down" skin incision several inches long. Women usually remained in the hospital 2 to 5 days post-obit surgery and returned to work in 2 to six weeks, depending on the level of concrete action required. Today, many of these operations can exist performed past "laparoscopy," using a pocket-size telescope with a camera and ii to iv smaller skin incisions approximately 1-quarter to half inch long. Following laparoscopy, women generally are able to go home the twenty-four hours of surgery and recover more apace, returning to full activities in three to 7 days.

Despite the advantages of laparoscopy, not all surgeries for ectopic pregnancy can be done with this technique. Emergency situations with extensive internal bleeding or large amounts of intra-abdominal adhesions may require immediate laparotomy. Some types of operations as well may exist also risky to perform laparoscopically, while in others it is not articulate that laparoscopy yields results as skillful as those by laparotomy. Finally, the surgeon's training, skill, and experience also play a significant function in deciding whether laparoscopy or laparotomy should exist used. When considering a pelvic operation, the patient and physician should discuss the pros and cons of performing a laparotomy versus a laparoscopy, including the surgical risks.

Effect

A woman who has had an ectopic pregnancy has a lower hazard of becoming significant over again. In addition, her run a risk of having some other ectopic pregnancy is higher. Fortunately, over half of women who feel an ectopic pregnancy will have a healthy baby sometime in the future. Women with 2 or more ectopic pregnancies may have tubal illness and may want to consider IVF. Yet, there is even so nearly a 2% chance of ectopic pregnancy with IVF. For more data on IVF, refer to the ASRM patient information booklet titled Assisted Reproductive Technologies.

Emotional Aspects

Ectopic pregnancy is a physically and emotionally traumatic feel. In addition to experiencing the loss of a pregnancy, women may fear the loss of future fertility. Feelings of grief and loss are normal. Sadness, anger, self-blame, guilt, and low are office of the grieving process and demand to be best-selling and expressed. It can be helpful to share these feelings in a support group, such as RESOLVE or SHARE, or through counseling. Time is necessary for both physical and emotional healing before attempting some other pregnancy. For more than data on these support groups, consult the Resource section below.

SUMMARY

Ectopic pregnancy refers to whatsoever pregnancy implanted outside the uterus, usually in the fallopian tube. Early on diagnosis is oft made using sensitive hormone tests, ultrasound exams, laparoscopy, and/or D&C. Modern surgical and medical treatments frequently allow women to avert extensive surgery and preserve their fallopian tube. Although the hazard of having another ectopic pregnancy is increased, many women volition successfully excogitate and have children in the hereafter, either naturally or with the aid of an assisted reproductive technology such as IVF.

Resource

RESOLVE -- http://www.resolve.org/
SHARE (Source of Help in Airing and Resolving Experiences) -- http://world wide web.nationalshare.org/

GLOSSARY

Intestinal pregnancy. An ectopic (extrauterine) pregnancy that has implanted on structures in the abdomen other than the uterus, fallopian tubes, or ovaries. It unremarkably implants on tissue in the abdomen known as the omentum.

Appendicitis. A condition where the appendix (a tubular structure attached to the large colon) becomes infected and inflamed and tin exist associated with the formation of adhesions in the proximity of the fallopian tube.

Cervix. The lower narrow stop of the uterus that connects the uterus to the vagina.

Diethylstilbestrol (DES). A synthetic hormone formerly given during pregnancy to prevent miscarriage. Women born from treated pregnancies tin can have abnormalities of the reproductive system, including an increased run a risk of ectopic pregnancy.

Dilation and curettage (D&C). An outpatient surgical procedure during which the cervix is dilated and the lining of the uterus is scraped out. The tissue is frequently microscopically examined for the presence of abnormality or pregnancy tissue.

Ectopic pregnancy. A pregnancy that implants outside of the uterus, usually in the fallopian tube. The tube may rupture or bleed equally the pregnancy grows and present a serious medical state of affairs.

Embryo. The primeval stage of human being development arising after the matrimony of the sperm and egg (fertilization).

Endometriosis. A condition where patches of endometrial-like tissue develop outside the uterine cavity in abnormal locations such equally the ovaries, fallopian tubes, and abdominal crenel. Endometriosis can abound with hormonal stimulation, causing pain, inflammation and scar tissue. It also may be associated with pelvic pain and infertility.

Fallopian tube. A pair of hollow tubes fastened one on each side of the uterus through which the egg travels from the ovary to the uterus. Fertilization normally occurs in the fallopian tube. The fallopian tube is the most common site of ectopic pregnancy.

Fertility drugs. Drugs that stimulate the ovaries to produce and mature eggs then that they can be released at ovulation.

Fimbriae. The flared (finger-like) end of the fallopian tube that sweeps over the surface of the ovary and helps to straight the egg into the tube.

Human chorionic gonadotropin (hCG). This hormone is produced by the placenta. Its detection is the basis of about pregnancy tests.

Implantation. The process whereby an embryo embeds in the uterine lining in order to obtain nutrition and oxygen. Sometimes, an embryo will implant in areas other than the uterus, such every bit in a fallopian tube. This is known as an ectopic pregnancy.

In vitro fertilization (IVF). A method of assisted reproduction that involves combining an egg with sperm in a laboratory dish. If the egg fertilizes and begins cell division, the resulting embryo is transferred into the woman'southward uterus where information technology volition hopefully implant in the uterine lining and further develop. IVF may be performed in conjunction with medications that stimulate the ovaries to produce multiple eggs in club to increase the chances of successful fertilization and implantation. IVF bypasses the fallopian tubes and is often the handling of option for women who have badly damaged or absent tubes.

Laparoscope. A thin, lighted, telescope-like viewing instrument that is unremarkably inserted through the navel into the abdomen to examine the contents of the pelvic and abdominal cavities. Other small incisions may likewise be made, and boosted instruments inserted to facilitate diagnosis and let surgical correction of pelvic abnormalities. The laparoscope can be used as both a diagnostic and operative instrument.

Laparoscopy. The insertion of a long, sparse, lighted, telescope-like instrument chosen a laparoscope into the belly through an incision usually in the omphalos to visually audit the organs in the intestinal crenel. Other small incisions may besides be made, and additional instruments inserted, to facilitate diagnosis and allow surgical correction of abnormalities. The surgeon can sometimes remove scar tissue and open up closed fallopian tubes during this process.

Laparotomy. Major abdominal surgery through an incision in the intestinal wall.

Methotrexate. A medication that destroys pregnancy-related tissue and hastens re-absorption of this tissue in a woman with an ectopic pregnancy.

Microsurgery. A type of surgery which uses magnification, meticulous technique, and fine suture material in club to go precise surgical results. Microsurgery is important for certain types of tubal surgery in the female, as well as for vasectomy reversal in the male.

Miscarriage. The naturally occurring expulsion of a nonviable fetus and placenta from the uterus, also known equally spontaneous abortion or pregnancy loss.

Ovaries. The ii female sex glands in the pelvis, located one on each side of the uterus. The ovaries produce eggs and hormones including estrogen, progesterone, and androgen.

Partial salpingectomy. An functioning in which the section of a fallopian tube containing an ectopic pregnancy is removed. This procedure attempts to preserve nearly of the tube for subsequent re-attachment using microsurgery in order to achieve future fertility.

Pneumonia. Lung inflammation.

Progesterone. A female hormone secreted by the corpus luteum after ovulation during the second half of the menstrual cycle (luteal stage). Information technology prepares the lining of the uterus (endometrium) for implantation of a fertilized egg and also allows for complete shedding of the endometrium at the time of menstruation. In the consequence of pregnancy, the progesterone level remains stable beginning a week or so after formulation.

Salpingectomy. An operation in which i or both of the fallopian tubes are removed.

Salpingo-oophorectomy. Removal of a fallopian tube and ovary together.

Salpingostomy. A surgical process in which the wall of the fallopian tube is opened and the ectopic pregnancy is removed. The tubal incision heals spontaneously.

Sexually transmitted infection (STI). An infection, such equally chlamydia or gonorrhea, that is transmitted by sexual activity. In the female, some STIs can crusade pelvic infections and lead to infertility by damaging the fallopian tubes and increasing the take a chance of ectopic pregnancy. In the male, STIs can cause blockage of the ductal system that transports sperm.

Transvaginal ultrasound. An imaging technique in which a smooth cylindrical probe that uses sound waves to view organs on a video screen is placed in the vagina.

Tubal ligation. A surgical procedure in which the fallopian tubes are clamped, clipped, or cut to foreclose pregnancy.

Ulcer. A lesion (sore) on the surface of the peel or on a mucous surface, usually inflamed. As an occasional side effect of methotrexate therapy, temporary ulcers may form in the rima oris.

Ultrasound. A moving picture of internal organs produced by high frequency audio waves viewed as an prototype on a video screen; used to monitor growth of ovarian follicles, retrieve eggs, or monitor growth and development of a fetus. Ultrasound can be performed either abdominally or vaginally.

Uterus (womb). The hollow, muscular female organ in the pelvis in which an embryo implants and grows during pregnancy. The lining of the uterus, chosen the endometrium, produces the monthly menstrual claret flow when at that place is no pregnancy.

Published by the American Social club for Reproductive Medicine nether the direction of the Patient Education Committee and the Publications Committee. No portion herein may be reproduced in any form without written permission. This booklet is in no manner intended to supervene upon, dictate, or fully ascertain evaluation and treatment by a qualified md. It is intended solely equally an aid for patients seeking general data on issues in reproductive medicine.

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