The Scoop on Ectopic Pregnancies

Looking back over the blog I realized that we have not posted anything about Ectopic Pregnancies yet we have quite a few ladies on the board that have experienced them. So let’s go over what a Ectopic Pregnancy is and sign and symptoms to look for. I personally have not experienced one so if any of the ladies that have would like to chime in on anything please get a hold of me.

What is a ectopic pregnancy?

An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, since internal haemorrhage is a life threatening complication. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death.

About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.

In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end and is a common type of miscarriage. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual.

If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal miscarriages. The advent of methotrexate* treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

*Methotrexate, abbreviated MTX and formerly known as amethopterin, is an antimetabolite and antifolate drug. It is used in treatment of cancer, autoimmune diseases, and ectopic pregnancy.

I’ve suffered an ectopic pregnancy, but my hCG keeps rising.. what could be going on?

There is a chance that you are still retaining tissue from your loss, you may be going through what is called a heterotopic pregnancy, or you may be going through a persstent ectopic pregnancy, either way you should be in contact with you doctor about your concerns for testing and monitoring.

Heterotopic pregnancy

In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound.

Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%.

Successful pregnancies have been reported from ruptured tubal pregnancy continuing by the placenta implanting on abdominal organs or on the outside of the uterus.

Persistent ectopic pregnancy

A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15-20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels. After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic to assure their decline, also methotrexate can be given at the time of surgery prophylactically.

What are some signs and symptoms I should be looking for if I do become pregnant?

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.
Early signs include:

  • Pain in the lower abdomen, and inflammation (pain may be confused with a strong stomach pain, it may also feel like a strong cramp).
  • Pain while urinating.
  • Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms.
  • Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the ‘implantation bleed’ of a normal early pregnancy.
  • Pain while having a bowel movement.

Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms:

  • External bleeding is due to the falling progesterone levels.
  • Internal bleeding is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active pelvic inflammatory disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID.

More severe internal bleeding may cause:

  • Lower back, abdominal, or pelvic pain.
  • Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign.
  • There may be cramping or even tenderness on one side of the pelvis.
  • The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.

What causes Ectopic Pregnancies?

There are a number of risk factors for ectopic pregnancies. However, in as many as one third to one half of ectopic pregnancies, no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, and tubal ligation.

Will experiencing an Ectopic Pregnancy lead to fertility problems in the future?

Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of infertility. The treatment choice, whether surgical or nonsurgical, also plays a role. For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.

*** All this information was obtained by certified sources on Wikipedia.org

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6 thoughts on “The Scoop on Ectopic Pregnancies

  1. Thanks for adding this VQ! I had an ectopic back in November at not even 5 weeks and still lost my tube due to rupture.

    For me the only symptom was a dull aching pain, closer to ovulation cramps than to menstrual cramps. It was mild that morning around 8am and stayed mild until probably noon.

    But when it started getting bad, it got bad quickly. I left work and drove myself to my doctor and just knew exactly what it was. I don't know how or why but I knew the pain was in my tube. About 5 minutes after arriving I wasn't even able to walk from the pain and they had to get a wheel chair just to get me to the exam room.

    Because I was so early on nothing was seen on the ultrasound. (Oh and my betas had all been normal up until this day. They were low but doubling close to every 20 hours. The only beta that came back that hadn't at least doubled was on this day. They went from 206 to 300. No sac in the uterus, no sac in a tube. My RE could see that my ovary was surrounded by some blood and my tube was filled with blood but at his office my pain was coming and going and the bleeding wasn't severe by any means. When the pain was there it was excruciating, as if my insides were exploding. I never experienced pain like this with my miscarriages.

    We were hopeful initially that maybe I had a ruptured cyst. There wasn't much blood on the ultrasound at that point and he said that because the pain had been so intense and then just stopped he was cautiously optimistic that a cyst had ruptured. But not long later the pain intensified again and we opted for surgery.

    Any persistent pain that just doesn't seem right no matter how early you are in pregnancy needs to get checked out. The hour before surgery I actually felt almost normal. But when my doctor had me on the operating table my tube had long since ruptured and I was bleeding into my belly despite my lack of pain beforehand.

    Take any odd, persistent symptoms seriously. It's better to “bother” your doctor for “nothing” than to let an ectopic go untreated.

    Also, an ectopic pregnancy was NEVER on my radar. I literally assumed that ectopics happened to “other” people and while I was worried about another miscarriage I never dreamed that this would be how my pregnancy ended. My only risk factor for an ectopic was my D&Cs for my first two miscarriages. And honestly I wasn't even aware that that was a risk factor until after the fact. My right tube had been just fine until my after my second D&C. At some point after that D&C my right tube became enveloped in scar tissue, inside and out, it explained why it was taking me longer to get pregnant this go round and of course why I had the ectopic.

    Ok, I'm done rambling now! (Stepping off my soapbox!)

    -Laurakat81

  2. I just wanted to add like Laurakat81…I didn't have any symptoms of an ectopic pregnancy. I has some bleeding early, but no one, not even my OB thought it was anything bad. My levels were rising appropriately. The day before my 1st real appt, I was just shy of 7 weeks. I had some pink tinged toilet paper. I went in, and there was noting in my uterus. I was sent to a radiology office, where an ectopic was confirmed.
    I had 2 doses of Methotrexate (MTX), one on day 0, and one on day 4. On day 7 my levels were tested and they were dropping. Two days later, I had horrible pain in my abdomin. The pain level went from 0-10 immediately. I was rushed to the ER where my fears were confirmed…my left tube ruptured. I lost 2 liters of blood.
    Since talking it over with multiple people, I personally think my HCG levels were too high for MTX, 12000 at the time my ectopic was diagnosted. If I would have taken the time to do some research prior to treatment, I would have opted for surgery to save my tube.

  3. Time to research is a blessing. I feel that if only I had educated myself more and not solely relied on the public health system that I would not have the post traumatic stress disorder that I have aquired from being misdiagnosed. I was 80km away from a medical facility when my right tube ruptured, I needed a full blood transfusion and flat lined 3 times on the table. The only symptom I had was sporatic pain down my right side, which was not considered a problem at the time.I had no bleeding and didnt bleed for 2 days after surgery which was considered unusual. I had received an abdominal ultrasound and was told the sac was in my uterus at 5 weeks 4 days only to rupture at 7 weeks and 2 days. It was the most painful and frightening moment of my life.I had to say goodbye to my Husband and my 4 year old for what i thought was the last time as i got medivaced out of there.I felt isolated, bruised, deceived and alone.I was supposed to be holding my baby this Saturday. The reason women die from an ectopic pregnancy is from the blood loss.The only reason I survived is because the medivac helicopter started stocking blood supplies 6 months prior to my rupture.I am very lucky. I urge any women who plan on becoming pregnant to make sure that they get a transvagingal dating scan, and check that there local health facility has access to blood supplies.Find out what your blood type is so that they do not have to waste prescious time screening you to find out.This is not mentioned enough and it saves lives. I blog about my experience, i treat it like a grief journal and an education tool. Education and supportive resources are scarce in Australia. Im endeavouring to not waste my survival, my intention is to put it to use to prevent other women going through what i went through. Thank you.

  4. Thank you for posting an article about ectopics. Like Laurakat, I didn't really have many symptoms that would indicate an ectopic pregnancy. At 7 weeks pregnant, I woke up to bleeding. I hadn't gone in for my initial appointment yet, as my OB office wanted to wait until 8 weeks.

    I went in that day and an u/s showed a “tiny” gestational sac that would be more consistent with a pregnancy of 4 weeks. Betas drawn from that day were 454 and progesterone 5.4. The nurse told me my pregnancy could be viable, but that I had my dates wrong (I was charting, however, so I knew this wasn't the case). Betas from 48 hours later rose only to 478 and should have doubled. At that point, I was told to wait for a natural miscarriage but to continue coming in for blood draws.

    I had blood drawn another 6 times, with slowly rising HCG levels before my OB decided to proceed with methotrexate (MTX) to end the ectopic pregnancy. The OB never saw any mass in my tubes, only a very small sac in my uterus which was later determined to be a “pseudosac.”

    Throughout the pregnancy, I had a feeling that something wasn't right, even before I started bleeding. I had abdominal cramping throughout the pregnancy and it got much worse after MTX, and I passed the pseudosac 6 days after the injection. Passing the sac was accompanied by back pain and persistent abdominal cramping. 2 weeks after the injection, my HCG was undetectable.

    Everyone's story with an ectopic is different and I didn't have a single risk factor to suggest that this would happen to me. Like Laurakat, it wasn't on my radar at all.

  5. Just one more person to echo what the ladies above have said. I did not have any of the classic symptoms of ectopic pregnancy – in fact, everything was normal until the morning my tube ruptured. No pain, no bleeding. When I woke up that morning, I had what I thought was gas pain. For a couple of hours it wasn't anything worse than that. Then I started getting dizzy. Still, I didn't have anything I would call “pain” in my abdomen for hours. Instead, I fainted (I was bleeding internally) and went into shock. It wasn't until ten hours after my rupture that I started having severe pain. By then I had waited it out at home longer than I should have – because I kept waiting for the classic symptoms I'd read about. I expected excruciating pain and when it didn't seem to describe what I was going through, I dismissed it. I really wish I hadn't and had gotten my butt to the ER sooner!

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