Ectopic pregnancy
Introduction
An ectopic pregnancy is a medical condition where a fertilized egg implants and grows outside the main cavity of the uterus. This condition is a significant cause of morbidity and mortality in early pregnancy and requires prompt diagnosis and management. The most common site for an ectopic pregnancy is the fallopian tube, but it can also occur in the ovary, cervix, or abdominal cavity.
Epidemiology
Ectopic pregnancies occur in approximately 1-2% of all pregnancies. The incidence has increased over the past few decades, partly due to the rise in pelvic inflammatory disease (PID) and the use of assisted reproductive technologies. Risk factors include a history of PID, previous ectopic pregnancy, tubal surgery, infertility treatments, and smoking.
Pathophysiology
The pathophysiology of ectopic pregnancy involves the failure of the fertilized egg to travel through the fallopian tube to the uterine cavity. This can be due to anatomical abnormalities, tubal damage, or impaired tubal motility. The trophoblast cells of the embryo invade the tubal wall, leading to local inflammation, bleeding, and potential rupture.
Clinical Presentation
Patients with ectopic pregnancy typically present with a combination of abdominal pain, vaginal bleeding, and amenorrhea. The pain is often unilateral and may be sharp or cramping. Vaginal bleeding can range from light spotting to heavy bleeding. In cases of tubal rupture, patients may present with signs of hypovolemic shock, including hypotension, tachycardia, and syncope.
Diagnosis
The diagnosis of ectopic pregnancy is based on clinical presentation, serum human chorionic gonadotropin (hCG) levels, and transvaginal ultrasound. A serum hCG level that rises abnormally or plateaus is suggestive of ectopic pregnancy. Transvaginal ultrasound can identify the location of the pregnancy and assess for the presence of an intrauterine pregnancy.
Management
Management of ectopic pregnancy depends on the patient's clinical stability, the size and location of the ectopic pregnancy, and hCG levels. Options include expectant management, medical management with methotrexate, and surgical intervention.
Expectant Management
Expectant management involves close monitoring of hCG levels and clinical symptoms. It is appropriate for patients with low and declining hCG levels, minimal symptoms, and no evidence of rupture.
Medical Management
Medical management with methotrexate is suitable for hemodynamically stable patients with an unruptured ectopic pregnancy and hCG levels below a certain threshold. Methotrexate inhibits DNA synthesis and cell replication, leading to the resorption of the ectopic pregnancy.
Surgical Management
Surgical intervention is indicated for patients with hemodynamic instability, signs of tubal rupture, or contraindications to methotrexate. Surgical options include laparoscopic salpingostomy or salpingectomy. Laparoscopy is preferred due to its minimally invasive nature and faster recovery time.
Complications
Complications of ectopic pregnancy include tubal rupture, internal hemorrhage, and infertility. Tubal rupture can lead to significant intra-abdominal bleeding and requires emergency surgical intervention. Recurrent ectopic pregnancy is a concern, with a recurrence rate of approximately 10-15%.
Prognosis
The prognosis for patients with ectopic pregnancy depends on early diagnosis and appropriate management. With timely intervention, the majority of patients recover fully. However, future fertility may be affected, particularly if there is significant tubal damage or recurrent ectopic pregnancies.
Prevention
Preventive measures for ectopic pregnancy include the early treatment of PID, smoking cessation, and careful monitoring of patients undergoing assisted reproductive technologies. Regular follow-up and early ultrasound in high-risk patients can aid in the early detection and management of ectopic pregnancies.