Ectopic pregnancy is nothing more than the development of the fetus outside the uterine cavity , it is also known as tubular pregnancy and is one of the pathological states induced by pregnancy. Today we will talk about this condition, its characteristics and how to identify some symptoms, so that you are attentive and can act in time.
Pregnancy is a moment of realization in one’s life, where a series of changes occur that every woman must understand and act on, from the moment of confirmation.
However, there are circumstances in which this gestation period does not turn out as it should, presenting certain pathologies that can put the health of the baby and the future mother at risk. Among these circumstances, ectopic pregnancy stands out .
Index
What is an ectopic pregnancy?
As we mentioned earlier, ectopic pregnancy refers to the implantation of the fertilized egg outside the uterine cavity. It is considered the most frequent emergency that occurs in the first trimester of pregnancy.
The cases have been increasing worldwide, however they remain rare situations, since it occurs in 2 out of every 100 pregnant women, however, the values have stabilized in recent years.
The stability of the number of cases of this disease is due to the increase in risk factors, the application of assisted reproduction methods and the innovation in diagnostic techniques for the detection of cases in earlier stages.
The most common location outside the uterine cavity is the fallopian tube, in 97% of cases and the remaining 3% is located in the cervix , ovary and abdominal cavity . The fallopian tubes do not have enough capacity to accommodate the fetus during its growth, so this pregnancy cannot continue normally.
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When it is diagnosed at the beginning, the embryo is extracted but there are cases where the pregnancy continues and the fallopian tube ruptures. What results in such a hemorrhage, then it is classified as an emergency situation .
The ectopic pregnancies are the most common cause of morbidity and mortality maternal during the first three months of gestation, where 9% of deaths due to this disease. Since women can have a miscarriage or serious bleeding that endangers their life.
In most cases it is predisposed to an ectopic pregnancy when there is a lesion of the uterine tissue and / or the interruption of the mobility of the tubes. Embryos that implant outside the uterus show abnormalities that require their disruption. Spontaneous tubal abortion happens in 50% of cases.
Risk factors for an ectopic pregnancy
A risk factor corresponds to any personal or family condition that a person presents, which makes him prone to suffer a certain disease. In this case, the risk factors for ectopic pregnancy will be the conditions that predispose women to developing an ectopic pregnancy.
The most solid factors of ectopic pregnancy correspond mainly to the previous tubal surgical history (tubal ligation), endometriosis, infection of the pelvis . Since they are related to the tubular area.
Other equally important factors are defects in the fallopian tubes, sterilization, confirmed previous genital infection, previous spontaneous abortion, induced abortion, previous and current smoking , women over 40 , women who have the IUD device in use or had it , documented tubal lesions, sexual promiscuity , exposure to diethylstilbestrum.
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There are also other factors such as: having suffered from conditions that damage or harm the reproductive tissue due to problems in the womb. Likewise, the intake of hormones, mainly progesterone and / or estrogen, as well as the morning-after pill can cause slow movement of the fertilized egg.
Some research shows that problems presented after an operation to treat appendicitis, as well as in vitro fertilization or a variety of previous abortions, may increase the chances of happening in the future, an ectopic pregnancy.
Next, we will describe some of these risk factors, mentioned above in order to clarify some doubts:
Be over 35 years old
It is common knowledge that women have that so-called biological clock, which informs women that their time to procreate is coming to an end as the years go by, the quantity and quality (normally seen) of the eggs decreases. ; This can result in certain problems with childbearing and with maintaining a healthy pregnancy.
The highest percentage of ectopic pregnancies is presented by women whose ages are between 35 and 44 years old, remembering that the levels of hormone production, number of eggs are usually lower in those; Due to a normal aging of the cells with the passage of time and the responsible organ (the ovaries) ages faster than others.
However, this does not mean that because you are 35 years or older you are going to suffer from an ectopic pregnancy, different risks can be found along the way. Currently, average pregnancy is widely seen, especially in Spain, where an approximate 30% has been found in the female population whose first pregnancy is close at that age.
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Tied tubes (previous tubular surgery) or other problems in them.
It is more likely after 2 years after the intervention . Those women who voluntarily decided to undergo tubal recanalization in order to conceive again will also have a greater chance of ectopic pregnancy.
This may be due to the fact that at the time of the surgery there was a complication, just as it was not successful (which can happen thanks to different circumstances); Also because the desired results were not obtained then there was a reversal of these, which turns out to be a danger for the woman, due to the changes in the existing tubal canalization.
The existence of infections in the tubes before pregnancy, as well as congenital defects that they may have, can make possible an implantation of the embryo external to the uterus, since it complicates or obstructs the descent of the embryo throughout the entire route, which causes let it stay there to develop.
Having suffered from Pelvic Inflammatory Disease
Upper reproductive tract infections that are due to an uncured sexually transmitted infection , such as gonorrhea or chlamydia . This is due to the inflammatory nature of these infections, as an inflammation may indicate a pelvic tissue with lesions. Having injured pelvic tissue is more likely to develop this problem.
Having had a Previous Ectopic Pregnancy
Each time an ectopic pregnancy occurs, the possibility that the pathology will form again in the future is increased by up to 25% . Because it happened once because you had a condition that caused or promoted it, the same possibility still exists. So it is vital to have the best gynecological control possible.
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IUD carriers
In the event that a woman becomes pregnant despite the intrauterine system, she will have a high risk of an ectopic pregnancy, mainly due to the use of levonorgestrel at the time of insertion.
This can happen in women who have it at the time of becoming pregnant, as well as in those who had it at some point, since the procedure when placing it can cause transgressions in the uterine routes.
Smokers
They have twice the chance of an ectopic pregnancy, as nicotine may paralyze the formation of the hardening layer of the fallopian tube.
Associated with the Use of Morning After Pills
Most scientists have denied this information, since they indicate that there is no relationship between these and the pills. However, it has been shown that if birth control pills fail, the probability of an ectopic pregnancy increases, due to changes in hormonal load.
There is also a 2.1-9.4% of the cases of people with ectopic pregnancy related to the use of Progesterone and / or clomiphene citrate that could reduce the mobility of the tube, which is linked to the appearance of ectopic pregnancy.
Symptoms of Ectopic Pregnancy
The clinical manifestations are determined by the level of invasion, viability of the pregnancy and the place of implantation. With invasion we refer to the blood supply where the fetus was located.
When implantation occurs outside the uterine cavity, bleeding usually occurs, increasing changes in the anatomy of the tubes. Most cases of ectopic pregnancy are asymptomatic and the same body is responsible for solving them, such as a miscarriage.
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Where the termination of pregnancy is so early that signs and symptoms are not observed and menstrual delay is not observed. However, the most common is that the ectopic pregnancy continues its course until the second or third month.
Symptomatic women are those who present the shock that is usually due to tubular rupture. Most of the symptoms at the beginning are similar to a normal pregnancy, but other studies are those that rule it out.
At the beginning there are the classic pregnancy symptoms that are nausea, fatigue, weakness, abdominal pain, only half have the symptoms of a form of ectopic pregnancy, the emergency symptoms for a rupture are:
- Very intense pains on the lower part of the abdomen , it is stabbing, it may cause pain when urinating, evacuating, coughing or making any sudden movement. When the rupture occurs the pain is constant sharp and spreads throughout the pelvis.
- It is possible to observe light vaginal bleeding for a few days before the pain, if the rupture occurred, the bleeding becomes intense.
- To a large extent, women with ectopic pregnancies suffer from nausea and dizziness, being quite cumbersome to be able to differentiate this symptom from a normal pregnancy.
- There have been cases of women who manifest weakness, fainting . If there is a rupture of the tube, tachycardia is added, changes in skin temperature.
- There is pain in the lumbar spine andpain in the shoulders is attached .
It is an emergency when observing the intense bleeding and that the abdominal pain is increasing , do not hesitate to go to a hospital and call your doctor, since surgical or outpatient intervention is probably necessary.
Diagnosis of Ectopic Pregnancy
The accurate diagnosis of this disease is made by vaginal ultrasound and serial measurements of quantitative Beta-HCG , this provides a diagnostic efficiency of 96% and specificity of 97%.
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However, at present biochemical markers have been used for the early detection of this disease, these markers are Progesterone, CA-125, plasma protein A, vascular endothelial growth factor, serum creatinine.
The mainstays of diagnosis then are : Clinical examination, Ultrasound and biological markers with the determination of quantitative Beta-HCG. Below we will describe what they are about:
Abdominal examination
It consists of performing the physical examination in the pelvis where the patient reports constant pain when mobilizing the cervical and a painful annexed mass is found, when a rupture occurs there is peritoneal irritation ( Blumberg’s sign and / or abdominal defense ) a picture of hypovolemic shock .
Ultrasound
Corresponds to diagnostic imaging thanks to the advances in obstetric ultrasound , an abdominal probe is performed first and then a vaginal probe , where a high-resolution ultrasound is required. What is sought with ultrasound to determine ectopic pregnancy is:
- Empty uterus, but with thick endometrium.
- Presence of the intrauterine sac.
- Observation of a gestational sac outside the uterus: It has a yolk vesicle, sometimes even the embryo is present.
- Positive Doppler.
- Fluid levels in Douglas space higher than usual.
Serial determination of quantitative Beta-HCG
It is nothing more than determining the fraction of B-HCG in the blood , since in a normal pregnancy its value increases twice every two days, so that an increase less than this value begins to presume a non-viable pregnancy, it is very useful when ultrasound does not allow an accurate answer.
Treatment of Ectopic Pregnancy
There are three methods of treatment: expectant, medical and surgical . Each has its advantages and disadvantages, so the key is to take into account the conditions in which the pregnant woman is in order to choose the one that best suits those conditions.
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Expectant Treatment
Many times the same organism reabsorbs or induces abortion naturally . However, in 90% of cases, patients with this condition and B-HCG above 2000 IU / L require surgical intervention.
The best patients for this type of treatment are those with B-HACG less than 1000IU / L and decreasing, ectopic mass less than 3cm without beats, and who are committed to complying with the required follow-up.
The expectant consists of making constant soundings through the echo and the HCG measurements, waiting for the same organism to be the one to eliminate the fetus or mass. Expectant management is said to be between 47 and 82% effective in managing cases.
Medical treatment
The medical treatment involves the application of an antagonist of folic acid, the most used is usually the methotrexate . There are two modalities, a single dose or multiple doses. In this case, again, care must be taken when selecting the patient, since she must meet the main requirement, which is to have low B-HCG levels below 5000IU / L.
The smaller the values, the better the treatment efficiency . Other requirements are: hemodynamic stability, ability to comply with follow-up, zero cardiac activity in the fetus, no signs of rupture, egg size not greater than 4 cm, informed consent, you should avoid another pregnancy in the next three months after treatment to avoid teratogenic effects.
The methodology for the use of Methotrexate is: a single dose of 50mg / m2 of body surface area in an intramuscular injection, if there is no 15% decrease in B-HCG levels in 4 or 3 days, the dose can be repeated. . Success is usually 87%.
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In the case of multidose, 1mg / kg is administered intramuscularly every other day (1, 3, 5, and 7) with 4 doses of 0.1mg / kg of intramuscular folinic acid on days 2,4, 6 and 8. The control is carried out with measurement of B-HCG from the 4th day. When the values are reduced in two consecutive days after the fourth dose. It is about 94% successful.
When comparing both methods, it is found that the single dose is usually less effective but has fewer side effects , low costs and ease of treatment placement, if there is no rupture, a single dose can be applied transvaginally. Ectopic pregnancy in the ovary can be treated with direct injection of the ectopic sac with Methotrexate .
SIDE EFFECTS OF METHOTREXATE
- Abdominal pain : It is the most common, it is a sudden pain that occurs in the first days after the consumption of the drug, it is usually controlled with analgesics in usual doses. The source of the pain is not known, but it may be from a miscarriage or an effect of the medication.
This makes it difficult to determine if it is a temporary pain or is the product of tubal rupture and intra-abdominal hemorrhage.
- Nausea, vomiting, diarrhea, stomatitis.
- Medullary aplasia, liver or kidney disease, alopecia, photosensitivity
Surgical Treatment
Before it was the treatment par excellence since it completely solves the problem and is the most efficient of all, however, today this has changed and surgical treatment has been transformed by the doctor.
The current reasons for a surgical intervention are the following:
- The patient does not comply with the requirements of medical treatment.
- Need for the use of Laparoscopy to diagnose ectopic pregnancy.
- Rupture or suspected rupture of the ectopic sac.
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To choose the appropriate surgical technique, it is necessary to take into account the clinical conditions of the patient: state in which she is, wishes to maintain her fertility, preferences of the patient, location of the ectopic sac.
If possible, laparoscopy is recommended, which has less morbidity , rapid recovery, excellent subsequent gestation rate, and fewer subsequent ectopic pregnancies. Laparotomy is ideal for hemodynamically unstable patients, the latter method can also be used when there are no qualified personnel to perform a laparoscopy.
In emergency cases due to rupture of the sac, with hypovolemic shock , salpingectomy is recommended , which is also useful for stable patients who cannot use methotrexate. On the other hand, the rate of subsequent pregnancies after the interventions is 50-89%.
Complications of Ectopic Pregnancy
The most common complication is hypovolemic shock , this means that the ectopic sac ruptures and serious internal bleeding occurs . Death is the most serious consequence, however it only occurs in 9% of cases, that is, it is rare.
Another complication is infertility , which is rare, since it only occurs in approximately 10-15% of women who have undergone an ectopic pregnancy.
Will I be able to get pregnant again after suffering an ectopic pregnancy?
One of the most frequent doubts in women who go through this disease is if they will have the possibility of getting pregnant again , especially if they were first time. It has been proven that in most cases, after an ectopic pregnancy it is possible to conceive and have a healthy pregnancy in the future.
It all depends on how the treatment has been applied and of course in what conditions the fallopian tubes are . If the tubes were removed or both tubes have scars, it increases the difficulty of you being able to conceive.
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On the other hand, it is very important to mention that once you had an ectopic pregnancy, the possibility that you will have another pregnancy of this type in the future increases, that is, this fact becomes a risk factor.
Therefore, if you want and / or hope to become pregnant and have suffered an ectopic pregnancy before, you must have a thorough and delicate gynecological control, which takes care of both the health of the mother and the baby.
Some people would also recommend that you visit a therapist in order to calm and treat the nerves, stress, negative emotions, which can be generated in this situation and which are completely normal, but do not help to improve or take care of the development of the fetus throughout the entire pregnancy.
How long should you wait to seek another pregnancy?
Before you start making plans or trying to get pregnant again, it is best to wait a while to recover physically and emotionally . Doctors mostly recommend waiting at least three months before trying again, in order to ensure that your body heals completely and is ready to conceive again.
Feelings can vary from one woman to another after going through an ectopic pregnancy, there are women who want to get pregnant again immediately; while on the other hand, there are those who are terrified of the idea of enduring the anguish and stress of another ectopic pregnancy.
It should be noted that even if you feel fear that another ectopic pregnancy could happen again, if you paid attention to this article you will realize that although it is a possibility, there is also the wide probability of having a healthy pregnancy with a happy term. It’s a matter of taking the necessary steps and giving your body time to fully heal.
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Emotional State after Ectopic Pregnancy
Many women wonder what they will feel after everything is over , the answer is that you must remember that like a miscarriage , all ectopic pregnancy corresponds to a premature loss of a pregnancy. Where you can experience the same feelings as any other type of loss , especially for those who were looking for pregnancy.
Many times you will have a mixture of feelings between fear, relief, disappointment, shock, grief. This is perfectly normal, with the passage of time its intensity will be less, if you are going through this situation we recommend that you seek support in your family, visit a psychologist in order to avoid severe depressive symptoms.
Some women have a tendency to suffer from severe depressions and also guilty feelings, they begin to wonder what is wrong with them for not having been able to provide a future for their baby, that is normal to happen and more when they have to decide about having surgery as it may feel like your baby is being murdered.
Therefore, the search for emotional support is recommended from the moment that it is known of the existence of this type of pregnancies, there may also be a reluctance on the part of the mother before the operation, it is necessary to make her enter into reason about dangers that may arise if it is not done.
Losing a baby, regardless of circumstances or gestation time, can be difficult to cope with and overcome. You may never get over it, but you will deal positively with a situation like this.
And the feelings of your partner?
The emotional roller coaster due to an ectopic pregnancy can put a huge strain on the relationship . This experience can bring you closer and strengthen the relationship or your partner may not understand your feelings or be supportive in any way.
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The truth is that many men find it difficult to express what they feel and think they are not capable of helping, but keep in mind that he is probably suffering too . Of course, your well-being is his priority, so many times it is likely that he feels that he must be strong for you and save his feelings so as not to affect you.
Generally, the feelings of the man in the process and after that, are put aside, it is known that the woman can carry the worst burden, but that does not deny in any way that the male population can feel in a situation of this caliber.
Most of the feelings suffered by women can also be suffered by men, such as sadness or guilt, it is recommended that you also attend with a therapist who will give you the necessary tools to deal with the pain.
In some cases, the couple receives psychological treatment together, since it allows them to bond even more and treat the loss in union, in addition to making the whole process easier, thanks to the fact that they can understand the feelings of the other and learn to treat them based on understanding, love between the two.
Some prevention measures
The ectopic pregnancies that occur in locations outside of the fallopian tubes probably are not preventable . However, tubal pregnancies in certain cases can be prevented, avoiding as much as possible those disorders that can generate scars in the fallopian tubes. These measures include:
- Avoid risk factors for pelvic inflammation disease (PID) which are promiscuity, unprotected sex, and sexually transmitted diseases (STDs).
- Go regularly to your doctor to have a gynecological check-up and of course to detect in time any signs or symptoms of any change, inflammation or sexually transmitted disease.
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Finally, having gone through this condition or having the fear of it happening is something very seen, especially in middle-aged women, the fact that there are factors that increase the possibilities does not mean that it cannot happen to any woman. There have been cases, where you have not suffered from anything and even so an ectopic pregnancy has occurred, it is not your fault.
Let us remember that it is something that happens in 2% of the general population, in previous decades the mortality rate could exceed 50%, today it has been reduced to less than 1%. So if you find yourself suffering from this kind of pregnancy, remember that it is not the end.
If you have the necessary precautions, you can have a healthy life, with healthy children, after having suffered an ectopic pregnancy in the past. Being positive and never losing hope is vital, something that can be done without leaving realism aside, this is not a fantasy, it is something said by specialists and that is verifiable.
But if it is necessary and very important, it is never to refuse the operation, the mother is in great danger with these pregnancies, it is understood how difficult it can be, since it can be seen as going against the maternal instinct, but you must think clear way in the future. It is essential to think positive and not give up.
