Ectopic pregnancy !

ECTOPIC PREGNANCY (ECTOPIC PREGNANCY, EXTRAUTERINE PREGNANCY)

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Ectopic pregnancy is one of the most important health problems faced by women of childbearing age. An ectopic pregnancy is the localization of the embryo outside the endometrial cavity, which is the normal place of residence, which often results in the death of the embryo. If not diagnosed and treated in time, ectopic pregnancy can be life-threatening. It is responsible for 9% of pregnancy-related deaths. It can also reduce women’s chances of conceiving.

Ectopic Pregnancy Definition

An ectopic pregnancy is when the fertilized ovum implants outside of the uterine cavity, such as the fallopian tubes, cervix, ovaries, uterine horns, or abdominal cavity. In this way, the gestational sac, which is placed abnormally, grows by being fed from the place where it is attached. While the ectopic pregnancy mass grows, it may cause rupture (cracking) of the organ in which it is placed, severe internal bleeding and death.

Frequency of Ectopic Pregnancy

An average of 2% of all pregnancies are ectopic pregnancies.

The Most Common Places of Ectopic Pregnancy

80% of the cases are seen in the bulbous part of the tubes, 12% in the tubal isthmic segment, 5% in the fimbria, 2% in the cornual and interstitial region of the tubes, 1.4% in the abdominal region, 0.2% in the ovarian or cervical pregnancy.

Ectopic Pregnancy Symptoms

-Lower abdominal pain (cramp-like)

– Menstrual delay

-Vaginal bleeding

– Early pregnancy symptoms (such as nausea, dizziness).

– Fullness in the breasts

-Fatigue, weakness

-Shoulder pain

Causes of Ectopic Pregnancy

Although there are many factors that predispose to ectopic pregnancy, ectopic pregnancy can occur mostly due to previous pelvic infection. In addition, various factors such as having had an ectopic pregnancy before, drugs and techniques to assist reproduction, intrauterine device, getting pregnant after tubal surgery or tubal ligation, inflammatory diseases in the tubes, smoking, and advancing age pave the way for ectopic pregnancy.

Pelvic Inflammatory Disease

Chlamydia trachomatis infection is the most common cause of pelvic inflammatory disease (PID). This infection may cause no symptoms and in some cases may lead to inflammation of the tubes, ovaries, and entire pelvic peritoneum. More than 50% of women don’t even realize they have PID. Another microorganism that causes PID is Neisseria Gonorrhea. In this disease, which causes inflammation of the tubes, the probability of ectopic pregnancy increases fourfold.

Having had a previous ectopic pregnancy

After having an ectopic pregnancy once, the chance of ectopic pregnancy increases 7-13 times in recurrent pregnancies. For those who have had an ectopic pregnancy once, the chance of ectopic pregnancy in the following pregnancy is 10-25%, and the chance of intrauterine pregnancy is 50-80%.

Application to Reproductive Medicines and Techniques

It is seen that the chance of ectopic pregnancy increases fourfold when assisted reproductive techniques are used. This situation is attributed to the high hormone level and the development of many follicles, which occur with the effect of clomiphene citrate or gonadotropin used during assisted reproductive techniques.

Using an Intrauterine Device

The probability of ectopic pregnancy is 3-4% in those who use Intrauterine Device (IUD). The risk of ectopic pregnancy does not increase with modern copper IUDs. The probability of ectopic pregnancy is higher in those who use progesterone-containing IUDs than those who do not use any contraceptive method.

Having had Tubal Surgery or Tubal Ligation

The possibility of ectopic pregnancy increases due to the damage to the tubal mucosa after various operations on the tube.

Especially in cases where sterilization is achieved by burning the tubes called bipolar tubal cauterization, if the burning is insufficient 1-2 years after the operation, fistula formation develops, which paves the way for sperm passage and ectopic pregnancy. This is not usually the case when tubes are tied, clips or rings are attached. Approximately 40% of pregnancies seen after tubes are tied are ectopic pregnancies. Almost half of the patients who had an operation (salpingectomy) due to ectopic pregnancy salpingitis isthmica nodosum It is seen that the tubal mucosa extends into the tuba by forming vesicles called diverticulum due to the damage to the tubal muscle tissue called Inflammatory diseases, conditions such as endometriosis can also cause it.

To smoke

Although the relationship between smoking and the occurrence of ectopic pregnancy has not been clearly demonstrated, it is observed that the probability of ectopic pregnancy is 2-4 times higher in smokers compared to non-smokers due to various reasons such as delayed ovulation, change in tubal motility and weakening of the immune system.

Advanced Age

Ectopic pregnancy is 3-4 times more common in women aged 35-44 compared to women aged 15-24. The reason for this is the gradual decrease of myoelectric activity in the tubes with advancing age and the slowdown of embryo transfer, paving the way for ectopic pregnancy.

Ectopic Pregnancy Laboratory Findings

Beta-human chorinonic gonadotropin (beta HCG): In early healthy intrauterine pregnancy, the serum level of beta HCG approximately doubles every two days. If this increase in beta HCG is less than 66%, it is most likely an ectopic pregnancy or an abnormal intrauterine pregnancy. However, in 13% of ectopic pregnancies, the beta HCG value may increase by at least 66% within two days, and in 15% of normal healthy pregnancies, beta HCG may increase by less than 66% after two days. Therefore, additional diagnostic modalities such as ultrasound and other biochemical markers are needed.

Progesterone: For this purpose, it is of great importance to look at serum progesterone levels in order to distinguish between an abnormal pregnancy and a healthy ongoing pregnancy. Serum progesterone level is not dependent on gestational age and remains relatively unchanged during the first trimester in normal and abnormal pregnancies. Levels of progesterone less than or equal to 5 ng/ml indicate nonviable pregnancy (in ectopic or abnormal pregnancy), while values ​​greater than 25 ng/ml indicate no ectopic pregnancy in 97-98% of cases. However, since there are many corpus luteum in IVF pregnancy and progesterone treatment is given, these results in blood cannot be reliable.

Ultrasonography: It is the most important tool to distinguish between normal pregnancy and ectopic pregnancy. When the expected menstrual period is one week later, the gestational sac can be followed by the transvaginal route, and the embryo can be followed at the average sixth gestational week. The first structure seen in the gestational sac is the formation called yolk sac in the form of a bright echogenic ring of 3-5 mm, and this structure can be observed at five weeks of pregnancy. The embryo is observed as a thickening at the edge of the yolk sac at 5-6 weeks of gestation. Gestational sac can be seen first with abdominal USG when the beta HCG value is 6000-6500 mlU/ml, and with transvaginal USG when it is 1500-1800 mlU/ml. In case of multiple pregnancy, gestational sacs can be monitored on ultrasound when these values ​​are higher. In some cases, both normal localized pregnancy (intrauterine pregnancy) and ectopic pregnancy (extrauterine pregnancy) can be followed simultaneously; this heterotropic pregnancy is named. Heterotropic pregnancy is seen at a rate of 1/4000-1/3000 in spontaneous pregnancies, while the rate increases 10 times when assisted reproductive techniques with ovulation induction are used.

Due to decidualized endometrial bleeding in the endometrial cavity in case of ectopic pregnancy pseudosac An eccentrically localized sac called the eccentric is observed and may be misinterpreted as an intrauterine gestational sac. When an ectopic pregnancy ruptures, free mai (blood) is observed in the cul-de sac cavity on ultrasound.

Color Doppler USGEctopic pregnancy can also be evaluated with studies.

Dilatation and Curettage: The surest way to rule out an ectopic pregnancy is to identify an intrauterine pregnancy. If even intrauterine pregnancy is not desired, then it is important to have an abortion. If beta HCG and progesterone values ​​show abnormal pregnancy, abortion should be performed. If the villous structure is detected in the pathological examination of the abortion material, intrauterine still pregnancy is diagnosed. If there is no villi, the diagnosis of ectopic pregnancy is finalized.

Differential Diagnosis in Ectopic Pregnancy

Many disease symptoms can show symptoms of an ectopic pregnancy. Before the diagnosis of ectopic pregnancy is made, the absence of the following diseases should be excluded:

-Normal pregnancy

-Urinary tract infection

– Ovarian cyst

– Ovarian cyst torsion

-Appendicitis

-Corpus luteum cyst rupture

-Tubular inflammation (salpingitis)

-Low threat

Ectopic Pregnancy Treatment

If an ectopic pregnancy is detected early, it will be easier to treat since there will be no bleeding during this period. While waiting treatment or medical treatment is preferred in cases with early diagnosis, surgical treatment is performed in delayed cases. Rh incompatibility should be given Rh-immuoglobulin therapy to protect against Rh sensitization in subsequent pregnancies.

expectant management In the waiting treatment, called ectopic pregnancy, while the patient is followed closely, the ectopic pregnancy may abort on its own and treatment may not be required. During follow-up, beta HCG drops spontaneously without any intervention.

Medical Treatment: If the gestational sac has not ruptured in early pregnancy and its diameter is not larger than 30 mm, if the beta HCG value is less than 5000, if there is no heartbeat in the embryo, medical treatment is preferred. For this purpose, methotrexate (50mg/m2) treatment is mostly applied.

Serial beta HCG monitoring for several weeks is required to monitor the side effects of methotrexate therapy, as well as to understand whether the treatment has been successful. It should be followed until the result is zero. Methotrexate treatment has no surgical risks, less damage to the tubes, better fertility preservation effect.

Surgical treatment: Surgical treatment is required if there are severe symptoms of ectopic pregnancy, if the ectopic pregnancy has ruptured, if internal bleeding is observed. A ruptured ectopic pregnancy is an emergency and can usually be resolved with a laparoscopic surgery. In surgical treatment, either an ectopic pregnancy mass can be removed from a section made into the tube (salpingostomy), or the tube segment with an ectopic pregnancy mass can be removed (salpingectomy). Although a quicker response is obtained with surgical treatment in ectopic pregnancy, depending on the location of the gestational sac and the type of surgery, the tubes may be damaged and scar tissue may adhere.

Salpingostomy and methotrexate treatment applied to terminate an ectopic pregnancy have almost equal effects when compared in terms of preserving female fertility for future pregnancies.

In cases of ectopic pregnancy resistant to methotrexate treatment, surgical treatment is started or if beta HCG level persists after surgical treatment, methotrexate can be used.

Kiss. Dr. Kutlugul Yuksel

Gynecology and Obstetrics Specialist

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