Purpose and Disclaimer
This writeup attempts to cover the facts and the feelings of this topic. Before we proceed, please note: I am not a medical specialist. My only expertise is that of personal experience, and subsequent attempts to understand what happened. As always, nothing on Everything2 should be considered medical advice. Consult with your own medical doctor before making any decisions about your health. See also the Everything2 medical disclaimer.
Please review my writeup at miscarriage for a more general discussion of early pregnancy loss.
Any pregnancy in which the fertilized ovum implants anywhere other than the endometrial lining of the uterus. Ninety-five per cent of ectopics occur in one of the fallopian tubes. Much more rarely they may be abdominal, cornual, ovarian, or cervical.
In most cases, a pregnancy canot be maintained in the wrong place. Fetal death is all but inevitable. In the fallopian tubes, there's just no space, and a growing pregnancy will rupture the tube, causing massive internal hemorrhage for the mother.
In a clinical high school sex-education class, the fallopian tubes may be pictured as simple, hollow tubes, to be glossed over quickly on the way to a lecture about the dangers of sexually transmitted diseases. The truth, as always, is more complex. The fallopian tubes are lined with cilia which ripple towards the womb, guiding the ovum gently downward towards destiny. But the tube is narrow and the cilia delicate. Even a small trauma can impede their function. "For the gate is small and the way is narrow that leads to life, and there are few who find it."
Anything that affects the fallopian tubes can make an ectopic more likely. Pelvic inflammatory disease--a common side effect of sexually transmitted diseases--can scar the tubes. Any previous tubal surgery may have caused damage, as might a previous ectopic. Other abdominal surgery may have created adhesions which pinch or twist a tube. Assisted reproduction like ovulation induction and in vitro fertilization may also increase the risk. As with most other aspects of pregnancy, risk of ectopics increases with age. And sadly, sometimes, there's just no apparent reason.
The most common presentation follows a missed period and a positive pregnancy test. Abdominal pain may develop suddenly (usually pronounced on one side), followed by irregular vaginal bleeding. This is often slight, and can easily be confused with implantation bleeding. The one-sided abdominal pain is one of the giveaways. (In our case, acute one-sided pain developed approximately 12 hours after more general cramping, shooting down my wife's right thigh and leg.)
Specialized hCG blood tests and an ultrasound are required to confirm ectopic pregnancy.
Plateauing hCG levels have the highest predictive value for ectopic pregnancy. A February 1989 study published in the Journal of Reproductive Medicine1 noted that the trend of hCG levels in ectopic cases across multiple blood tests was:
- Falling levels 57%
- Abnormally rising levels 36%
- Normally rising levels 6.4%
Normally, hCG levels should rise at least 66% every 48 hours, and at least double in 72 hours.
After our previous miscarriage, we were excited when our first test's hCG level was in the 1700s. Four digits? Fantastic. But the first night we went to emergency with cramping, the number was only 1840. By the next day (back in Emerg via ambulance) we were at 1310. Coupled with the one-sided cramping, the situation was all too clear.
In early pregnancy it will be difficult to diagnose with an ultrasound examination. A vaginal ultrasound can reliably detect pregnancy in the womb at around 4 or 5 weeks of gestation. But if the pain symptoms and hCG levels indicate trouble before then, the scans can still be made.
The usual finding for ectopic pregnancy is a mass on one side, some fluid (blood) in the pelvis, and a lack of normal pregnancy structures in the uterus. Because ours was early, and the hCG levels were below 2000, there was some initial uncertainty ... but each of the above symptoms was present.
There are many other causes of lower stomach pain. Nonetheless, if you think you are having an ectopic, go to your doctor or nearest hospital with an Emergency department. A ruptured fallopian tube can kill you. Do not mess around. (And if they misdiagnose you at first and send you home, as they did us, go the hell back as soon as your symptoms worsen.)
Ectopic pregnancy can occur almost immediately following conception, within the first two to three weeks, or up to as late as twelve weeks later.
Surgical procedures for ectopic pregnancy can involve laparoscopy (usually same-day surgery) or laparotomy. If the fallopian tube has not ruptured, laparoscopy is usually performed. If there has been rupture, especially with significant hemorrhage into the abdomen, laparotomy will be used in order to repair the problem as quickly as possible. This may require resection of the affected area of the tube, or possibly a full salpingectomy.
In recent years, medical treatment via methotrexate (a chemotherapy drug) have been used instead. The advantage of this approach is preservation of tubal or uterine function to allow future attempts at a normal pregnancy. Methotrexate inhibits the rapid growing of cells--cancer cells or a growing pregnancy. Side effects seen with low doses of this drug are usually mild, chiefly nausea and lack of appetite. Outpatient monitoring with weekly hCG checks is required until the hCG count returns to zero. (If it does not, surgery is indicated.) Until the drug is fully flushed from the system, another pregnancy should not be attempted.
Most hospitals have social workers who can refer support groups. Beyond that, I can only refer you to my weak offering in miscarriage. It's no easier the second time around, in fact it is significantly more difficult. The spectre of recurrent ectopics makes casual "you can just try again" assurances particularly hollow.
- Daus et al, Journal of Reproductive Medicine, February, 1989, p.162
as cited on http://www.advancedfertility.com/ectopic.htm