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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 parent, 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 In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. 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 Detection of ectopic pregnancy in early gestation has been achieved mainly due to enhanced diagnostic capability. Despite all these notable successes in diagnostics and detection techniques ectopic pregnancy remains a source of serious maternal [ morbidity and mortality worldwide, especially in countries with poor prenatal care.[2 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 as a tubal abortion. Tubal abortion 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 abortions. 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
Classification
Tubal pregnancy
The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopics[clarification needed]), the ampullary section
(80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%).Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and .alterations in the tubal environment allowing early implantation to occur
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
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[clarification needed] to assure their decline, also .methotrexate can be given at the time of surgery prophylactically
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 (hematoperitoneum) 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
Causes
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), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), .smoking, previous ectopic pregnancy, and tubal ligation Although older texts suggest an association between endometriosis and ectopic pregnancy this is not evidence based and current research suggests no association between endometriosis and ectopic pregnancy
Other
Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could
act as a surrogate for other risk factors. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies.[3] Women exposed to diethylstilbestrol (DES) in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women[citation needed]. It has also been suggested that pathologic generation of nitric oxide through increased iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which .may consequently result in ectopic pregnancy
Diagnosis
.An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic .pregnancy An abnormal rise in blood -human chorionic gonadotropin (-hCG) levels may indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy is around 1500 IU/ml of -hCG. A high resolution, transvaginal ultrasound showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for -hCG has been reached. An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the -hCG level approximately 48 hours later and repeating the ultrasound. If the -hCG falls on .repeat examination, this strongly suggests a spontaneous abortion or rupture
A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a .normal looking fallopian tube Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been .derived from a ruptured ectopic pregnancy .Cullen's sign can indicate a ruptured ectopic pregnancy
Treatment
Medical
Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment[22] since at least 1993.[23] If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as .an ectopic mass > 3.5 cm
Surgical
If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a [ stable patient with minimal evidence of blood clot on ultrasound.[citation needed Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful [ surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.[24
Complications
The most common complication is rupture with internal haemorrhage which may lead to hypovolaemic shock. Death from rupture is rare in women who have access to .modern medical facilities
Prognosis
Future fertility
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. .Rate of fertility may be better following salpingostomy than salpingectomy
The case of Olivia, Mary and Ronan had an extrauterine fetus (Ronan) and intrauterine twins. All three survived. The intrauterine twins were taken out first.[32
.Leg of fetal lamb appearing out of the uterus during cesarian section
.Internal view of fetal sac, the necrotic distal part is to the left
.External side of fetal sac, proximal end, with ovary and uterine horn
References
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