Introduction:
Ectopic pregnancy is a high-risk pregnancy that happens in 1.9 % of reported pregnancies. This is the prime cause of pregnancy-related death during the first trimester. If abdominal pain, syncope, vaginal bleeding, or hypotension is present in women of reproductive age, then healthcare professionals should perform a pregnancy test. Suppose the transvaginal scan shows no signs of the intrauterine gestational sac and a patient has a human chorionic gonadotropin level of more than 1,500 mIU per mL. In that case, ectopic pregnancy should be suspected. The health care professionals should offer appropriate treatment for women with non-ruptured ectopic pregnancy; they may include medical management with Methotrexate, expectant management, or surgery. This article explains in detail the management of ectopic pregnancy.
What Is an Ectopic Pregnancy?
When pregnancy happens outside of the uterus, it is referred to as ectopic pregnancy. Usually, the fertilized egg implants into the lining of the uterus. An ectopic pregnancy commonly occurs in a fallopian tube (a tube that connects the uterus and the ovaries). An ectopic pregnancy can occur in other areas of the body, like the ovary, the lower part of the uterus (cervix), and the abdominal cavity. This is a life-threatening condition, and the pregnancy cannot proceed normally. This is because the fertilized egg can not survive outside the uterus and cause severe bleeding, which can be harmful to the mother.
What Is the Treatment for Ectopic Pregnancy?
The fetus cannot grow outside of the uterus, so the treatment involves the removal of the fetus before growing too big, as it can cause serious complications for the mother.
1) Expectant Management - If there are mild or no symptoms and the pregnancy cannot be found in such cases, close monitoring is advised. This is because there is a high chance of pregnancy dissolving by itself; this is referred to as expectant management. The benefit of this treatment is this treatment does not have any side effects. During the treatment, the doctors may advise doing the following:
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Regular blood tests are advised to check the drop in the hCG (human chorionic gonadotropin hormone) level in the blood.
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If there is no drop or increase in the level of hCG, then further treatment is planned.
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Vaginal bleeding can be noted. If vaginal bleeding occurs, sanitary pads should be used rather than tampons.
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In case of abdominal pain, the use of pain relievers may be advised.
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But in some cases, the fallopian tube can rupture, which may require further treatment.
2) Medications - If the diagnosis of an ectopic pregnancy is made in the early stage, but active monitoring is not possible, then medication is prescribed. Methotrexate is commonly prescribed for ectopic pregnancy. A single dose of Methotrexate is injected into the buttocks of the patient. A second dose is hardly required. The mechanism of action of the drug is to stop the pregnancy from growing. The patient will not need to stay in the hospital after treatment, but regular blood tests will be carried out to check if the treatment is working.
The indications for medications in an ectopic pregnancy are as follows:
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No signs or symptoms of active bleeding.
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If the ultrasound identifies the pregnancy outside the uterus.
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Absence of cardiac activity in fetus on ultrasonographic findings.
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There should not be any evidence of tubal rupture.
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The patient must be able to return for follow-up care.
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The gestation size should not exceed four centimeters at its greatest dimension on ultrasonographic measurement. When this size is exceeded, then medical therapy is contraindicated.
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Beta-HCG level should be less than 5000 mIU/mL.
Reliable contraception should be used for at least three months after the treatment because Methotrexate can be harmful to a baby if women become pregnant during this period. Alcohol should be avoided until told by a doctor, as drinking soon after getting a dose of Methotrexate can be harmful to the liver. Dizziness, abdominal pain, fatigue, and diarrhea are other side effects of Methotrexate.
3) Surgery - Linear salpingostomy and total salpingectomy are common surgical procedures done in patients with ectopic pregnancies.
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Linear Salpingostomy - Linear salpingostomy is the best procedure for unruptured ectopic pregnancies. The involved fallopian tube is identified, then freed from surrounding structures. To reduce bleeding, Vasopressin in a dose of 20 mL may be injected into the mesosalpinx. Care should be taken to avoid injecting into the blood because intravascular injection of Vasopressin can cause bradycardia (slow heart rate) and acute arterial hypertension.
A one to two-centimeter incision is made along the fallopian tube's convex side along the gestation's thinnest segment. While doing so, the fetus usually protrudes and may slip out of the tube. And the bleeding from the fallopian tube is stopped using micro bipolar forceps. However, this technique carries a higher rate of bleeding, tubal damage, remnants of the fetal tissues, and recurrent ectopic pregnancy.
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Total Salpingectomy - In some cases, resection of the fallopian tubal segment containing the gestation is preferred over salpingostomy. This is done in cases of isthmic pregnancies where the mucosal lining of the fallopian tube is usually damaged. If linear salpingostomy is performed in such patients, there is a high rate of recurrent ectopic pregnancy.
This is performed by grasping the tube at both the end containing the gestation, and coagulation is done thoroughly from the outer surface of the tube, and then this portion is excised. The fallopian tube segment is coagulated and excised to reduce the damage to the surrounding vasculature.
Recovery - Proper pain control is achieved by pain relievers, and hemodynamic stability is maintained and monitored. Mostly, if a laparoscopy procedure is performed, then the patient is discharged on the same day of the procedure. However, in some cases, overnight admission may be required in order to achieve adequate pain control and monitor postoperative bleeding. If a laparotomy is performed, hospitalization is required for a few days.
Conclusion:
Ectopic pregnancy is a high-risk pregnancy because severe bleeding can happen if the fallopian tube rupture, and it can be life-threatening for the mother. So when a woman is diagnosed with ectopic pregnancy, appropriate treatment should be planned to avoid any complications.
