Ectopic Pregnancy: Meaning, Causes, Diagnosis, Treatments, and Concerns
Ectopic Pregnancy is a scary topic and one that not many people know about. Below, Board Certified Reproductive Endocrinologist and Fertility Expert Dr. Edward Ditkoff answers some questions regarding what an ectopic pregnancy is, it’s causes, diagnoses, treatments, future concerns and more.
Q: What does ectopic pregnancy mean?
A: The definition of an ectopic pregnancy is a pregnancy that occurs outside the uterine cavity. The most common site for an ectopic pregnancy is the fallopian tube, however, there are other areas where an extra-uterine pregnancy may attach. Extra-uterine or ectopic pregnancies may also occur in other areas, such as the ovary, the interstitial or cornual part of the uterus. This is the part of the uterus between where the fallopian tube and uterus join. They can occur in the cervix—called cervical pregnancies, abdominal pregnancies and even Caesarean scar pregnancies. Ectopic pregnancies can even occur while there is a normal pregnancy in the uterus. This is called a hetero-ectopic pregnancy. These are different meanings of an ectopic pregnancy.
Q: Why does an ectopic pregnancy happen?
A: It’s felt that any patient with any underlying tubal disease or tubal damage or trauma is at increased risk for an ectopic pregnancy. On the other hand, any pregnant woman could potentially have an ectopic pregnancy even without these risk factors. As mentioned, damage to the fallopian tubes will predispose these women to an ectopic pregnancy. High-risk conditions include: prior ectopic pregnancy, history of tubal surgery, previous tubal sterilization, history of any sexually transmitted infections, tubal infection or pelvic adhesions, and current use of an IUD can increase the probability of having an ectopic pregnancy if one is pregnant with an IUD in place. Conceptions resulting from IVF are thought to increase the risk of an ectopic pregnancy up to 1% (or 1 out of 100). Those are various reasons why it happens.
Q: How is it diagnosed?
A: It’s diagnosed primarily by testing hCG levels in the blood and ultrasound examination. These are the two most useful methods of diagnosing an early ectopic pregnancy. It is said that hCG levels should increase at a minimum of at least 53% over a 48-hour period. Once the hCG level reaches that conservative/discriminatory number, it’s felt that the pregnancy should be visualized in the uterine cavity by that time. In other words, if the hCG level is not rising appropriately and/or the hCG level is above the discriminatory zone and there is no evidence of a pregnancy in the uterus, these patients are considered at high risk for an ectopic pregnancy and should be followed more closely.
Q: How is it treated?
A: Typically, if an ectopic pregnancy is not ruptured, it’s generally treated these days by using methotrexate. There are two methotrexate protocols that are generally used. We generally use what’s called the single methotrexate protocol. The single dose methotrexate treatment protocol means that once we suspect there is an ectopic pregnancy and there are no contraindications to the use of methotrexate, then this drug is given. In the case of a ruptured ectopic pregnancy or an urgent medical condition where the patient is at risk for bleeding and having hemodynamic instability, then surgery becomes the treatment for ectopic pregnancy. The single methotrexate dose is thought to be 15 mg/m2 intramuscular. That dose is given and then four days later the patient has her hCG level rechecked and again three days after that. Day 1 is the first day of treatment; Day 4 and Day 7 are follow-up checks of hCG levels. If the hCG level is not decreasing by more than 15%, then the second dose of methotrexate would be given.
Sometimes ectopic pregnancies are treated empirically because we don’t really know where the pregnancy is. The two main forms of treatment are methotrexate, which is medical management, and surgery, which is surgical management.
Q: What concerns might a woman have if she wants to become pregnant again?
A: Unfortunately, patients who have had one ectopic pregnancy are at increased risk for having another ectopic pregnancy. The odds ratio is ten-fold increased in a patient with a history of one ectopic pregnancy compared to the general population. On the other hand, if someone has had at least 2-3 ectopic pregnancies, their risk factor goes up another 25%. Women with a prior history of an ectopic pregnancy need to be followed very carefully once they suspect they are pregnant. If they miss a period or if they are having irregular vaginal bleeding, they should be evaluated to see if they are pregnant because of this high degree of recurrent risk of another ectopic pregnancy.
Q: What other measures might your doctor take to monitor the pregnancy?
A: I think the best measure we can take in these types of patients is to see them as early as they are pregnant and follow the hCG blood test levels, as I mentioned earlier, to make sure the levels are rising appropriately so we can visualize a pregnancy in the uterine cavity at the earliest time possible. Typically, we can see a gestational sac in the uterus by 5 – 5 ½ weeks pregnant, and we could/should hopefully see a heartbeat by 6 weeks gestation. However, because dating of ovulation is not always precise, we have to be lenient and look at the big picture because we don’t want to treat a patient with methotrexate prematurely.
Q: William Kiltz
A: Dr. Edward Ditkoff, Board Certified Reproductive Endocrinologist and Fertility Specialist