Ectopic pregnancy

and Sabine Schrör, medical journalist

Sabine Schrör is a freelance writer for the medical team. She studied business administration and public relations in Cologne. As a freelance editor, she has been at home in a wide variety of industries for more than 15 years. Health is one of her favorite subjects.

More about the experts All content is checked by medical journalists.

In an ectopic pregnancy, the fertilized egg does not implant in the uterus, but in the fallopian tube. This can happen if the fallopian tube is not completely permeable. The fallopian tube can tear as a result of the growing embryo. Life-threatening bleeding in the abdominal cavity is the result. Since the symptoms of an ectopic pregnancy hardly differ from those of a normal pregnancy, only a specialist can make the diagnosis. Read more about ectopic pregnancy here!

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. O00

Brief overview

• What is an ectopic pregnancy? Pregnancy in which the fertilized egg is implanted in the fallopian tube instead of in the uterus. Most common form of ectopic pregnancy (pregnancy with implantation of the embryo outside the uterus).
• Causes: False tubes that are not or not completely permeable. Various risk factors such as sticky or kinked fallopian tubes, fallopian tube polyps, previous fallopian tube inflammations, previous fallopian tube pregnancies, abdominal or pelvic operations, smoking, IUDs, fertility disorders, artificial insemination, etc.
• Symptoms: labor-like abdominal pain, vaginal bleeding, dizziness, circulatory problems, general malaise.
• Complication: rupture of the fallopian tube with heavy bleeding into the abdominal cavity and circulatory shock (danger to life!).
• Treatment: Depending on the stage of the ectopic pregnancy. Mostly surgical removal of the embryo, if possible while preserving the affected fallopian tube. In a very early stage, possibly drug treatment. Sometimes waiting under medical supervision (the Embyro can come off spontaneously).
• Prognosis: With proper treatment, complete healing. Later pregnancies can be normal.

Ectopic pregnancy: description and causes

Ectopic pregnancy (tubal pregnancy) is the most common form of so-called extrauterine pregnancy (extrauterine pregnancy, EUG) with around 96 percent. This is understood to mean pregnancies in which the fertilized egg is implanted outside the uterus (ectopic implantation). In the case of an ectopic pregnancy, the egg cell becomes lodged in the fallopian tube. In other forms of ectopic pregnancy, the egg nests in the ovaries (ovarian pregnancy), in the cervix (cervical pregnancy) or in the abdominal cavity (ectopic pregnancy). It cannot be carried out.

This happens with an ectopic pregnancy

If the fertilized egg incorrectly nests in the fallopian tube instead of the uterus, a risky ectopic pregnancy arises.

Ectopic pregnancy accounts for one to two percent of all pregnancies.

Forms of ectopic pregnancy

Depending on where the egg cell is implanted in the fallopian tube, doctors differentiate between three types of tubal pregnancy:

• Ampullary ectopic pregnancy: implantation takes place in the first third of the fallopian tube.
• Isthmic fallopian tube pregnancy: The fertilized egg cell is implanted in the last third of the fallopian tube just before it opens into the uterus.
• Interstitial / intramural pregnancy: The fertilized egg is implanted at the transition from the fallopian tube to the uterus.

An ectopic pregnancy cannot be carried to term. Without treatment, the growing embryo can tear open the fallopian tube. This causes life-threatening bleeding in the abdominal cavity.

Causes of an ectopic pregnancy

Normally, the fertilized egg migrates through the fallopian tube into the uterus and nests there. But if the fallopian tube is not or only partially permeable, the egg remains stuck in it on its way into the uterus and grows firmly. The patency of a fallopian tube can be impaired for various reasons. These include:

• Adhesion or kinking of the fallopian tube

• Fallopian tube polyps
• congenital anatomical features such as cavities in the wall of the fallopian tube
• Scars or adhesions of the oviduct, for example from previous operations in the abdominal or pelvic area
• previous inflammation of the fallopian tubes, especially if it was caused by chlamydia.
• previous ectopic pregnancies
• Fertility disorders and artificial insemination
• Local damage to the fallopian tubes, for example due to endometriosis (foci of scattered uterine lining, for example in the fallopian tubes)
• Abortions
• Miscarriages
• Muscle weakness
• Insufficient cilia on the inner wall of the fallopian tubes (the hair-thin cilia propel the egg forward in the fallopian tube)
• Taking the morning-after pill
• hormonal imbalance
• tuberculosis

Smoking also favors the development of an ectopic pregnancy. Nicotine restricts the mobility of the cilia.

Women who use IUDs are also at an increased risk: the IUD makes it easier for microorganisms to gain access to the fallopian tubes, where they can cause inflammation. These in turn favor an ectopic pregnancy.

The number of ectopic pregnancies has increased over the past few decades. Experts discuss various reasons for this, including increased fallopian tube infections as a result of sexually transmitted diseases, more frequent fertility treatments, the use of IUDs as a contraceptive, and smoking.

Ectopic Pregnancy: Recognizing Symptoms

An ectopic pregnancy initially proceeds like a normal pregnancy:

• Missing your period
• Nausea in the morning (possibly at other times of the day)
• Tension in the breasts

Even a pregnancy test cannot differentiate between a normal and an ectopic pregnancy. It also shows a positive result for the latter. Because the placenta (placenta) forms the pregnancy hormone beta-HCG (human chorionic gonadotropin) in an ectopic pregnancy as in a normal pregnancy, to which the test reacts positively.

Ectopic pregnancy: signs

The signs of an ectopic pregnancy typically don't show up until between the sixth and ninth weeks of pregnancy. These include:

• unusual, usually one-sided, cramp-like or labor-like pain in the abdomen
• tense abdominal wall that is sensitive to touch
• Bleeding from the vagina (often as a weak, brownish discharge = spotting, but sometimes also dark red with clots of clotted blood and / or pieces of tissue)
• Dizziness and paleness
• Shortness of breath
• racing pulse
• Nausea and vomiting
• general malaise
• slightly increased temperature

The symptoms of an ectopic pregnancy can vary from woman to woman. They can also be sudden and intense, or they can increase slowly.

The symptoms mentioned are not specific to an ectopic pregnancy. Similar symptoms can also occur with inflammation of the kidneys, appendicitis, ovarian inflammation or fallopian tube inflammation. Only a doctor can determine the exact cause of the symptoms.

Ectopic pregnancy: complications

Complications occur in around three out of ten women with an ectopic pregnancy: The fallopian tube ruptures as the embryo grows. Important blood vessels (usually the uterine artery or the ovarian artery) are injured. The consequences are severe internal bleeding. Warning signs for this are sudden, very strong, unilateral abdominal pain that can radiate to the upper abdomen, back and shoulder. The loss of blood can lead to dizziness, fainting, or shock.

If there are signs of an ectopic pregnancy, you should see a doctor immediately. If the fallopian tube ruptures, there is a danger to life! Then alert the emergency doctor immediately!

Ectopic pregnancy

A very rare ectopic pregnancy, like ectopic pregnancy, is a form of ectopic pregnancy: the fertilized egg cell falls through the upper opening of the fallopian tube into the abdominal cavity and nests here - usually on the intestinal wall or the back wall of the uterus.

Usually an ectopic pregnancy is discovered during preventive ultrasound examinations. The embryo in the abdominal cavity is usually not viable. In most cases it dies on its own. If that doesn't happen, it'll be surgically removed.

You can find out more about the topic in the article ectopic pregnancy.

Ectopic pregnancy: examinations and diagnosis

If an ectopic pregnancy is suspected, the gynecologist (gynecologist) will first discuss the patient's medical history (anamnesis): He has the symptoms described in detail and asks about possible risk factors (previous ectopic pregnancies, fallopian tube infections, miscarriages or abdominal operations, endometriosis, etc. ).

Gynecological check

This is followed by a vaginal palpation examination: the internal and external palpation is part of the normal gynecological examination. The doctor can gain important information from this. If there is an ectopic pregnancy, the uterus is smaller than it should actually be based on the current week of pregnancy. The doctor may also notice during the palpation that one of the fallopian tubes is enlarged on one side.

Palpation of the fallopian tube in which the embryo has implanted can be a little painful.

Ultrasonic

Where exactly a fertilized egg has implanted can usually be determined by means of an ultrasound examination. It can be done through the vagina (transvaginal sonography). This makes it possible to see whether the pregnancy is normal (i.e. with implantation in the uterine cavity). If no egg can be seen in the uterus, this can be due to the following reasons:

• The embryo has implanted itself in the uterus, but is still too small to be recognized by ultrasound. The pregnancy is then less advanced than expected based on the last menstrual period observed.
• Although the embryo was in the uterus, it was rejected (miscarriage, abortion).
• The embryo has actually implanted outside the uterus (ectopic pregnancy such as ectopic pregnancy).

In order to check the third possibility, the gynecologist can use a special variant of the ultrasound examination, the color Doppler sonography. It can make tissue that is well supplied with blood visible - for example the area of ​​the mucous membrane in which the egg cell has lodged (e.g. in the fallopian tube).

Blood test

In addition, the doctor can determine the amount of the pregnancy hormone beta-HCG (human chorionic gonadotropin) in the blood of the pregnant woman several times over a longer period of time. In normal pregnancies, the blood level of this hormone doubles every two days. If, on the other hand, the egg has implanted incorrectly (as in an ectopic pregnancy), the HCG level rises only slowly, stagnates or even falls again.

Laparoscopy

In unclear cases, the doctor can also perform a laparoscopy. It can be determined with certainty whether there is actually an ectopic pregnancy. If so, the incorrectly nested egg can also be removed immediately during the examination (see: Treatment).

Ectopic pregnancy: treatment

Depending on how far the ectopic pregnancy has progressed, there are different treatment approaches.

Laparoscopy

If an ectopic pregnancy is associated with abdominal pain, bleeding in the abdominal cavity, or abnormal HCG levels, a laparoscopy will usually be required. This allows the ectopic pregnancy to be recognized and treated at the same time. During the procedure, the doctor inserts a so-called endoscope into the abdominal cavity through three small incisions in the abdominal wall. It's a thin, flexible hose with a light source and a small camera on top. The doctor can insert the finest medical instruments through the endoscope to remove the embryo from the fallopian tube.

Open surgery

In some cases of ectopic pregnancy, an open operation (laparotomy) is necessary: ​​the surgeon opens the abdominal wall with a larger incision to remove the embryo in the fallopian tube. Open surgery is necessary, for example, if a laparoscopy is not possible for certain reasons, if the woman has extensive adhesions or an unstable circulation. Open surgery is also necessary in cases in which the ectopic pregnancy has already led to a rupture of the fallopian tubes. This is the only way to stop the heavy bleeding as quickly as possible.

If the bleeding is very heavy or the fallopian tube is badly damaged, it sometimes has to be removed completely. However, doctors always do their best to preserve the fallopian tube whenever possible.

Medication

A very early ectopic pregnancy can also be treated with medication in individual cases. The active ingredient methotrexate is usually administered to pregnant women. The attending physician injects the cytotoxin under ultrasound control into the fruit cavity, whereby the embryo dies. In the following days, the doctor will regularly check whether the beta-HCG level in the pregnant woman's blood has fallen. This drop indicates that the pregnancy has actually ended.

Drug treatment is only possible under certain conditions. The ectopic pregnancy must not cause any discomfort. In addition, the embryo and the surrounding tissue must be smaller than four centimeters. Last but not least, the HCG level in the pregnant woman's blood must be below a certain threshold value.

Wait and watch

Many ectopic pregnancies end on their own within the first three months of pregnancy. Since the fallopian tube does not offer enough space for the growing embryo and cannot guarantee adequate supply, the egg cell bursts. Platzenta and fruit sac then detach from the wall of the fallopian tube. They come off naturally with the embryo.

So if there are no symptoms and if the level of the pregnancy hormone beta-HCG in the blood is exceptionally low, you can possibly wait a few days before starting therapy. The pregnant woman is carefully monitored. If the concentration of the pregnancy hormone continues to decrease during this time and the embryo no longer grows, the pregnancy is very likely to have ended. However, if the embryo continues to grow, the fallopian tube can tear within a very short time and lead to dangerous bleeding. One must be prepared for this possibility: It must be ensured that the pregnant woman can be operated on quickly in such an emergency.

Ectopic pregnancy: course and prognosis

An ectopic pregnancy often goes unnoticed and ends on its own - the incorrectly nested egg is rejected along with the placenta. If this does not happen, the ectopic pregnancy should be ended as early as possible with an operation or medication.

Drug treatment is considered to be gentler on the affected fallopian tube than surgery, but is only possible in certain cases. If surgery (laparoscopy, open surgery) cannot be avoided, the fallopian tubes can be preserved in most cases. Its patency is usually 80 to 90 percent after the procedure. The same also applies if the ectopic pregnancy is treated with medication.

on various factors. For example, it matters how badly the fallopian tube was damaged by the ectopic pregnancy, whether it needs to be removed and how well the second fallopian tube works. It also has an influence whether the woman has already had more than one ectopic pregnancy. For example:

After a first ectopic pregnancy that was surgically terminated (while preserving the affected fallopian tube), the risk of a second such ectopic pregnancy is around 15 percent. If a woman has already had two ectopic pregnancies, the "recurrence risk" is around 40 percent.

In general, however, the following applies: More than half of all women who have had an ectopic pregnancy (or other ectopic pregnancy) will have a child later.

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