The EPT

Who is at risk of ectopic pregnancy?

Who is at risk? Any sexually active woman of childbearing age is at risk of an ectopic pregnancy. However, ectopic pregnancies are more likely if you have had: -

• Pelvic Inflammatory Disease – a past infection of the fallopian tubes (for example, by an organism called Chlamydia).
• Endometriosis – a condition which could cause damage to the tubes.
• Abdominal surgery – any previous operation on the tummy, such as caesarean section, appendectomy or previous ectopic pregnancy.
• An operation on the tubes – such as sterilisation.
• A contraceptive coil (IUCD) fitted -the coil prevents a pregnancy in the uterus but is less effective in preventing a pregnancy in the tube.
• Are on the ‘mini-pill’ (progesterone-only pill) – this type of contraceptive pill alters motility of the tube.
• Become pregnant in the same cycle, after trying to prevent pregnancy with emergency oral contraception (the morning after pill.)
• Fertility treatment (eg IVF).
• A previous ectopic pregnancy.

How is Ectopic Pregnancy diagnosed?

Ectopic can be notoriously difficult to diagnose as it can often present with symptoms which can be suggestive of gastroenteritis, miscarriage or even appendicitis.

However, where ectopic is being considered, we  at the EPT have what we suggest are the gold standard – doctors are at liberty to follow their own protocols, and in the UK if they use anything at all, it is the Greentop Guidelines.

What we would suggest if someone is suspected of suffering with ectopic pregnancy is to do an ultrasound scan and to follow up with beta hCG blood tests 48 hours apart if the scan is inconclusive.

What are hCG levels?

The hormone human chorionic gonadotropin (better known as hCG) is produced during pregnancy. It is made by specialised trophoblast cells, which are only found in the body as a result of a fertilised egg implanting, and which eventually would develop into the placenta, which nourishes the egg, after it has been fertilised and has attached(ideally) to the uterine wall. Levels of hCG can first be detected by a normal blood test about 11 days after conception and about 12 – 14 days by a urine test. In general, the hCG level will double every 48 to 72 hours. The levels will reach their peak somewhere between 8 to 11 weeks of pregnancy (the end of the second beginning of the third month) and then will decline and level off for the remainder of the pregnancy.

About 85% of normal pregnancies will have the hCG level double every 48 – 72 hours. As the pregnancy progresses and the hCG level gets higher, the time it takes to double can increase to about 96 hours.

What do they tell us?

They tell us that a fertilised egg has implanted. If levels are rising normally, they can give a suggestion (but not a certain answer) that the pregnancy is implanted in the uterus. If they are rising by less than 66% over 48 hours this suggests (but is not a certain indication) that the pregnancy may be ectopic. If they are falling over this time period, it tells us that the pregnancy has ended and will be miscarried over the next days or weeks.

Why do women need to wait until hCG levels are a certain number before they start trying to conceive again after an ectopic pregnancy or other loss?

If a woman has hCG levels in her system because of a growing pregnancy, then the hCG naturally suppresses ovulation. It is not possible to become pregnant a second time until the hCG levels have fallen to a level of less than 5mIU/mL

Should I know what my level is?

Your hCG would only need to be tested if you have reached 6 weeks pregnant and the scan does not clearly show a developing pregnancy in the uterus. The hCG can then indicate a failing pregnancy or ectopic pregnancy as described above.

I am worried about shoulder-tip pain. Please describe it.

Shoulder tip pain is the typical pain of ectopic pregnancies. This may be due to internal bleeding irritating the diaphragm when you breathe in and out. It is exactly where it says – not the neck or the back but the tip of your shoulder. If you look to the left over your shoulder and then cast your eyes down, the tip of your shoulder is where your shoulder ends and your arm starts.

Shoulders cause pain when we are stressed because we hold our selves more rigidly, and muscles in the back and neck go in to spasm – this is not shoulder tip pain. Shoulder tip pain is very distinctive and you know when you have it because it is a very ‘weird’ pain you have never had in your life before (unless you had pain of this nature with gall stones).

If you take 2 paracetamol (which are known to be safe in pregnancy, and providing you have taken this medicine in the past without problems), apply a cold pack to your shoulder for 10 minutes, and find that 30 minutes later your shoulder pain has eased, that is unlikely to be ectopic related shoulder pain. However if in any doubt, consult your doctor about it.

Is ectopic pregnancy an abortion?

Definition of abortion

In medicine, an abortion the term used for the premature exit of the products of conception (the foetus, foetal membranes, and placenta) from the uterus. It is the loss of a pregnancy and does not refer to why that pregnancy was lost. A spontaneous abortion is a medical term used to describe a miscarriage. The miscarriage of 3 or more consecutive pregnancies is termed in medicine as habitual abortion.

Ectopic pregnancy is not and never could be regarded as an abortion in the more widely understood meaning of the word. Ectopic pregnancy is a life-threatening condition, where the egg has implanted outside of the uterus. If left unmanaged, it can cause a rupture or breach of the wall of the structure it has attached itself to, with the consequence of life threatening internal bleeding, possibly resulting in the death of the mother. In the UK it is still the most common cause of maternal death.

The Catholic church does not accept all methods of managing an ectopic pregnancy. It has ruled that early intervention with a drug called methotrexate, which stops the cells of the pregnancy dividing, is morally and ethically unacceptable. It does however accept that surgical intervention with the removal of the ectopic pregnancy is acceptable. It is very important when considering these issues to be clear about the medical terminology.

Conclusions

Abortion is a generic medical term to describe the premature exit of the products of conception from the uterus before 28 weeks, but is becoming less commonly used in medicine because of the confusion the term creates.

Elective termination of pregnancy is a surgical procedure to evacuate the usually viable products of conception from the uterus and is an elective (ie chosen) procedure. This is also sometimes called abortion. Elective termination can also be a choice, following antenatal test results which confirm that the foetus has a condition which is not compatible with life. Conditions described as not compatible with life will result in the baby being unable to survive outside the uterus and would usually result in a stillbirth or the birth of a baby who dies shortly after delivery.

Miscarriage is an event where the pregnancy ends naturally at any point before 28 weeks of pregnancy. Viability has usually ended for the foetus before the miscarriage occurs. In some cases, following a miscarriage where the pregnancy has ended but the woman has not begun to bleed or may be bleeding only slightly, doctors may perform a surgical procedure referred to as an ERPC  – this is short for the evacuation of the retained products of conception. This is also not a termination of pregnancy or abortion in the normal usage of the word.

Ectopic pregnancy is a life threatening condition which, if not medically managed and or treated, can end the life of the mother. It should not be confused either with miscarriage which is not usually life threatening, or with an elective termination of pregnancy which is a surgical procedure to end a viable pregnancy or with one which ends a pregnancy where the foetus has a condition which is not compatible with life.  An ectopic pregnancy is an out of place pregnancy and so does not fit the medical definition of premature exit of the products of conception from the uterus. In the majority of instances (more than 90%) of ectopic pregnancy the foetus has never been viable and there has never been a heartbeat.

Some doctors use the term ‘tubal abortion’ to explain why no products of conception can be found in a ruptured tube, when it is examined after the diagnosis and treatment of ectopic pregnancy but again, this is not the same as the premature exit of the products of conception from the uterus. Tubal abortion refers to the products of conception separating from the wall of the fallopian tube to be passed in much the same way they might be in a miscarriage.