75–80 % of EPs occur. Contraindications include liver, kidney, or blood disease, as well as an ectopic embryonic mass > 3.5 cm. r In France, the single dose protocol is followed, but a single dose has a greater chance of failure. In around 60% of cases, it is an inhomogeneous or a noncystic adnexal mass sometimes known as the "blob sign". Most often, such a pregnancy occurs for no apparent reason and is always unexpected, but doctors can still distinguish the high-risk group. This is related to the increasing number of cesarean deliveries and the advances in imaging. An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in one of the fallopian tubes. [1] This may require testing on more than one occasion. Isthmic ectopic pregnancy 1. Severe bleeding may result in a fast heart rate, fainting, or shock. Ectopic pregnancy can be caused when the fertilized egg cannot pass easily into the uterus and attaches to other areas. h Endometriosis 4. Ectopic pregnancy (EP) is defined as the implantation of an embryo at a location outside of the uterine cavity (Sivalingam et al. The estimated reading time is less than a minute. Scarring to the fallopian tubes (possibly from a ruptured appendix or previous pelvic surgery) 3. [23] Women exposed to DES in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy. [1], Prevention is by decreasing risk factors such as chlamydia infections through screening and treatment. [4], Persisting PUL is where the hCG level does not spontaneously decline and no intrauterine or ectopic pregnancy is identified on follow-up transvaginal ultrasonography. An untreated ectopic pregnancy can be a medical emergency. [63] In comparison, the cumulative pregnancy rate of women under 40 years of age in the general population over two years is over 90%. [4] Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. [4] Ectopic pregnancies where there is visualization of cardiac activity are sometimes termed "viable ectopic".[4]. In addition, for each of the types of ectopic pregnancy, a schematic representation and examples on 2D and 3D ultrasound are provided. This may help in identifying failing PUL that are at low risk and thereby needing less follow-up. Hair-like cilia located on the internal surface of the fallopian tubes carry the fertilized egg to the uterus. Source: AHIMA Press. [4], Dilation and curettage (D&C) is sometimes used to diagnose pregnancy location with the aim of differentiating between an EP and a non-viable IUP in situations where a viable IUP can be ruled out. [2], The rate of ectopic pregnancy is about 1% and 2% that of live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology. If left untreated, it can cause organ damage or death. This page was last edited on 23 February 2021, at 15:40. Background: Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. This leaflet aims to explain what ectopic pregnancy is, to provide you with information and to answer some of the most common questions about both facts and feelings. Ectopic pregnancy can be a very distressing and frightening experience. B. Tubal. Death from rupture is the leading cause of death in the first trimester of the pregnancy. In conclusion, when ectopic pregnancy is suspected, as well as diagnosis of ectopic pregnancy, non-tubal and other rare types should be considered when no tubal ectopic is detected. With the increase in Cesarean sections performed worldwide,[38][39] cesarean section ectopic pregnancies (CSP) are rare, but becoming more common. [4] Between 6% and 20% of pregnancy of unknown location are subsequently diagnosed with actual ectopic pregnancy. [3] The first known description of an ectopic pregnancy is by Al-Zahrawi in the 11th century. [4] People that undergo salpingectomy and salpingostomy have a similar recurrent ectopic pregnancy rate of 5% and 8% respectively. In a normal pregnancy, the sperm fertilizes the egg in the fallopian tube and implants it into the spongy lining of the uterus. Types of ectopic pregnancy. In the case of an ectopic pregnancy, the fertilized egg doesn’t attach to the uterus. [1] The primary goal of diagnostic procedures in possible ectopic pregnancy is to triage according to risk rather than establishing pregnancy location. An ectopic pregnancy is a type of miscarriage that happens when a fertilized egg attaches outside of the uterus. This sign has been estimated to have a sensitivity of 84% and specificity of 99% in diagnosing ectopic pregnancy. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. Intramural pregnancy 8. [32] If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. An ectopic pregnancy occurs when the embryo implants outside the uterus, usually in one of the fallopian tubes. {\displaystyle hCG~ratio={\frac {hCG~at~48h}{hCG~at~0h}}}, An hCG ratio of 0.87, that is, a decrease in hCG of 13% over 48 hours, has a sensitivity of 93% and specificity of 97% for predicting a failing pregnancy of unknown location (PUL). Transvaginal ultrasonography has a sensitivity of at least 90% for ectopic pregnancy. Previous ultrasounds had not discovered the problem. The ovary is distinguished from it by having follicles, whereof one is visible in the field. [64], Methotrexate does not affect future fertility treatments. Ectopic pregnancies are rare but serious, and they need to be treated. Transvaginal ultrasonography of an ectopic pregnancy, showing the field of view in the following image. [1] Severe bleeding may result in a fast heart rate, fainting, or shock. Fallopian pregnancy. [54], The United States uses a multi dose protocol of methotrexate (MTX) which involves 4 doses of intramuscular along with an intramuscular injection of folinic acid to protect cells from the effects of the drugs and to reduce side effects. a and b. The working group formulated 17 recommendations on the diagnosis of the different types of ectopic pregnancies on ultrasound. Types of Ectopic Pregnancy: There are different types of ectopic pregnancies. Types of ectopic pregnancy. [23] If however both tubes were completely blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. What are the symptoms of teenage pregnancy? For this reason hCG levels may have to be monitored after removal of an ectopic pregnancy to assure their decline, also methotrexate can be given at the time of surgery prophylactically. It is important to recognize this type because of the potential of life-threatening hemorrhage if dilatation and curettage is attempted. C The different types of ectopic pregnancy are classified based on the place outside the womb where the embryo attaches. [1] The pain may be described as sharp, dull, or crampy. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. Ovarian In the case of an ectopic pregnancy, the fertilized egg is implanted outside the uterus, and it is more dangerous than it appears as it can be fatal to the mother. Septic . Ectopic pregnancy is defined as the implantation of a fertilized ovum outside the normal endometrial lining of the uterine cavity, and it accounts for 1–2% of all pregnancies [1, 2].The true incidence of ectopic pregnancy is unknown but it accounts for 18% of women seen in the emergency room for first trimester vaginal bleeding, or abdominal pain, or both []. July 15, 2019 at 12:00 am 1. Ectopic gestation exists in mammals other than humans. Instead, it may attach to the fallopian tube, abdominal cavity, or cervix. = of cases of tubal ectopic pregnancy. Progestin-only birth control pills 6. [28] 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. t G On color Doppler imaging, the hypervascular trophoblastic ring is seen . Ectopic pregnancy (EP) describes any pregnancy implantation outside of the uterine cavity. [42][45][46] Given the rarity of the diagnosis, treatment options tend to be described in case reports and series, ranging from medical with methotrexate or KCl[47] to surgical with dilation and curettage,[48] uterine wedge resection,[citation needed] or hysterectomy. There are five types of Ectopic Pregnancies. [56] It is estimated that an acceptable rate of PULs that eventually undergo surgery is between 0.5 and 11%. A significant number of Catholic moralists consider use of methotrexate and the salpingostomy procedure to be not "morally permissible" because they destroy the embryo; however, situations are considered differently in which the mother's health is endangered, and the whole fallopian tube with the developing embryo inside is removed.[70][71]. No visible IUP on transvaginal ultrasonography with a serum hCG of more than 2000 mIU/ml. [2] The use of the medication methotrexate works as well as surgery in some cases. E. No difference . Primary hepatic pregnancy 5. [1] The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography increases the likelihood of an ectopic pregnancy 100-fold (LR+ 111). Leg of fetal lamb appearing out of the uterus during caesarian section. Pregnancy occurs in the blind rudimentary horn of a bicornuate uterus. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP). [4], For nontubal ectopic pregnancy, evidence from randomised clinical trials in women with CSP is uncertain regarding treatment success, complications and side effects of methotrexate compared with surgery (uterine arterial embolization or uterine arterial chemoembolization). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883. History of inferti… [1], Most women with a PUL are followed up with serum hCG measurements and repeat TVS examinations until a final diagnosis is confirmed. This is called a heterotopic pregnancy. 1. Call your doctor immediately if you have heavy vaginal bleeding that causes lightheadedness, fainting, or shoulder pain. [58], Published reports that a re-implanted embryo survived to birth were debunked as false. The serum hCG ratios and logistic regression models appear to be better than absolute single serum hCG level. h No signs of intrauterine nor extrauterine pregnancy on transvaginal ultrasonography. Causes. Endometriosis. [9][10][11], There are a number of risk factors for ectopic pregnancies. Use of an IUD 7. Ectopic pregnancy occurs in an estimated 1 to [4] The diagnostic ultrasonographic finding in ectopic pregnancy is an adnexal mass that moves separately from the ovary. A majority of ectopic pregnancies are tubal, but extra-tubal pregnancy may pose more challenges in diagnosis and treatment. The reason for the site of implantation is still unclear, but, is/are associated with some forms of infections, anatomical abnormalities, and some birth control methods. An ectopic pregnancy must be excluded by ultrasound. Signs and symptoms of ectopic pregnancy include increased hCG, vaginal bleeding (in varying amounts), sudden lower abdominal pain,[4] pelvic pain, a tender cervix, an adnexal mass, or adnexal tenderness. Pregnancy of unknown location (PUL) is the term used for a pregnancy where there is a positive pregnancy test but no pregnancy has been visualized using transvaginal ultrasonography. In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. Implantation occurs in the isthmus of uterine tube, the closest segment to the uterus. An ectopic pregnancy occurs when an embryo implants somewhere other than the uterus, such as in one of the fallopian tubes. [4] The majority of cases of ectopic pregnancy will have serial serum hCG levels that increase more slowly than would be expected with an IUP (that is, a suboptimal rise), or decrease more slowly than would be expected with a failing PUL. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, 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. [4] Mathematical models also aim to identify PULs that are low risk, that is, failing PULs and IUPs. An ectopic pregnancy is any pregnancy which is implanted at a site outside of the uterine cavity. [4] In another 20% of cases, there is visualization of a gestational sac containing a yolk sac or an embryo. Types of Ectopic pregnancy. Maternal morbidity and mortality from extrauterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. [1] Of these, in turn, 13% are located in the isthmus, 75% are located in the ampulla, and 12% in the fimbriae. The diagnosis and … In the UK, 1 in 80-90 pregnancies are ectopic. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[34]. Pregnancy after hysterectomy 3. The kind of ectopic pregnancy a person has depends on where the fertilized egg implants. [4] In cases of pregnancy of unknown location and a history of heavy bleeding, it has been estimated that approximately 6% have an underlying ectopic pregnancy.   Test your skills with a new coding question from Clinical Coding Workout every Monday. Click on each one to read more. [4] High-risk cases of PUL require further assessment, either with a TVS within 48 h or additional hCG measurement.[4].   How many teenage pregnancy are there a year in the US? [4], Salpingectomy as a treatment for ectopic pregnancy is one of the common cases when the principle of double effect can be used to justify accelerating the death of the embryo by doctors and patients opposed to outright abortions. The fallopian tube is the dominan t site [24] in the majority. The tubes have a delicate mucous membrane lining inside the tube, thrown up into folds, which almost fill each tube (see diagram below). C. Ampulla . . Multiple Ectopic pregnancy 2. D. Fimbria . Symptoms of an ectopic pregnancy include pelvic pain, lower back pain, abnormal vaginal bleeding, and dizziness. Other types of pregnancies that result in a miscarriage are outlined below. Diagnosing an ectopic pregnancy can be challenging, as confirming the location of the embryo is not always clear-cut early in pregnancy. Most cases occur in the fallopian tube and are thus sometimes called tubal pregnancies. An empty uterus with levels higher than 1500 mIU/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. [4] A treated persistent PUL is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation. [6] The word "ectopic" means "out of place".[7]. [4], Because of frequent ambiguity on ultrasonography examinations, the following classification is proposed:[4], In women with a pregnancy of unknown location, between 6% and 20% have an ectopic pregnancy. [4], Currently, Doppler ultrasonography is not considered to significantly contribute to the diagnosis of ectopic pregnancy. [23] This risk is not reduced by removing the affected tube, even if the other tube appears normal. However, in as many as one third[12] to one half[13] no risk factors can be identified. TYPES-1) Tubal pregnancy 2) Abdominal pregnancy 3) Cervical pregnancy. Labelled diagram of the different types of ectopic pregnancy. Also known as tubal pregnancy, a fallopian ectopic pregnancy can be further divided into three sub-types: Ampullary (in the middle part of the fallopian tube), accounting for 80% of ectopic pregnancies; Isthmic (in the upper part of the fallopian … A heterotopic pregnancy is a "hybrid" type of ectopic pregnancy in which an extrauterine and intrauterine pregnancy occur at the same time. [4] Maternal morbidity and mortality are reduced with treatment. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. [1] In the absence of ultrasound or hCG assessment, heavy vaginal bleeding may lead to a misdiagnosis of miscarriage. Ectopic Pregnancy Types. In general, the options are: [74], On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8 kg) baby girl, Durga, via caesarean section. [4] The presence of echogenic fluid is estimated at between 28 and 56% of women with an ectopic pregnancy, and strongly indicates the presence of hemoperitoneum. C [4], A common misdiagnosis is of a normal intrauterine pregnancy is where the pregnancy is implanted laterally in an arcuate uterus, potentially being misdiagnosed as an interstitial pregnancy. Cesarean scar ectopic pregnancy (CSEP) is a rare type of abnormal implantation. [4] Treatment should only be considered when a potentially viable intrauterine pregnancy has been definitively excluded. It is important to recognize this type because of the potential of life-threatening hemorrhage if dilatation and curettage is attempted. Non tubal pregnancy –types Cervical(0.1-1%) Ovarian(0.5-2%) Abdominal(0.3-0.5%) Interstitial(2-3%) Angular Cornual(1:1lakh) Heterotropic Multiple ectopic pregnancy Ectopic in caesarean scar<1%) Pregnancy after hysterectomy 72. Can caffeine cause miscarriage in early pregnancy? [1] Other causes of similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis. A person need not have identifiable risk factors to have an ectopic pregnancy, but some known risk factors are: 1. [17] The risk of ectopic pregnancy after chlamydia infection is low. For instance, in the UK, between 2003 and 2005 there were 32,100 ectopic pregnancies resulting in 10 maternal deaths (meaning that 1 in 3,210 women with an ectopic pregnancy died). Test your skills with a new coding question from Clinical Coding Workout every Monday. The fallopian tube is the dominan t site [24] in the majority. [4] A further marker of serious intra-abdominal bleeding is the presence of fluid in the hepatorenal recess of the subhepatic space. [22] This results from the build-up of scar tissue in the fallopian tubes, causing damage to cilia. Additionally, their intrauterine pregnancy rates are also similar, 56% and 61%. Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks of pregnancy. An ectopic pregnancy occurs when an embryo implants somewhere other than the uterus, such as in one of the fallopian tubes. [29] The low socioeconomic status may be risk factors for ectopic pregnancy. 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. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP). If you smoke or drink during pregnancy, this can increase your risk of an ectopic pregnancy. [35][36][37] However, the vast majority of abdominal pregnancies require intervention well before fetal viability because of the risk of bleeding. [2] Surgery is still typically recommended if the tube has ruptured, there is a fetal heartbeat, or the person's vital signs are unstable. In such a situation the placenta sits on the intra-abdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Ectopic pregnancies happen when a fertilized egg implants someplace other than in the uterus, such as in one of the fallopian tubes. Cervical ectopic pregnancy is a very rare type (<1%). The embryo attaches in the Fallopian tube, causing inflammation and blockage. [4] Ectopic pregnancy is responsible for 6% of maternal deaths during the first trimester of pregnancy making it the leading cause of maternal death during this stage of pregnancy. Ectopic pregnancy. The most common implantation site for an EP is the Fallopian tube, commonly referred to as a tubal ectopic pregnancy (tEP) Sivalingam et al. Tubal ectopic pregnancy—the fertilized ovum was implanted anywhere within the fallopian tube. A pregnancy can’t survive outside of the uterus, so all ectopic pregnancies must end. The father, John Dalton took home video inside the delivery room. 1. With very rare exceptions the fetus is unable to survive. Types of pregnancy loss. When there are no adnexal abnormalities on transvaginal sonography, the likelihood of an ectopic pregnancy decreases (LR- 0.12). Ectopic pregnancies can be divided into the follwoing categories: Tubal pregnancy / ampullary pregnancy – Pregnancy occurring in the fallopian tube mostly located in the ampullary portion of the fallopian tube, almost 80% Ectopic pregnancies are tubal pregnancy Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the fallopian tubes is likely to lead to an ectopic pregnancy.
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