Eccyesis or tubal pregnancy refers to the implantation of the blastocyst outside the uterine cavity. Thereby, affected patients suffer from acute abdominal pain. Eccyesis or tubal pregnancy can be quickly diagnosed by means of an ultrasound and laboratory analysis. In severe cases, in the case of rupture and hemorrhage, the fastest possible action is required. Surgery comes into question from a therapeutical viewpoint.

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ectopic pregnancy

Image: “ectopic pregnancy” by Hic et nunc. Licence: CC BY-SA 3.0

Definition of Ectopic Pregnancy

Eccyesis or tubal pregnancy as ectopic pregnancy

In the case of ectopic pregnancy, the implantation of a blastocyst outside the uterine cavity takes place (cavum uteri (uterine cavity)).

Epidemiology of Ectopic Pregnancy

Dissemination of ectopic pregnancy

Cases of ectopic pregnancies occur worldwide much more frequently and have already doubled in part. This accumulation is attributed, among other things, to an improved diagnosis. Secondly, intrauterine devices represent a risk factor for multiple emergences. Ascending genital infections and infertility treatments also implement a high risk for it.

Etiology of Ectopic Pregnancy

Causes of ectopic pregnancy

The biggest number of all ectopic pregnancies is manifested in the tubes (= tubal pregnancy). The uterine tube is divided into such parts as: ampulla, isthmus and intramural. The ampulla portion is affected more often. The isthmic and intramural portions are affected less often.

Approximately 1 % of ectopic pregnancies can affect the uterus, ovary, peritoneum (= abdominal pregnancy) or the cervix.

Ectopic Pregnancy

Image: “Ectopic Pregnancy” by BruceBlaus. Licence: CC BY-SA 4.0

Pathogenesis of Ectopic Pregnancy

Origin and development of ectopic pregnancy

The tubal mucosa is similar to the endometrium of the uterus in its ability to convert decidually, though not to a comparable extent. When a fertilized egg on the 5th or 6th day is not yet in the womb it settles at the corresponding location of nidation. This is usually the tube.

The reasons may be disorders connected with the ovulation mechanism and tubal passage. The tube passage may be blocked by congenital anomalies and acquired obstacles. In addition, functional impairment is possible in terms of disruption of cilium activity or tube motility.

Frequently, adhesions are the cause for a blockade of transport from the fimbrian funnel to the uterine cavity. This can happen due to inflammation as for example in the case of adnexitis. Adhesions can also be caused by endometrial implants, surgical interventions (for example scarring) or previous ectopic pregnancies.

Women with an intrauterine device (= IUD) are more often affected by ectopic pregnancy than women without IUDs. A decreased peristalsis might be the reason.


Symptoms of ectopic pregnancy

The ectopic pregnancy is an important differential diagnosis for the acute abdomen. Here, the symptoms vary greatly. It depends on the localization of an ectopic pregnancy, the condition of the pregnancy product (an embryo is intact or already dead) and the age of the pregnancy. Thus, asymptomatic processes as well as very painful symptoms up to a circulatory shock are possible. In addition, symptoms may be described corresponding to unsafe pregnancy signs. These include breast tenderness and morning sickness.

Initially, secondary amenorrhea is usually designated. After about 5 weeks, a unilateral pain appears in the adnexal region. This may also be accompanied by spotting. This bleeding usually corresponds to a hormonal withdrawal bleeding and less to the bleeding directly from the tube.

Pain symptoms in the shoulder area may arise, if the tube has been already ruptured (often a result of an ectopic pregnancy at the isthmus), and the case has already come to an intra-abdominal bleeding. This is caused by an irritation of the phrenic nerve.

Diagnosis of Ectopic Pregnancy

Schematic figure of vaginal ultrasound in ectopic pregnancy

Image: “Schematic figure of vaginal ultrasound in ectopic pregnancy” by Mikael Häggström, from original by BruceBlaus. License: CC BY 3.0

A clinical examination is indicated in addition to anamnestically described abdominal pain symptoms and secondary amenorrhea. Herein, a painful to pressure resistance and pain on the movement of cervix are diagnosed. Subsequently, a laboratory analysis must be initiated. An increased serum beta-HCG concentration would be still detectable even with a negative pregnancy test. Thus, beta-HCG plays an important role in the diagnosis.

Ectopic pregnancy ultrasound

Image: “Ectopic pregnancy in ultrasound” by X.Compagnion. License: Public Domain

Furthermore, an ultrasound examination is concerned. In this case, an empty uterine cavity without the amniotic sac can be detected. Often a pseudo gestational sac is visible. This is caused by accumulation of fluid in the endometrium and looks similar to the fetal sac. You may also see an extension of the tube with the amniotic sac. Eventually, the tube has already been ruptured, and the examiner may observe free liquid in the pouch of Douglas.

The suspected diagnosis of an ectopic pregnancy is provided in the synopsis of all findings. However, the diagnosis is confirmed by means of laparoscopy (or pelviscopy).

Tubal rupture

Image: “Schematic drawing of a ruptur of the Fallopian tube in case of a ectopic pregnancy.” by Hic et nunc. License: CC BY-SA 3.0

Differential Diagnosis

Similar diseases of ectopic pregnancy

Other reasons of an acute abdomen come into question with the differential diagnosis, in addition to gynecological causes. These include the sigmoid diverticulitis or appendicitis and also require clarification.

Other gynecological differential diagnoses include endometriosis, acute adnexitis, abortions, ovarian torsions and urological colic.

Therapy of Ectopic Pregnancy

Treatment of ectopic pregnancy

Therapeutically the diagnostic-therapeutic pelviscopy is used. Depending on the desire to have children the radical nature of the treatment may come into question. With an existing desire to have children a conservative organ-preserving procedure is applied. However, again this increases the risk of recurrence of an ectopic pregnancy.

Ectopic pregnancy removal

Image: “Removal of an ectopic pregnancy out of the right Fallopian tube” by Hic et nunc. License: CC BY-SA 3.0

A salpingostomy as a surgical incision into a fallopian tube is performed. This means that a longitudinal incision is made, and the gestational sac is removed from the tube. If there are no more children to be desired, the tube is radically removed via surgery (= salpingectomy).

In the early stages of ectopic pregnancy, a conservative action is also possible. It is characterized by a drug therapy. In the case of a local treatment, prostaglandins or methotrexate can be injected. Likewise, a systemic drug therapy is possible with the intramuscular methotrexate administration. This medication can be a cause of an embryo’s death. Conservative treatment is applied if there is no bleeding or rupture detected.

In the course of treatment, beta-HCG is regularly controlled for it not to fall below the detection limit.

Prognosis of Ectopic Pregnancy

Recurrence probability of ectopic pregnancy

The recurrence probability is very high. It compounds 5 % – 20 % of all the affected.

Review Questions

Correct answers can be found below the references.

1. Which of the following diseases are not in the scope of the differential diagnosis of an ectopic pregnancy?

  1. Acute appendicitis
  2. Renal cyst on the right kidney
  3. Acute pelvic inflammatory disease
  4. Stone in the left kidney
  5. Imminent abortion

2. What is not a part of the diagnosis of an ectopic pregnancy?

  1. Medical history
  2. Clinical examination of motor function of the lower extremities
  3. Beta-HCG determination in serum
  4. Ultrasound examination of the uterus and appendages on both the sides
  5. Abdominal palpation

3. In which zone is ectopic pregnancy manifested most frequently?

  1. Tubes
  2. Cervix uteri
  3. Abdominal
  4. Vulva
  5. Vagina

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