Much like when she had conceived for the first time, Samiya (name changed) did an at-home urine test to confirm her second pregnancy. But before she could visit her gynecologist to confirm the good news, the 33-year-old started experiencing excruciating pain in the lower abdomen and had to be rushed to a hospital where she was operated on and one of her fallopian tubes was removed. At that time, she was told that she had an ectopic pregnancy, about which Samiya had “no clue”.
“When women get pregnant, they assume it is always going to be intrauterine. They do not realise the importance of an ultrasound scan (thinking ultrasounds are harmful and should be avoided in early pregnancy) even if they observe unusual signs like lower abdominal pain or bleeding from the vagina. This is because the awareness about ectopic gestation is still low, even among the educated population,” said Dr Deepti Asthana, Senior Consultant- Obstetrics and Gynaecology, Fortis Memorial Research Institute, Gurugram.
For the unversed, an ectopic pregnancy occurs when a fertilized egg attaches and grows outside the uterus, most commonly in the fallopian tubes but rarely in other places like the ovary or the abdominal cavity. Concurring with Dr Asthana, Dr Shilpi Reddy, Clinical Director, Obstetrics and Gynecology, KIMS Cuddles, Hyderabad, said there is a lack of awareness among women, and any pregnancy outside the uterus is not expected by the general population.
According to a 2016 National Library of Medicine report, the incidence of ectopic pregnancy among all pregnancies is about 0.25-2.0 per cent globally. “Ectopic pregnancy is the leading cause of maternal mortality in the first trimester,” said Dr Anitha Kunnaiah, Sr Consultant Obstetrician and Gynaecologist, Infertility Specialist, Citizens Specialty Hospital, Hyderabad. In India, ectopic pregnancy accounts for 3.5-7.1 per cent of maternal mortality, stated the same report.
Experts highlight that while there are many organisations in India that disseminate information about various ailments and conditions, there is hardly any that spreads awareness about ectopic pregnancies. There are organisations like FOGSI and ISOPARB that are involved in spreading awareness about ectopic pregnancy and its outcomes and diagnosis to doctors and nursing staff, but not at the level of the common population, informed Dr Reddy.
What causes an ectopic pregnancy?
“The causes are unclear,” said Dr Asthana, adding certain causes have, however, been linked to ectopic pregnancy; these include hormonal derangements, history of smoking, fertility treatments like in-vitro fertilization (IVF), previous history of an ectopic pregnancy, 35 years or above maternal age, history of diseases like endometriosis, pelvic inflammatory disease, sexually transmitted infections (STIs), or history of pelvic or abdominal surgery, and post tubectomy (a permanent method of contraception for women in which clips fallopian tubes are clipped to avoid pregnancy), or placement of an intrauterine device (IUD).
“Such women are at a higher risk of ectopic pregnancy and need to be more watchful. They should monitor their beta HCG levels (a quantitative human chorionic gonadotropin (HCG) test that measures the specific level of HCG in the blood. HCG is a hormone produced during pregnancy) every 48 hours, which can help in the early diagnosis of ectopic pregnancy,” said Dr Reddy. If these hormone levels are less or are not doubling in 48 hours, it may indicate ectopic gestation.
Signs and symptoms
In cases of symptomatic ectopic pregnancy, signs usually start showing between the fourth and 12th weeks of pregnancy. Whereas in the case of asymptomatic ectopic pregnancy, women don’t experience any symptoms at first. “Further, if it is an unruptured ectopic pregnancy, they may not find out they have an ectopic pregnancy until an early scan shows the problem or they develop more serious symptoms later on. In case of ruptured ectopic pregnancy, however, the patient presents with bleeding and or abdominal pain,” Dr Kunnaiah shared.
The most common symptoms include severe pain on one side of the abdomen, which could be a shooting pain or one that keeps increasing and does not alleviate even with mild painkillers. Also, low blood pressure, fainting episodes, and in case of a rupture, constant pain towards one side, are some of the features of ectopic pregnancy.
“Ectopic pregnancy, if diagnosed early, can be dissolved with drugs. But, if diagnosed late when a large mass of pregnancy is already formed and tube ruptured, surgical removal of a fallopian tube (salpingectomy) is the only option,” informed Dr Asthana.
To dissolve an ectopic pregnancy medically, a methotrexate injection can be given to the patient. However, the drug can be taken only when the beta HCG level is less than 5000 iu/L ( as per NICE guidelines 2022), there is no documented blood in the abdomen, the gestation sac size is less than 3.5 cm, and when cardiac activity has not appeared. However, when the injection is given a little late and not as per the guideline laid down by medical bodies, pregnancy may rupture even after taking it.
As per Dr Asthana, there are a number of predictors of success:
*Initial serum beta HCG levels: Success rates are higher with lower beta HCG levels. Success rates of 81-98% have been reported if serum beta HCG levels are less than 1000 iu/L compared to only 38% if beta HCG levels are greater than 5000 iu/L.
*Ultrasound appearance of the ectopic pregnancy: Success rates are higher when no gestational sac is visible. The presence of a yolk sac, foetal pole, or foetal cardiac activity is a significant predictor of failure.
*Pre-treatment changes in serum beta HCG levels: The smaller the increase in beta HCG level prior to administration of methotrexate, the higher the chance of successful medical treatment. An increase of up to 11 – 20% over 48 hours prior to the administration of methotrexate has been associated with higher rates of success.
Since methotrexate is an anti-cancer drug, it comes with its own disadvantages. The most common side effects of methotrexate include excessive flatulence and bloating (due to intestinal gas formation), stomatitis (inflamed and sore mouth), and a transient mild elevation in liver enzymes. However, serious adverse effects include bone marrow suppression, pulmonary fibrosis, nonspecific pneumonitis, liver cirrhosis, renal failure, and gastric ulcers. In this, regimen toxicity is unlikely and most of these effects resolve spontaneously within 4 weeks of treatment.
Once ectopic pregnancy ruptures or the beta HCG levels are higher than the one prescribed to take injection then salpingectomy is the only treatment.
Can ectopic pregnancies be avoided?
“Ectopic pregnancies can be prevented to some extent by reducing the associated risk factors, such as smoking and practising safe sex and using condoms while having multiple partners,” informed Dr Kunnaiah. In addition, if a woman has a history of pelvic infection or has a tubal blockage, it must be treated first. And, if a woman already has damaged tubes or had an ectopic pregnancy in the past, she should be warned beforehand.
“To be more watchful, as a rule, women should get routine evaluation done by a certified clinician within one month of missing their periods. This is important, especially for those at risk of ectopic pregnancy,” said Dr Kunnaiah.