--------------------- ECTOPIC PREGNANCY :------------------------- ECTOPIC PREGNANCY DEFINITION :-- An ectopic pregnancy occurs when a fertilized egg implants somewhere other than the main cavity of the uterus. Pregnancy begins with a fertilized egg. Normally, the fertilized egg attaches itself to the lining of the uterus.An ectopic pregnancy most often occurs in one of the tubes that carry eggs from the ovaries to the uterus (fallopian tubes). This type of ectopic pregnancy is known as a tubal pregnancy. In some cases, however, an ectopic pregnancy occurs in the abdominal cavity, ovary or neck of the uterus (cervix).An ectopic pregnancy can’t proceed normally. The fertilized egg can’t survive, and the growing tissue might destroy various maternal structures. Left untreated, life-threatening blood loss is possible.Early treatment of an ectopic pregnancy can help preserve the chance for future healthy pregnancies.ECTOPIC PREGNANCY CAUSES :---------------------------------------------Common causes of fallopian tube damage that may lead to an ectopic pregnancy include:Smoking. Women who smoke or who used to smoke have higher rates of ectopic pregnancy. Smoking is thought to damage the fallopian tubes’ ability to move the fertilized egg toward the uterus.Pelvic inflammatory disease (PID), such as from a chlamydia or gonorrhea infection. PID can create scar tissue in the fallopian tubes.Fallopian tube surgery, often used to reverse a tubal ligation or to repair a scarred or blocked tube.A previous ectopic pregnancy in a fallopian tube.Although pregnancy is rare after a tubal ligation or with an intrauterine device (IUD), those pregnancies that do develop may have an increased chance of being ectopic.ECTOPIC PREGNANCY PATHOPHYSIOLOGY Effective transport of embryos in the fallopian tube requires a delicately regulated complex interaction between the tubal epithelium, tubal fluid, and tubal contents. This interaction ultimately generates a mechanical force, composed of tubal peristalsis, ciliary motion, and tubal fluid flow, to drive the embryo towards the uterine cavity. This process is subject to dysfunction at many different points that can ultimately manifest as ectopic pregnancy.Oocyte migration difficulty is most often associated with abnormal fallopian tube anatomy. This can result from tubal pathology (e.g., chronic salpingitis, salpingitisisthmicanodosa), tubal surgery (e.g. reconstruction, sterilisation), or in utero DES exposure. It is thought that alterations in molecular signalling between the oocyte and the implantation site may make an ectopic pregnancy more likely. A number of molecular factors are under investigation for possible involvement in premature implantation. These factors include cellular and extracellular matrix proteins such as lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors, and cytokines.Studies have not supported a role for chromosomal abnormalities in abnormal implantation. Karyotypes of the chorionic villi from 30 viable surgically removed ectopic pregnancies did not find any difference compared with the control intrauterine pregnancies.As the ectopic grows, the outer layer of the fallopian tube stretches. This ultimately leads to tubal rupture and bleeding.ECTOPIC PREGNANCY SYMPTOMS :---------------------------------------------------At first, an ectopic pregnancy might not cause any signs or symptoms. In other cases, early signs and symptoms of an ectopic pregnancy might be the same as those of any pregnancy — a missed period, breast tenderness and nausea.If you take a pregnancy test, the result will be positive. Still, an ectopic pregnancy can’t continue as normal.Light vaginal bleeding with abdominal or pelvic pain is often the first warning sign of an ectopic pregnancy. If blood leaks from the fallopian tube, it’s also possible to feel shoulder pain or an urge to have a bowel movement — depending on where the blood pools or which nerves are irritated. If the fallopian tube ruptures, heavy bleeding inside the abdomen is likely — followed by lightheadedness, fainting and shock.ECTOPIC PREGNANCY DIAGNOSIS :-----------------------------------------------------Most ectopic pregnancies can be detected using a pelvic exam, ultrasound, andblood tests. If you have symptoms of a possible ectopic pregnancy, you will have:A pelvic exam, which can detect tenderness in the uterus or fallopian tubes, less enlargement of the uterus than expected for a pregnancy, or a mass in the pelvic area.A pelvic ultrasound (transvaginal or abdominal), which uses sound waves to produce a picture of the organs and structures in the lower abdomen. Atransvaginal ultrasound is the most dependable way to show where a pregnancy is. A pregnancy in the uterus is visible 6 weeks after the last menstrual period. An ectopic pregnancy is likely if there are no signs of an embryo or fetus in the uterus but hCG levels are elevated or rising.Two or more blood tests of pregnancy hormone (human chorionic gonadotropin, or hCG) levels, taken 48 hours apart. During the early weeks of a normal pregnancy, hCG levels double every 2 days. Low or slowly increasing levels of hCG in the blood suggest an early abnormal pregnancy, such as an ectopic pregnancy or a miscarriage. If hCG levels are abnormally low, further testing is done to find the cause.Sometimes a surgical procedure using laparoscopy is used to look for an ectopic pregnancy. An ectopic pregnancy after 5 weeks can usually be diagnosed and treated with a laparoscope. But laparoscopy is not often used to diagnose a very early ectopic pregnancy, because ultrasound and blood pregnancy tests are very accurate.Follow-up testing after treatment :----------------------------------------------During the week after treatment for an ectopic pregnancy, your hCG (human chorionic gonadotropin) blood levels are tested several times. Your doctor will look for a drop in hCG levels, which is a sign that the pregnancy is ending (hCG levels sometimes rise during the first few days of treatment, then drop). In some cases, hCG testing continues for weeks to months until hCG levels drop to a low level.What to think about:----------------------------If you become pregnant and are at high risk for an ectopic pregnancy, you will be closely watched. Doctors do not always agree about which risk factors are serious enough to watch closely. But research suggests that risk is serious enough if you have had a tubal surgery or an ectopic pregnancy before, had DES exposure before birth, have known fallopian tube problems, or have a pregnancy with anintrauterine device (IUD) in place. A urine pregnancy test-including a home pregnancy test-can accurately diagnose a pregnancy but cannot detect whether it is an ectopic pregnancy. If a urine pregnancy test confirms pregnancy and an ectopic pregnancy is suspected, further blood testing or ultrasound is needed to diagnose an ectopic pregnancy.ECTOPIC PREGNANCY TREATMENT:-----------------------------------------------------A fertilized egg can’t develop normally outside the uterus. To prevent life-threatening complications, the ectopic tissue needs to be removed.If the ectopic pregnancy is detected early, an injection of the drug methotrexate is sometimes used to stop cell growth and dissolve existing cells. It’s imperative that the diagnosis of ectopic pregnancy is certain before this treatment is undertaken.After the injection, your doctor will monitor your blood for the pregnancy hormone human chorionic gonadotropin (HCG). If the HCG level remains high, you might need another injection of methotrexate.In other cases, ectopic pregnancy is usually treated with laparoscopic surgery. In this procedure, a small incision is made in the abdomen, near or in the navel. Then your doctor uses a thin tube equipped with a camera lens and light (laparoscope) to view the area.Other instruments can be inserted into the tube or through other small incisions to remove the ectopic tissue and repair the fallopian tube. If the fallopian tube is significantly damaged, it might need to be removed.If the ectopic pregnancy is causing heavy bleeding or the fallopian tube has ruptured, you might need emergency surgery through an abdominal incision (laparotomy). In some cases, the fallopian tube can be repaired. Typically, however, a ruptured tube must be removed.Your doctor will monitor your HCG levels after surgery to be sure all of the ectopic tissue was removed. If HCG levels don’t come down quickly, an injection of methotredxate may be needed.