Often, the egg is not fertilised and it dies. The hormones change and the endometrium also dies and is shed. There is some bleeding from the raw endometrium for a few days. This is a typical period. The cycle then starts again for the next month.
If the egg is fertilised it starts making extra hormones. These make the uterus and endometrium grow to take the developing baby.
What has gone wrong?
With a tubal pregnancy your fertilised egg does not pass from your Fallopian tube into your uterus. The much smaller sperm have travelled up the tube to fertilise your egg but your egg has not moved in the opposite direction. This may be because of scarring, called adhesions, in and around your Fallopian tube. This scarring could be from a previous infection in your tube or your pelvis, or from a previous operation. As the embryo develops, blood vessels from the growing placenta will burst through the thin walls of your Fallopian tube or through the tissues near the ovary. This can result in internal bleeding and pain.
The aims
The aim of the operation is to stop your bleeding by removing your ectopic pregnancy. Ideally, we only remove the pregnancy, although we may have to remove part or all of your Fallopian tube. The earlier your ectopic pregnancy is dealt with, the greater the chance of saving your Fallopian tube. We also remove any blood that has built up.
We usually do the operation using keyhole surgery, called a laparoscopy. We use the laparoscopy to first confirm that you have an ectopic pregnancy, find its exact position and then remove it. Occasionally, we convert to an open operation if we cannot complete the operation using keyhole surgery. This may be to clear out a large amount of trapped blood or if you have adhesions from previous operations or infections. Discuss the options with your gynaecologist.
The benefits
This operation is often lifesaving. An ectopic pregnancy will usually bleed until it is removed. Keyhole surgery has several advantages over an open operation:
- The laparoscopy can confirm the diagnosis and the exact position of the ectopic pregnancy.
- There is less bleeding from the operation with less chance of needing a blood transfusion.
- Less pain.
- Recovery is usually quicker with a shorter hospital stay.
- The chance of having a normal pregnancy later is higher, about seven in 10 (70%) rather than about five in 10 (50%) after open surgery.
- The chance of another ectopic pregnancy is lower, about three in 20 (15%) rather than five in 20 (25%) after open surgery.
Are there any alternatives?
We can sometimes treat an ectopic pregnancy by giving a drug called methotrexate. We usually give this drug as an anti-cancer treatment. When we give it to treat an ectopic pregnancy it stops the embryo from growing any bigger. The embryo dies and the body slowly absorbs the remains. This can avoid the need for surgery.
If you need surgery you could have an open operation, called a laparotomy. Due to the benefits of laparoscopy over open operations, it is usually better to avoid this. If for some reason a laparoscopic operation is not possible, your surgeon will recommend an open operation. One reason for this would be if you were very ill due to internal bleeding from the ectopic pregnancy.
What if you do nothing?
Doing nothing is usually not an option. Continuous internal bleeding is life threatening. Sometimes tests show that the ectopic pregnancy has already stopped growing and a removal operation is not necessary. We would still need to monitor you very closely for some time.
Who should have it done?
If a pregnancy test shows you are pregnant but no fetus or sac is seen in your uterus during an ultrasound scan the pregnancy is probably ectopic. We may see a mass or fetus in your pelvis or Fallopian tube during the scan. If we confirm or believe there is a high chance that you have an ectopic pregnancy you should have this operation.
Who should not have it done?
Sometimes, it is not clear from your scans whether your pregnancy is in your uterus and not in your tube. Often we need to operate to find out what is going on. A laparoscopy will not harm a normal pregnancy and the general anaesthetic does not seem to be harmful. If we are not sure of the location of your pregnancy you could wait and repeat the ultrasound scan after a few days. This may avoid the laparoscopy, but it does carry the additional risk of a sudden serious internal bleed during the waiting period. If this happens you may need an emergency open operation.
Author: Dr David Hutchon F.R.C.O.G. Consultant Gynaecologist.
© Dumas Ltd 2006
