What is an Ectopic Pregnancy?
By Professor Charles Kingsland, Consultant Gynaecologist & Specialist in Reproductive Medicine
When I started my very first day in gynaecology, I was introduced to Professor John Beazley, Head of the Academic Department of Obstetrics and Gynaecology at the University of Liverpool. When I set up my first and Merseyside’s original IVF unit, we used Professor Beazley’s office as a sperm production room for the males. I called it the ‘Professorial Mastubatorium’. Not only was the room fairly remote and peaceful, it was the only room in the University that one could guarantee would be empty during the day.
On that first day as an embryonic gynaecologist, the Professor uttered the words to me that I carry with me to this very day. “Don’t forget David,” (he was never very good at remembering names), “all women are liars, all women are pregnant and all pregnancies are ectopic”. Initially, after picking myself up from the floor, as even in the early 80s there was a pervading air of political correctness, nowhere near as pungent as it is today, but nevertheless, enough for me to be mild to moderately outraged with what was this chauvinistic statement. On reflection, however, this has been an extremely useful rule, and has probably allowed me to save a number of lives.
There are very few things that will kill a previously young and fit woman in front of your very eyes as will the catastrophic haemorrhage from a ruptured ectopic pregnancy. An ectopic is a pregnancy growing in the wrong place, which does not have the luxury of expanding in the large muscular uterus but often in a flimsy fallopian tube which, unlike the uterus, does not possess the muscularity to allow it to grow. So, it expands a little to accommodate the developing baby usually to about six weeks gestation, when it cracks, leaks and eventually, if not recognised, bursts open with occasionally fatal consequences. Ectopics are notoriously difficult pregnancies to diagnose and often present very late, hence the danger.
Even today, if I am called to the Emergency Room to see a patient, I remind myself of the old algorithm taught to me on that first day in the Professors office 35 years ago. “Is there any chance you could be pregnant?”, “No doctor, absolutely not!” (Lie number one). She’s pregnant and what’s more the pregnancy is festering within the tube of Fallopius. Once I have excluded, an Ectopic Pregnancy, I can relax a little, safe in the knowledge that the patient will not die in front of my eyes, whilst I fumble for a diagnosis. at occurrence, I would suggest, is a career limiting step if ever I knew one.
Some years ago, again whilst on call, I remember it as if it were yesterday; I was sitting in my office in my IVF unit. It was about 11am, as I remember I was drinking my third cup of coffee. My bleep went off and the flashing light told me it was the Gynaecology ward. I made a call to the Nurses Station whereupon the Registrar on call, a young man I had never met, answered and told me about a lady he was just “not sure” about. The patient was in her mid-thirties and was about eight weeks into her second pregnancy, the first resulting in the birth of a healthy male infant some two years previously. “What’s her pulse?” It was highish. At that point I had a vision of a steamy Professor Beazley, rising out of my coffee cup, recounting those words I had first heard, over 20 years earlier. I put the phone and my coffee down, not necessarily in that order, and jogged around to the ward some three minutes away.
In the first six bedded bay on the left, second bed on the right, there was a pale and rather anxious looking lady, surrounded by a plethora of Nurses, ultrasonographers, a confused looking Doctor, a cleaner and a tea lady. (I’m not sure if she was a tea lady, but she could have passed for one, you know, grey hair, jovial, adjacent to a trolley with a teapot, jug of milk and some cups on it).
As I pushed through, this medical soap opera cast, I chanced upon the clearly sick patient, who before I had chance to introduce myself to her, she gently took hold of my arm and said in a hushed tone, “Doctor, I think I am going to die”. I looked at her, cold, clammy and pale face, felt her racing pulse and thought to myself, “I think you’re right”. I didn’t tell her that, because I thought it would not be of help to anyone, and unlike the scenario I have described, I was not in an episode of Holby City.
We rushed her around to theatre, anaesthetised her and opened her abdomen. After removing two litres of clot, resembling blackcurrant jam, I saw the steady drip drip drip of a ruptured fallopian tube, leaking blood similar to a kitchen tap, not quite turned off. Two clamps were hastily placed around the tube and the bleeding immediately stopped. One hour later, minus one fallopian tube and with the second of four units of blood transfusing into her increasingly pinkish arm, the young lady was back on the ward and two days later she had returned, well to her family. Thanks for the advice Prof.
WHAT IS AN ECTOPIC PREGNANCY?
An Ectopic Pregnancy is a pregnancy which grows in a part of the body where it shouldn’t. Pregnancies are supposed to grow in the uterus, but up to 8% don’t make it. So, how does this happen? There are two ways of looking at an ectopic pregnancy. The best place to start, I think, is at the point of conception when a sperm swims up to and into the egg, bringing about fertilisation.
Fertilisation takes place in the outer third of the fallopian tube. Immediately after conception, the embryo sets about growing and dividing. It also begins to send messages to the uterus to inform the juicy lining – the endometrium – to prepare for reception and implantation.
The embryo is then wafted down the fallopian tube by the synchronous, rhythmical beating of the cilia – tiny little hairs that line and lubricate the fallopian tube. They are supposed to beat like a field of corn swaying gently in the breeze. But, like corn and other crops, cilia are liable to infestation and damage. The invader par excellence that, given the opportunity, will munch his way through a field of cilia is a horrible little bug called Chlamydia. He will, following the briefest of introductions to the female genital tract (usually thumbing a lift on the back of an infected penis) set up home, multiply in the lush warm environment of the endosalpinx and chomp away, together with his growing family, until the corn field resembles a damp, dark red, infected and snotty bog.
Ironically, the tube may become blocked thus impeding the passage of the embryo, but mostly it is only when the tube is slightly or moderately disabled that the embryo can slip down. What happens then, however, is that the embryo cannot traverse through the goo and stick like shoots of what used to be healthy cilia, so the poor embryo gets stuck and implants into the tube at the site where it cannot get past.
The embryo then draws a blood supply and starts to grow and develop. However, unlike the pliable, muscular reproductive cathedral of the uterus, the thin tubular fallopian tube has little in the way of muscle, so it can’t expand. The embryo soon fills the tube and starts to stretch it. Now, depending on which part of the tube the embryo has come to land in, the tube will stretch accordingly. If it’s in the narrow so called isthmus region of the tube as opposed to the larger outer of ampullarf area, the embryo will crack the tube earlier, usually between five and six weeks of growth, with the result that the tube will begin to leak blood and inflammatory fluid. Slowly at first, but then more quickly and then probably catastrophically, a bit like a sinking Titanic. That’s the commonest site of ectopic. They can, however, end up in all sorts of places.
I’ve seen ectopics on the ovary, or on the outside of the tube. Very rarely, if an ectopic pregnancy falls out of the tube, it may land inside the abdomen and grow, quite happily outside the uterus, but inside the relatively large abdominal space, getting its blood supply from a neighbouring organ.
I once looked after a young woman who we thought was having a perfectly normal pregnancy until she went into labour six weeks prematurely at about 34 weeks. Her uterus, not knowing any better started contracting but we later discovered it was empty, the baby having grown up to that stage, normally in the abdomen with the afterbirth stuck onto the liver. That is when the fun began, because as you can imagine, the liver is designed to carry out tasks far different from the uterus and as a consequence, has a different and quite heavily blood filled constitution. Also, livers do not take too kindly to having afterbirths growing on them with the result that upon attempted removal, they have an irritating capacity to bleed, quite heavily, in fact.
You may ask why we didn’t spot this conundrum earlier. There are two reasons in reality. Firstly, Gynaecologists are only human, (although some I have met think differently). Secondly, common things are common and rare things are rare, so when you see an apparently happy healthy infant, doggy paddling its way around a vast open space, one presumes it is within the swimming baths and not floating around in the changing rooms. In the end, and somewhat miraculously, we delivered the baby and the placenta and Mum was rewarded with a fourteen pint blood transfusion and an extended holiday in the Intensive Care Unit. Mother and baby eventually left hospital, happy and healthy, but yours truly needed a Mediterranean holiday and copious quantities of San Miguel to recover from the trauma.
If physical damage to the structures within the female pelvis is the first cause of ectopic pregnancy, the second and often most likely cause is that something drastic goes wrong either at fertilisation and/or embryo division. The embryo starts to grow abnormally and again begins to send messages to the uterus. Unfortunately, these messages reflect the abnormality and to the uterus are just plain old gobbledygook. As a result, the uterus does not understand what is going on and responds inappropriately. Hence, instead of the embryo being guided carefully into the harbour of the uterus, it heads for the rocks and is washed up in the tubes.
Whatever happens, an ectopic pregnancy is doomed and any mad capped ideas to try and save it as one of my old, and terminally deranged bosses tried to do many years ago in a series of extraordinarily ignorant cases. What he tried to do, and I witnessed, as a very young and inexperienced Doctor, was to try and squeeze the ectopic pregnancy out of its place in the fallopian tube and place it in the uterus. When his patient came around from the anaesthetic, he told her that he had saved the pregnancy and had safely placed it in the uterus. When she miscarried an infected and non-viable mass of products of conception a few days later, she was naturally distraught for a second time. The Consultant left the NHS quite shortly after.
WHAT ARE THE SYMPTOMS?
So, what are the symptoms of an Ectopic Pregnancy? As with any pregnancy, the first sign is a missed period. There may then be a period of relative calm with normal pregnancy related symptoms. The hormone, Human Chorionic Gonadotrophin (HCG) may be produced by the abnormally developing pregnancy and it may be excreted in sufficient quantity in the urine to turn a pregnancy test positive initially.
However, in the blood, in a normally developing pregnancy, the HCG levels, which can be measured far more accurately and sensitively, should double in value every 48 hours if a pregnancy is growing normally. In the case of an ectopic, the pregnancy is not normal, and does not grow properly. The result? The HCG level in the blood does not double.
Meanwhile, back at human level, the woman may be starting to experience some odd symptoms; the pregnancy related feelings may subside, she may start to bleed vaginally, maybe only a little at first, especially in the early stages of the pregnancy because as, after all, at this stage there’s not much blood about.
More worryingly, she may start to develop generalised lower abdominal pains, non-specific at first, but then more localised over the site of the ectopic. If a woman bleeds into her abdomen from an ectopic, there is one tell-tale sign that gives the story away. Often it is a throwaway line, volunteered by the patient, but it is very important nevertheless. “When I lie down Doctor, I get a pain in my shoulder”, she may say quizzically.
What in fact is happening is that she is bleeding slowly into her abdomen and as she lies down the blood seeps up under her diaphragm. The nerves to the diaphragm, it just so happens, are the very same that provide sensation to the muscles of the shoulder, hence, the shoulder pain. At that point, alarm bells sound.
Another trick of the trade, so to speak, is that young women whose health and maybe life, is in danger, don’t tend to say much. I have often witnessed women in casualty, who will wax lyrical about the nature, duration and extent of their incapacity. “You just wouldn’t believe the agony I’m suffering Doc. I’m flooding off me feet” (a Liverpool term for experiencing very heavy vaginal bleeding). “And the pain, the pain. It goes down my left side, down my leg, across the floor and back up my right side”.
“There just nothin down for me Doc” (another Scouse term meaning I fear the prognosis is somewhat guarded Doctor). The chances are that this patient is not as ill as she thinks, especially when she has all the breath in her body to devote to telling me how ill she is. The ill patient, however, will want to remain quiet and divert her failing energies elsewhere, in an effort to keep herself alive as long as possible.
Another trick is to gently palpate the abdomen whilst asking the patient about her symptoms. At the point when she is answering your enquiries, remove your hand. The ill patient will generally experience pain, not on pressing, but on removing the hand. This is due to the fact that if there is bleeding into the abdomen, the free blood will irritate the lining of the abdomen, a filmy layer called the peritoneum. The pain is caused by the irritated peritoneum bouncing back to its original position following the initial downward pressure.
Also, if blood is running out of your blood vessels, your blood pressure will go down. In an effort to maintain your blood pressure, your heart will start to beat faster, a so called tachycardia.
It’s a fact that in young previously fit individuals, they tend to compensate for body trauma, that is, they will maintain their vital signs, until they crash catastrophically. This is unlike older or infirm people, who will tend to ‘go off’, slowly and insidiously.
This is the reason why an ectopic pregnancy, if undiagnosed, can be so dangerous. One minute you’re faced with a healthy woman, next minute you’ve got a seriously ill or dead one. Always, always think ectopic.
HOW IS IT DIAGNOSED?
An ultrasound scan can be helpful. Sometimes you can see an ectopic pregnancy. Often, however, it’s the presence of a positive pregnancy test in the absence of a baby in the uterus that makes the diagnosis. At a later stage, when the writing is really on the wall, you can see the blood swishing around in the pelvis. Not a good sign.
Ectopic pregnancies can be notoriously difficult to diagnose. In the case of my lady on that Saturday morning, particularly because she had been pregnant before and had a good idea of what is supposed to happen in a normal pregnancy, a brief look in her fear filled eyes and that comment to me in hushed tones about her impeding demise, said it all. The eyes can tell you a lot about what a woman is feeling. You have to look though.
HOW IS IT TREATED?
In some cases if caught early enough, Doctors can use a drug, methotrexate, which is used as a chemotherapeutic agent mostly, but can be highly effective at destroying an ectopic pregnancy without having to resort to surgery. Otherwise gynaecologists have to remove the offending tube. There is little point saving a damaged tube, by removing the pregnancy and restoring the tube especially nowadays as IVF can be performed at a later stage, and a badly infected fallopian tube is highly likely to be a sight for further trouble. It just ain’t going to get better.
The good news following ectopic pregnancy is that if you lose a fallopian tube, it doesn’t half your chance of getting pregnant. What you have to remember is that tubes do not stick out sideways from the uterus, they fold around a bit so that an egg from the left ovary can go down the right tube and vice versa.
Therefore, if you do have the misfortune to lose a fallopian tube, your cumulative conception rate after five years, i.e. your chance of having a baby after five years of trying is about the same as a woman with two tubes.
What you must remember, however, is that if you have had the misfortune to have an ectopic once, you have an increased chance of having another one. There’s still, however, a 90% chance that you won’t.