Ectopic pregnancy

It is defined as the placement of the pregnancy material, that is, the embryo, outside the uterus. In general, it constitutes 1-2% of all pregnancies, 6-16% of the patients who come to the emergency service with vaginal bleeding or pain complaints in early pregnancy. Due to the more frequent follow-up of sexually transmitted diseases and the more frequent use of assisted reproductive techniques, the incidence is increasing day by day. It is the most important cause of maternal deaths in the early stages of pregnancy in developed countries. Ruptured ectopic pregnancies are responsible for 10-15% of all maternal deaths. This rate decreases with the widespread use of transvaginal ultrasound and B-HCG and the diagnosis can be made earlier.

The clinical significance of ectopic pregnancy is that it causes life-threatening internal bleeding by rupture as a result of not having sufficient volume for the pregnancy material growing in an area outside the uterus. The greatest and life-threatening danger of ectopic pregnancy is caused by this bleeding. In such late cases, surgery is required to stop the bleeding. With today’s early diagnosis and treatment methods, provided that the patient applies early, ectopic pregnancy can be diagnosed before internal bleeding develops and can be treated with drugs in the form of injection without the need for surgery. When non-surgical treatment is diagnosed early, success rates of up to 90% have been reached. Therefore, even if the expectant mothers do not have any risk factors in terms of ectopic pregnancy, they should go to regular check-ups from the early period of pregnancy. In this way, the location of the gestational sac inside or outside the uterus is determined, and if it is outside the uterus, the chance of treatment with medication without the need for surgery is obtained.

Clinic:
Examination findings of ectopic pregnancy vary depending on whether there is a rupture in the tube, or a rupture. In the absence of a tear, inguinal pain and vaginal bleeding, in the presence of tearing, severe abdominal pain and even shock can be seen due to bleeding into the abdomen. Risk factors include the presence of previous ectopic pregnancy, previous fallopian tube surgery, intrauterine device (spiral), assisted reproductive techniques, sexually transmitted diseases and endometriosis, but none of them are encountered in many patients.

Diagnosis:
It is not difficult to diagnose an external pregnancy that has advanced stages and continues internal bleeding. A positive pregnancy test with signs of blood loss and detection of free blood in the abdomen in the examination and ultrasound are sufficient to make a diagnosis.

The diagnosis of an ectopic pregnancy that has not reached this stage yet is not that easy. For this, it may be necessary to refer to serial b-hcg measurements. In serial measurements made for this purpose, the rate of increase of beta hcg level in blood in a certain time interval is checked.

B-hcg:
It is the most important diagnostic test to be done in ectopic pregnancy. In normal intrauterine pregnancies, serum B-hcg value doubles every 48 hours. Pregnancies without this doubling pattern are abnormal pregnancies. Normally, if the B-hcg level is 1500-3000mlU / ml, it is transvaginal, if it is 5000-6000 mIU / ml, the gestational sac in the uterus should be seen with the ultrasound performed from the abdomen, which we call transabdominal. Despite these values, if there is no gestational sac in the uterus on ultrasound and the b-hcg values do not decrease, the possible diagnosis is ectopic pregnancy.

Treatment:
It is divided into surgical (with surgery) and medical (with medication) treatment.

When the diagnosis of ectopic pregnancy is made early, that is, when the tube is caught before the tube is ruptured, the chance of treatment with laparoscopic method (closed surgery) is quite high before the patient starts to lose blood.

Moreover, laparoscopic treatment has the advantage of ensuring that the patient’s tube is treated by “emptying the tube” without removing the tube, thus protecting the tube. In places where laparoscopy devices are not available, the same procedure can be performed with laparotomy (opening the abdomen).

Another treatment method used in the early period is treatment with a drug called methotrexate. If certain criteria are met and the general condition of the patient also meets the appropriate conditions, ectopic pregnancy can be treated with a single or several doses of a drug called methotrexate (ie, drug therapy in the form of injection) without the need for surgery.

When the fallopian tube is ruptured and internal bleeding begins, usually the only and most appropriate treatment consists of opening the abdomen by surgery with a procedure called laparotomy and stopping the bleeding by partially removing the ruptured tube.

Rare forms of ectopic pregnancy:
Ectopic pregnancy can rarely settle in areas other than tubes. Sometimes the pregnancy that is placed in the tube results in miscarriage after a while and the material falls into the abdominal cavity. Since it has not lost its vitality yet, it settles here and continues to develop. In the literature, there are pregnancies that settle in the abdominal cavity and reach term. Apart from the tubes, ectopic pregnancy can also be seen in the ovaries and cervix.

The most unfortunate form of ectopic pregnancy is the condition called heterotopic pregnancy. Here, there is an ectopic pregnancy and a normal intrauterine pregnancy at the same time. Ectopic can be missed very easily, as a pregnancy that develops normally in the uterus is seen in ultrasonography.