Non-Surgical Treatment for Ectopic Pregnancy - Can an Ectopic Pregnancy be moved to the uterus and saved?
Published: 12/14/2015
Ectopic Pregnancy / Tubal Pregnancy
An ectopic or tubal pregnancy occurs when the embryo is not able to get out of the fallopian tube and into the
uterine cavity in a timely fashion. In a normal situation, fertilization occurs in the distal end of the tube and
the early dividing embryo will spend 4 days or 96 hours in the fallopian tube; at which time, it will quickly travel
through the proximal part of the tube and into the uterus. Once in the uterus, it will float free for the next two
and a half days, then implant on day 6 1/2. Some woman can have slight bleeding or spotting at this time, known as
implantation bleeding. Anything that interferes with the embryo's ability to move down the tube and into the
uterus
will cause the embryo to "get stuck" where it will either become non-viable or continue to grow in the
tube until it
causes the tube to rupture and puts the patient at risk of internal bleeding, hemorrhaging and shock secondary to
significant blood loss.
Causes of Ectopic Pregnancy
Tubal pregnancies occur because of damage to the fallopian tubes, which can be due to a number known or unknown
causes. The most common known reasons are: previous infection from pelvic inflammatory disease (PID), STDs like
gonorrhea or chlamydia or IUD use,
previous tubal surgery, conceiving after having a tubal ligation, conceiving
after a reversal of sterilization, external
constriction secondary to scarring from endometriosis, and
even after an
embryo transfer where the embryo can float into the fallopian tube and can not be brought back down into the uterus
by the normal ciliary or hair-like movements of the tube.
Ectopic Pregnancy Diagnosis
In this day and age, an ectopic pregnancy should not be missed, let alone rupture. At Arizona Center for Fertility
Studies, the philosophy is that every patient has an ectopic pregnancy until proven otherwise. To make sure that the
patient does not have an ectopic pregnancy; as soon as any of our patients are late on their periods, even by a few
days, they get a urine pregnancy test (at no charge) or a blood pregnancy test, and if positive, are scheduled for
an early transvaginal ultrasound at 5 1/2 to 6
weeks, also at no charge. Once the pregnancy is confirmed in the
uterus everyone can relax and they are no longer at risk of an ectopic or tubal pregnancy that can rupture and cause
internal hemorrhaging.
The only exception, is in the case of a heterotopic pregnancy, where are pregnancy can occur both in the uterus and
in the fallopian tube. The spontaneous incidence of this is 1 in 25,000; and with IVF, where multiple embryos are
transferred into the uterus, the incidence can be as high as 1 in 1000. Although, this diagnosis is more difficult
to make and seeing a pregnancy in the uterus makes you think everything is okay; if a patient is at high risk for an
ectopic pregnancy, then you always have to think about the possibility of a heterotopic pregnancy.
The
diagnosis of a tubal pregnancy is made by having a high suspicion for a patient at risk, no ultrasound evidence of a
intrauterine pregnancy, abnormally increasing hCG levels, abdominal pain, vaginal bleeding or ultrasound evidence of
a mass or pregnancy outside of th
Ectopic Pregnancy Treatment Options
Once the diagnosis is made there are several treatment options available.
- Surgery can be done by diagnostic laparoscopy, where a laparoscope is
placed through the belly button and into
the abdomen under general anesthesia. If diagnosed early enough, you should always be able to save the involved
fallopian tube. The procedure is done by first injecting epinephrine into the tissue around the tubal pregnancy
to stop any bleeding and then making an incision over the area in the tube where the pregnancy is and allowing
the pregnancy to "pop out". Any small bleeders can be gently cauterized and the tube is left open to
heal
normally. The thinking being, "once an ectopic, not always an ectopic", and the
involved tube can have the
possibility of next time carrying a pregnancy into the uterus. If diagnosed early, you should never have to have
a laparotomy or open incision.
- The other option is to avoid surgery and treat the ectopic pregnancy with methotrexate (MTX),
which is a
chemotherapeutic agent, that destroys rapidly dividing cells, which is what pregnancy tissue is. If you are
uncertain of the diagnosis of an ectopic pregnancy, blood hCG levels are not compatible with a healthy, ongoing
pregnancy, but you know that the pregnancy is not in the uterus, then an in-office D&C is recommended. This
is
done to see if there is any pregnancy tissue in the uterus, which would indicate that you are having a
miscarriage based on the clinical findings. The tissue is sent 'STAT' to pathology for evaluation. If
there
isn't any tissue in the uterus, then the only other logical place for it to be is in the fallopian tube. If
that
is the case, then the treatment options are surgery or MTX. If the diagnosis is made early, as it can be if the
thinking is "everyone has an ectopic pregnancy till proven otherwise", then MTX is a logical option.
Three
criteria need to be met before using MTX. This includes having the hCG levels under 10,000 IU or less, the
patient is having minimum to no symptoms of pain, and if there is a mass outside the uterus on ultrasound, it
has to be 3 centimeters are less. Once these criteria are met and with early diagnosis they should be, then MTX
can be used to treat and eliminate the tubal pregnancy. It can be given orally for 5 days, given as an
intramuscular injection at 50 mg every other day until hCG levels drop by 30% or given in a single dose of 150
mg intramuscularly. Since MTX destroys cells that are dividing rapidly, it can cause gastrointestinal side
effects like nausea, vomiting, diarrhea, cold sores and abdominal pain. These are usually mild and do not occur
in most patients. By using MTX, you will eliminate the need for surgery. This may decrease the risk of
additional compromise to the involved fallopian tube; thus increasing the chance that it will function normally
with the next pregnancy. Neither surgery or MTX will guarantee that the involved tube will function normally
with the next pregnancy but at least you will be given the possibility. If the ectopic pregnancy has ruptured
and the patient is bleeding internally, surgery is the only option and, most of time, if not all of time, the
involved fallopian tube needs to be removed, regardless if the other tube is absent or badly damaged. This
is
why early diagnosis of an ectopic or tubal pregnancy is so important.