Ectopic by Reinier de Graaf
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Ectopic pregnancy

An ectopic pregnancy is one in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. more...

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Overview

In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. As the embryo implants and grows, the tube becomes stretched and inflamed, causing increasing pain in the pregnant woman. If left untreated, the affected Fallopian tube will likely burst, causing gynecologic hemorrhage and endangering the life of the woman. Only 2% of ectopic pregnancies occur outside of the fallopian tubes. About 1% of pregnancies are in an ectopic location.

Causes

Cilia damage and tube occlusion

Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Damage to the cilia, or blockage of the Fallopian tubes is likely to lead to an ectopic pregnancy.

Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia and possibly tube occlusion.

Tubal surgery, such as tubal ligation (or the reversal thereof), is also likely to cause cilia damage. And because ectopic pregnancy is treated with tubal surgery, a history of ectopic pregnancy increases the risk of future occurrences.

Excessive estrogen and progesterone

High levels of estrogen and progesterone increase the risk of ectopic pregnancy because these hormones slow the movement of the fertilized egg through the Fallopian tube. The use of progesterone-secreting intrauterine devices (IUDs), the morning-after pill, and other hormonal methods of contraception often result in high estrogen and progesterone concentration and may increase the risk of ectopic pregnancy. Ectopic pregnancies are seen more commonly in patients undergoing infertility treatments.

Other

Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching has been shown to increase ectopic pregnancies.

Symptoms

Patients with an ectopic pregnancy typically have:

  • Lower back, abdominal, or pelvic pain.
  • There may be cramping or even tenderness on one side of the pelvis.
  • The pain is of recent onset, and often getting worse.
  • Vaginal bleeding may be present.
  • Low serum hematocrit (due to loss of blood)
  • Elevated serum human chorionic gonadotropin (due to pregnancy)

Ectopic pregnancy is noted that it can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynecologic problems.

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Multidose vs. Single-Dose therapy in pregnancy - Tips from Other Journals - methotrexate for the treatment of ectopic pregnancy - Author Abstract
From American Family Physician, 9/15/03 by Anne D. Walling

Approximately 2 percent of pregnancies in this country are ectopic, a condition that may cause significant hemorrhage and other serious complications. The success rates of medical treatment are comparable to those of surgery, with the added advantages of avoiding anesthetic and surgical risk while retaining fertility. Two protocols are currently used for medical treatment of ectopic pregnancy. "Single-dose" methotrexate therapy is given in a dosage of 50 mg per [m.sup.2] of body surface area. The "multidose" regimen consists of 1 mg per kg of methotrexate, alternating with 0.1 mg per kg of leucovorin, for up to four doses of each agent. Both regimens are effective but have not been compared directly in a clinical trial. Barnhart and colleagues compared evidence for the efficacy and tolerability of single-dose and multidose regimens of methotrexate in the treatment of ectopic pregnancy.

Through electronic and manual searches, the authors identified 213 relevant articles, 26 of which met criteria for quality and inclusion in the analysis. They reviewed 1,327 cases of women with ectopic pregnancy who had been treated with methotrexate. The overall success rate of treatment was 89 percent, with 36 percent of women reporting side effects. In the single-dose group, 14.5 percent of women required more than one dose of methotrexate. In the multidose group, 53.5 percent received four or more doses. The overall success rate in the 1,067 women treated with the single-dose regimen was 88.1 percent compared with 92.7 percent in the 260 women treated with the multidose regimen. Side effects were reported by 31.3 percent of women receiving single-dose therapy and 41.2 percent of those receiving the multidose regimen. Rates of hospital admission were similar in the two groups (12.4 percent for single-dose therapy and 11 percent for multidose therapy).

The authors conclude that although the multidose regimen of methotrexate is associated with significantly more side effects and is more complicated to administer, it is more effective than the single-dose protocol for treatment of unruptured ectopic pregnancy. Because unsuccessful medical treatment could result in hemorrhage, emergency surgery, or even death, the additional efficacy of multidose treatment outweighs the greater convenience and lower rate of side effects associated with single-dose treatment.

Barnhart KT, et al. The medical management of ectopic pregnancy: a meta-analysis comparing "single dose" and "multidose" regimens. Obstet Gynecol April 2003;101: 778-84.

ANNE D. WALLING, M.D.

COPYRIGHT 2003 American Academy of Family Physicians
COPYRIGHT 2003 Gale Group

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