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Case History

image A 32-year-old woman, who has been trying to conceive for 13 months, presents with seven weeks of amenorrhoea and bleeding like a light period. She has mild pain in the right iliac fossa. Transvaginal ultrasound scanning (TVS) shows a thickened endometrium, no intrauterine gestational sac, but free fluid in the pelvis. Serum human chorionic gonadotrophin (hCG) level is 2749 IU/l. Emergency laparoscopy and a salpingectomy are performed to remove a rupturing ectopic pregnancy.

What factors predispose an individual to ectopic pregnancy?

How does a typical ectopic pregnancy present and evolve?

Under what circumstance would one attempt to preserve the affected tube and how likely is she to achieve a successful pregnancy in future?


image An ectopic pregnancy is one implanted outside the uterine cavity, and 95% of such pregnancies are tubal. However, ectopic pregnancies can implant in the ovary, the omentum, the abdominal wall or the cervix. Typically, tubal pregnancies present at six to seven weeks, but pregnancies in more unusual locations tend to present later in the pregnancy and, particularly for the abdominal sites, may not present until term. Rarely, a multiple pregnancy may implant in two different sites. This is termed a heterotopic pregnancy and occurs spontaneously approximately once in 10 000 pregnancies. Following in vitro fertilization (IVF) the incidence is much higher, perhaps as high as 1 in 500 pregnancies.1

What factors predispose an individual to ectopic pregnancy?

Any event which leads to tubal damage or altered tubal transport will increase the risk of tubal pregnancy (Table 27.1). A history of ectopic pregnancy increases the risk of a second ectopic, with a 10% risk of ectopic in subsequent pregnancy. Tubal damage may occur as a result of pelvic infection, particularly chlamydia, or as a result of abdominal surgery, particularly tubal surgery. A history of subfertility may pre-date the ectopic, and IVF is associated with an increased risk of tubal pregnancy. Conception while taking the progesterone-only pill increases the risk. The copper intrauterine contraceptive device does not increase the absolute risk of ectopic pregnancy but it will not prevent implantation within the tube. Thus, if a pregnancy occurs with a copper device in situ, it is more likely to be an ectopic pregnancy. Levonorgestrel-releasing devices are associated with a very low failure rate, but of these resulting pregnancies approximately half will be ectopic.2

Table 27.1Risk factors for tubal pregnancy

How does a typical ectopic pregnancy present and evolve?

The diagnosis of ectopic pregnancy can be extremely difficult and it may ...

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