ETERNAL PREGNANCY (ECTOPIC PREGNANCY)
Ectopic pregnancy is when the fertilized egg cell settles somewhere else rather than inside the uterus. In other words, the product of pregnancy has settled in another area, not the uterus. Until recent years, it was one of the most important causes of maternal deaths in the first three months of pregnancy. Death here occurs due to the rupture of the ectopic gestational sac, internal bleeding in the mother, and this bleeding not being diagnosed or the patient not being able to get to a hospital. However, thanks to the developments in modern diagnostic methods, ectopic pregnancy can now be diagnosed and treated very early. The treatment of ectopic pregnancy has undergone significant changes over the years. For example, although in the past the only treatment option was surgery, today a significant portion of ectopic pregnancies diagnosed early can be treated with a drug called methotrexate. Methotrexate is a drug that is used in some types of cancer and has cell-killing properties. In cases diagnosed at an early stage, before the ectopic gestational sac ruptures, when given to the patient, it can kill the fetal (embryo) cells and terminate the pregnancy.
Approximately 1-2% of all pregnancies develop as ectopic pregnancy. The rate of ectopic pregnancy has been increasing over the years. Increasing risk factors related to ectopic pregnancy, rapid development of early diagnosis methods and the increasingly widespread use of assisted reproductive techniques (in vitro fertilization) play a major role in this increase. Approximately 5% of pregnancies resulting from in vitro fertilization methods result in ectopic pregnancy.
How does the disease occur? What are the predisposing risk factors?
In women, fertilization of male and female cells takes place in the fallopian tubes (tuba uterina). This fertilized cell is transported through the canal to the uterus (inside the uterus). Any reason that prevents this migration process causes an ectopic pregnancy. 98% of ectopic pregnancies are located in the ducts, 1.5% in the abdominal cavity, 0.25% in the ovaries and 0.25% in the cervix.
We can divide the risk factors of the disease into three groups: significantly effective, moderately effective and mildly effective risk factors. Significant ones: Previous root canal surgeries (increases the risk of ectopic pregnancy by 21 times), tubal ligation, previous ectopic pregnancy (8 times), spiral use (6 times), assisted reproductive techniques. Moderately effective ones can be listed as infertility, previous genital infections (4 times), and the woman being polygamous. Mildly effective risk factors are smoking and having first sexual intercourse under 18 years of age.
What are the main symptoms of the disease?
Along with a positive pregnancy test, lower abdominal pain and light bleeding are the most common symptoms. Especially women in the high-risk group should be examined very carefully when the pregnancy test is (+). Thus, it is possible to detect patients in their asymptomatic stages and treat them with medication. In patients who cannot be detected early, the ectopic gestational sac ruptures over time. This may cause internal bleeding in women, severe abdominal pain, cold sweats, and fainting (due to anemia). Depending on the degree of this bleeding, the patient may die.
How to make early diagnosis?
The first condition for early diagnosis is to diagnose patients in the earliest period of their pregnancy (at 4,5-5 weeks). to consult a doctor. In a woman with a positive pregnancy test during this period, if a gestational sac cannot be seen in the uterus by ultrasonography, ectopic pregnancy should be suspected. In such cases, pregnancy hormone (B-HCG) is checked from the blood. If the value of this hormone is above 2000 IU/L but the intrauterine gestational sac cannot be found, an ectopic pregnancy can be diagnosed. If the hormone value is below 2000 IU/L, B-HCG hormone is checked every 48 hours. If the increase between the two values is over 65%, intrauterine pregnancy is considered and expected. If the increase rate is below 66%, diagnosis can be made with additional methods such as taking samples from the uterus. Today's modern ultrasonography devices can detect a pregnancy of 5.5 weeks vaginally. Starting from the 6th week of pregnancy, the structure of an ectopic pregnancy can be observed in the canals with ultrasonography. Additionally, if there is bleeding into the abdomen due to ectopic pregnancy, this can also be detected by ultrasonography. In fact, the degree of this bleeding is often determined accurately.
What are the treatment methods?
There are three main treatment methods.
1- Monitoring:
B-HCG value is below 1000 IU/L and ectopic pregnancy cases that disappear spontaneously can only be followed up with close monitoring. Patients' B-HCG values are measured every few days and followed until they approach zero. Up to 68% of pregnancies may dissolve spontaneously. However, there is always a risk of internal bleeding in these patients. Therefore, this approach is not preferred.
2- Drug treatment:
In recent years, methotrexate has been used successfully in the treatment of ectopic pregnancy. The following conditions are required for this treatment: The ectopic gestational sac is not ruptured, the diameter of the sac is 4 cm. B-HCG value is below 10.000 IU/L, fetal heartbeat is not seen. A ruptured ectopic gestational sac requires emergency surgery. The chance of success of drug treatment increases significantly in pregnancies with B-HCG values below 3000 IU/L. Methotrexate has several administration doses.
- Single dose treatment
- Two dose treatment
- Multiple dose therapy
It is a single dose treatment that produces minimal side effects for the patient. Two doses of treatment slightly increase the chance of success. Multiple dose therapy is not used much today. Patients should not use folic acid-derived drugs during methotrexate treatment. The main side effects of the drug are; bone marrow suppression, liver damage, hair loss, sensitivity to light, irritation in the gastrointestinal tract. These side effects can often be observed after multiple dose therapy. Patients should be warned about this. The patient should be examined for side effects before treatment. This treatment should not be given to risky patients. It is monitored at fifty intervals until the pregnancy hormone is cleared from the blood. This method is successful in 85-90% of pregnancies. In cases where drug treatment fails, surgical treatment is applied. The chance of the canal remaining open is 80%, the chance of intrauterine pregnancy is 60%, and the risk of recurrent ectopic pregnancy is 7%.
3- Surgical treatment:
Depending on the doctor's experience, surgery can be performed using the open method or the laparoscopic (closed) method. The torn canal must be removed. If the diagnosis is made without rupture of the ectopic gestational sac and if the patient's desire for a child continues, the canal is cut longitudinally and only the product of pregnancy is evacuated. The success rate of surgical treatment is 90%, the chance of intrauterine pregnancy is 57%, and the risk of recurrence of ectopic pregnancy is 13%.
Ectopic pregnancy types located in the abdomen, ovaries and cervix are very rare. The increasing rates of heterotopic pregnancy (pregnancy both inside and outside the uterus at the same time) in recent years are due to the increase in in vitro fertilization treatments. Heterotopic pregnancies, which used to be seen in 1/30.000, are seen in 1-3% of those receiving in vitro fertilization treatment. For this reason, the first ultrasonographic examination of women who become pregnant through in vitro fertilization should be performed very carefully.
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