Dear Doctor,

I became five weeks pregnant last week and went for my first scan. However after two external scans and an internal scan, doctors couldn’t find any fetus and told me I’m at a high risk of having an ectopic pregnancy. Of late, I have been experiencing sharp pains in the lower left side of my abdomen. The doctors gave me two options to consider; medical drugs or a surgical procedure. Among the two, what is the best option for me? Secondly, what fertility hazards could I be facing if I don’t terminate the pregnancy?

Hilda, Gikondo

Dear Hilda

Was it a confirmed pregnancy test after missing periods for two weeks or was it suspected to be a pregnancy by you?

Ectopic pregnancy is the one where the embryo is inserted at a site other than the inner lining of uterus. Between 5-42% of women who have a positive pregnancy test but no fetus visible inside the uterus have an ectopic pregnancy or pregnancy at an unknown location (PUL). The most common site for ectopic pregnancy is the fallopian tubes. But it can also be located in the cervix (lower part of uterus, connecting to vagina) horn of uterus, ovary or also within the abdomen.

The risk factors for causing ectopic pregnancy are pelvic inflammatory disease, sexually transmitted diseases like Chlamydia and Gonorrhea, use of intra uterine contraceptive devices, tubal surgery, intra uterine surgery, use of fertility drugs, interventions done for conceiving like IVF, smoking, among others.

Abnormalities of the fallopian tubes present since birth can also give rise to ectopic pregnancy. But in many cases no identifiable cause is found.

A woman with ectopic pregnancy may have cramp like abdominal pain, pain over the rectum, nausea, vomiting and rarely, diarrhea. One or more of these symptoms may be present in different combinations. The main risk is from bleeding. Rupture of the fallopian tubes can cause massive hemorrhage because it is not suitable to carry the growing fetus. Thus this becomes an emergency needing urgent treatment. The baby usually is not able to continue till full term.

There may be miscarriage in early stages.

In any woman, having a positive pregnancy test with severe abdominal pain, vaginal bleeding and empty uterus seen on routine ultrasound, ectopic pregnancy is a strong possibility. Levels of human chorionic gonadotropin, transvaginal ultrasound are other means to diagnose an ectopic pregnancy. A laparoscopy or laparotomy is useful as directly the ectopic pregnancy can be visualised. This is usually employed when there is severe abdominal pain.

Mild cases can be monitored regularly to see growth of the baby and its viability. Methotrexate is used for medical treatment of mild cases of ectopic pregnancy. This drug arrests growth of the fetus resulting in abortion. But severe cases always need surgical intervention.

Future fertility depends on other risk factors a woman may have like a history of smoking, sexually transmitted diseases, hormonal imbalance and also on the type of surgical intervention done. If ectopic pregnancy has been removed by just a nick in the fallopian tube and the other tube is intact, the uterus is not damaged; one can have a baby very well in future. But if the fallopian tube/ uterus is damaged and or other risk factors are present, there can be problem with conceiving in the future.

Dr. Rachna is a specialist in internal medicine at Ruhengeri Hospital.