An ectopic pregnancy is an irregular pregnancy that occurs outside the uterus. Most ectopic pregnancies happen in the fallopian pipe, but implantation can too happen in the cervix, ovaries, and stomach. The causes of ectopic pregnancy are unidentified. There are some speculative specific causes or associations. Smoking, advanced maternal age and prior tubal damage of any origin are well known risk factors for ectopic pregnancy. Ectopic pregnancy occasionally occurs in women who have had a hysterectomy. Rather than implanting in the absent uterus, the fetus implants in the abdomen, and must be delivered via caesarean section. Patients are at higher risk for ectopic pregnancy with advancing age. Vaginal douching is thought by some to increase ectopic pregnancies; this is speculative. Women exposed to diethylstilbestrol in utero also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women. In a normal ectopic pregnancy, the embryo does not hit the womb, but instead adheres to the lining of the Fallopian pipe. The implanted embryo burrows actively into the tubal lining. Most usually this invades vessels and will induce bleeding. This bleeding expels the implantation out of the tubal end as a tubal abortion. Many factors are known to increase the risk of having an ectopic pregnancy. Taking hormones, specifically estrogen and progesterone, can slow the normal movement of the fertilized egg through the tubes and lead to ectopic pregnancy. Most women who have had one ectopic pregnancy are later able to have a normal pregnancy. A repeated ectopic pregnancy may occur in 10 - 20% of cases. Women who have in vitro fertilization or who have an intrauterine device using progesterone also have an increased risk of ectopic pregnancy. Early symptoms are either missing or delicate. Some women thinking they are having an abortion are really having a tubal miscarriage. There is no inflammation of the pipe in ectopic pregnancy. Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is locally irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Later presentations are more common in communities deprived of modern diagnostic ability. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. An ectopic pregnancy has to be suspected in any woman with lower abdominal pain or unique hemorrhage who is or might be sexually involved and whose pregnancy examination is constructive. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. Early treatment of an ectopic pregnancy with the antimetabolite methotrexate has proven to be a viable alternative to surgical treatment. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery, however, surgical intervention is still required in cases where the fallopian tube has ruptured or is in danger of doing so. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy or remove the affected tube with the pregnancy.
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