Normally, pregnancies develop in the mother's uterus, but the egg and sperm usually meet in the tube. This early pregnancy must make it into the uterus to survive. When it doesn't make it into the womb to implant, it is called an "ectopic" pregnancy.

The "tubal" pregnancy is the most common form of ectopic pregnancy, but on rare occasions, the pregnancy may also implant in the cervix. on the ovary or even in the abdomen. There are many causes of tubal pregnancies, such as, in born tubal malformations, endometriosis and adhesions from tubal infections. The incidence of ectopic pregnancies has risen over the last decade from 1 in 200 pregnancies to nearly 1 in 80 pregnancies. Possibly, this increase is due to the delaying of childbirth, which can allow endometriosis to do more damage to the tubes before they are used to reproduce. The rise in sexually transmitted diseases that can damage tubes, such as chlamydia, may also be partly responsible.

Ectopic pregnancies are a very serious medical problem; they are the number one cause of maternal death in the first twelve weeks of pregnancy. The uterus is designed to accept the growing pregnancy, enlarge and supply it with blood, nutrients and oxygen. If the pregnancy implants in the tube, the tube can not expand to support it. The tube can be stretched to the point of bursting and cause terrible pain, or can rupture and cause life threatening internal bleeding.

I usually suspect an ectopic pregnancy when there is pain or vaginal bleeding early in a pregnancy. The pain is from the stretching of the tube and the bleeding is from the lining of the uterus. Yes, the uterus is the source of the bleeding and not the tube, because the placenta implants poorly in the tube and can't supply the body with enough hormone to support the lining of the uterus. This is similar to why one spots a little if a birth control pill is missed.

When a tubal pregnancy is suspected, a sonogram can be done. If the pregnancy is very early, it can be very difficult to tell the difference between a threatened miscarriage and a tubal pregnancy. If the pregnancy is clearly seen in the uterus, one can assume there is no tubal pregnancy. There is though, a possibility of having twins, with one in the tube and one in the uterus; this is very rare. If the pregnancy can't be seen with a sonogram, I must follow the rise in the hormone that we use to detect a pregnancy. This is human chorionic gonadatropin (HCG) and it is the basis of all modern pregnancy tests. The actual blood level of this hormone is followed for the normal rise of a healthy pregnancy; if this does not occur, then an "ectopic" is diagnosed.

Once a tubal pregnancy is diagnosed it must be removed or treated medically. I have been asked several times if I could just move it into the uterus; I wish I could. In the past, the woman's abdomen always had to be opened and the tube removed. She then faced the recovery from a major surgery. This still must be done sometimes, if the tube has burst, but if the tube is not ruptured, I will usually treat the patient with a medication called methyltrexate and if the shot does not work then I try to remove the pregnancy from the tube and if possible save the tube for future fertility. I also can frequently do this all with just the laparoscope (belly button surgery), using a laser or electricity. This allows the patient to go home the next day and be back to normal activity in just a few days with no major abdominal scar. There is also an experimental new oral medicine being studied for treatment of ectopic pregnancies.

Treating and resolving an ectopic pregnancy is life saving, but unfortunately, whether the tube is saved or removed the patient is at a very high risk for a recurrent pregnancy in the tube. This means that all future pregnancies need to be followed carefully from early on, to make sure they are where they are supposed to be.

This problem and others, are why I try to see my obstetrical patients as early as possible in their pregnancy. If you have pain or bleeding, and you think you may be pregnant, don't wait, see your doctor.