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Fortunately for Ms Avril Chua, her doctor picked up the signs that a fertilised egg had implanted itself outside of her uterus. If diagnosed late, ectopic pregnancies can be life threatening. JOAN CHEW reports
 Ms Avril Chua, 36, was thrilled to learn last April that she was five weeks pregnant with her second child. However, when the gestational sac, the first sign of a pregnancy, could not be detected on the ultrasound scan despite positive blood tests, her doctor had a sense of foreboding. Dr Peter Chew, an obstetrician and gynaecologist at Peter Chew Clinic for Women, recognised the signs of an ectopic pregnancy, which occurs in one out of every 300 pregnancies.
This is when the fertilised egg implants itself outside of the uterus or womb. Such pregnancies will be terminated either with medical intervention or through ruptures as the baby cannot develop properly. By her seventh week, further tests convinced Dr Chew that Ms Chua’s pregnancy was abnormal. The foetus, which had implanted itself in her left fallopian tube, was removed, leaving her fallopian tube intact. The assistant sales director of a recruitment firm has a four-year-old son, but suffered two miscarriages after her son was born. Failing yet again to carry another baby to term crushed her. Doctors say that about 95 per cent of ectopic pregnancies such as Ms Chua’s occur in the fallopian tube. Others can occur in the ovary, abdomen or cervix.
 An ectopic pregnancy is the most dangerous condition that a woman can face during the early stages of pregnancy and can be life threatening to mothers if not diagnosed early. Of the 15,000 pregnancies handled by KK Women’s and Children’s Hospital (KKH) each year, 350 to 400 are ectopic. Dr Chew described the condition as a time bomb which can erupt at any time, usually from the seventh week on. But diagnosis is difficult because many women with early or unruptured ectopic pregnancies have no symptoms, as in Ms Chua’s case. Those who have ruptured ectopic pregnancies have symptoms such as lower abdominal pain, abnormal bleeding from the vagina, lower back ache or cramping. Even if these symptoms are present, they may be confused with ruptured ovarian cysts, appendicitis or a threatened miscarriage, Dr Chew added.
Unless the ultrasound scan clearly shows the gestational sac in the fallopian tube, a high degree of suspicion is required before a diagnosis of an ectopic pregnancy is made, said Dr Benjamin Tham, obstetrician and gynaecologist at private practice WC Cheng & Associates. In most cases, this is when the growing foetus cannot be located in the uterine cavity even with a high level of human chorionic gonadotrophin, a hormone produced after conception.
In a normal pregnancy, the egg is fertilised in the fallopian tube and travels down to the uterus, where it implants itself. An ectopic pregnancy is usually caused by conditions that obstruct or slow down this process, so it is more common in women with fallopian tube problems, said Dr Cindy Pang, associate consultant at the department of obstetrics and gynaecology at the Singapore General Hospital. They may have a history of pelvic infection or pelvic surgery, or endometriosis, which leads to a distortion or blockage of the tubes. Smokers and those who have undergone assisted reproduction are also at greater risk. Others, like Ms Chua, have no known risk factor. Dr Anupriya Agarwal, consultant at the department of obstetrics and gynaecology at the National University Hospital, said that the womb has thick walls of about 2.5cm, unlike the fallopian tubes which have 1 to 2mm-thick walls.
When a fertilised egg implants itself in a fallopian tube and starts to grow, the fallopian tube will balloon. When it can no longer accommodate the growing foetus, it will burst. Dr Pang warned that a ruptured ectopic pregnancy can lead to massive internal bleeding, shock and death, though this rarely happens here because of good medical care. Dr Irene Chua, consultant at the department of obstetrics and gynaecology at KKH, said there have been no such deaths at KKH over the last decade. Dr Agarwal said if ectopic pregnancies are detected early at six or seven weeks, the woman is injected with a drug known as metrotrexate, which causes the ectopic pregnancy tissue to stop growing and get absorbed into the body. But eight out of 10 ectopic pregnancies are detected later than at seven weeks, said Dr Agarwal. In those cases, a thin tube with a camera attached to it is inserted into the abdomen to remove the ectopic tissue.
Dr Chua said that doctors will try to conserve the fallopian tube during surgery unless it is too badly damaged, though keeping it could also increase the odds of another ectopic pregnancy. Doctors said the only way to prevent an ectopic pregnancy is to avoid the risk factors. These include contracting inflammatory pelvic disease and sexually transmitted diseases through multiple partners or having sex without a condom. Women with these conditions should seek treatment before they get pregnant. Said Dr Tham: “To prevent a tragic outcome, early diagnosis of an ectopic pregnancy is important. Mothers should seek medical help and have ultrasound scans early in pregnancy.”
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