Examine individual changes

'{{Infobox_Disease | Name = Ectopic pregnancy | Image = Ectopic.gif | Caption = Ectopic by [[Reinier de Graaf]] | DiseasesDB = 4089 | ICD10 = {{ICD10|O|00||o|00}} | ICD9 = {{ICD9|633}} | ICDO = | OMIM = | MedlinePlus = 000895 | eMedicineSubj = med | eMedicineTopic = 3212 | eMedicine_mult = {{eMedicine2|emerg|478}} {{eMedicine2|radio|231}} | MeshID = D011271 }} An '''ectopic pregnancy''', or '''eccyesis''', is a [[complication of pregnancy]] in which the pregnancy implants outside the [[uterus|uterine cavity]].<ref>{{cite book |author=Page EW, Villee CA, Villee DB |title=Human Reproduction, 2nd Edition |publisher= W. B. Saunders, Philadelphia, 1976| isbn=0-7216-7042-3 |page=211}}</ref> With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, internal bleeding being a common complication. Most ectopic pregnancies occur in the [[Fallopian tube]] (so-called '''tubal pregnancies'''), but implantation can also occur in the [[cervix]], [[ovary|ovaries]], and [[abdomen]]. An ectopic pregnancy is a potential [[medical emergency]], and, if not treated properly, can lead to death. ==Overview== [[File:Ruptured ectopic pregancy.JPG|thumb|right|Ruptured tubal pregnancy with approx 6-weeks-embryonic-age or 8-weeks-gestational-age embryo, with intact amniotic sac]] [[Image:Tubal Pregnancy with embryo.jpg|thumb|right|Oviduct with an ectopic pregnancy (tubal pregnancy) showing an embryo of approx. 6-7 menstrual weeks]] [[Image:Tubal pregnancy, gross pathology 01ee049 lores.jpg|thumb|right|Tubal pregnancy necessitating removal of fallopian tube (fetus is 8 weeks gestational age, 6 weeks from conception)]] In a normal [[pregnancy]], the fertilized egg enters the [[uterus]] and settles into the [[uterine lining]] where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.<ref>{{cite web | author=Serdar Ural | title=Ectopic pregnancy | url=http://www.kidshealth.org/parent/pregnancy_newborn/pregnancy/ectopic.html | month=May | year=2004 | publisher=KidsHealth | accessdate=2006-11-26}}</ref> In other words it can be said that in an ectopic pregnancy the embryonic implantation occurs outside the uterus, most commonly in the fallopian tubes but at times also in the extra tubal locations. It poses serious threat to the general and reproductive health of the mother. Ectopic pregnancy comprises 2% of all pregnancies reported to the Center for Disease Control and Prevention (CDC). It has been noted that ectopic pregnancy is steadily and persistently rising since 1970; between 1970 and 1992, the rate of ectopic pregnancy increased from 4.5 to 19.7 per 1000 reported pregnacies (including live birth, legal abortions and ectopic pregnancies).<ref>Riviere L, Culpeper N, Cole A, Rowland W. On Barrenness.In The Practice of Physick, Book 15.London:Peter Code,1658;131, p.916.</ref><ref>Gream GT. Dilatation or division of the cervix uteri. Lancet 1865;1:381 </ref> Detection of ectopic pregnancy in early gestation has been achieved mainly due to enhanced diagnostic capability. Despite all these notable successes in diagnostics and detection techniques ectopic pregnancy remains a source of serious maternal morbidity and mortality all over the world. In a typical ectopic pregnancy, the [[embryo]] does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding ([[hematosalpinx]]) expels the implantation out of the tubal end as a tubal abortion. Some women thinking they are having a [[miscarriage]] are actually having a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by [[prostaglandin]]s released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby [[Sampson artery]], causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. 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. This intervention may be [[laparoscopic]] or through a larger incision, known as a [[laparotomy]]. <!-- methotrexate if identified early before symptoms on an early scan perhaps, but in cases of rupture surely 100% surgical intervention. Davidruben --> <!-- Well, hard to say if a tube has ruptured or not. The presence of fluid or even blood is not prima fasciae evidence of rupture as it could as easily be a tubal abortion with some free blood. That will be self limiting. Opinions have been known to differ on individual cases precisely because of this difficulty. --> ==Classification== ===Tubal pregnancy=== The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopics), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%).<ref name=speroff>{{cite book| author=Speroff L, Glass RH, Kase NG |title=Clinical Gynecological Endocrinology and Infertility, 6th Ed. |publisher=Lippincott Williams & Wilkins (1999) |page=1149ff |isbn=0-683-30379-1}}</ref> Mortality of a tubal pregnancy at the isthmus or within the uterus ([[interstitial pregnancy]]) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur. <ref>{{cite journal |author=Shaw JL, Dey SK, Critchley HO, Horne AW |title=Current knowledge of the aetiology of human tubal ectopic pregnancy |journal=Hum Reprod Update |volume= 16|issue= 4|pages= 432–44|year=2010 |month=January |pmid=20071358 |pmc=2880914 |doi=10.1093/humupd/dmp057 |url=}}</ref> ===Nontubal ectopic pregnancy=== Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal [[ultrasound]] examination is usually able to detect a [[cervical pregnancy]]. An [[ovarian pregnancy]] is differentiated from a tubal pregnancy by the [[Spiegelberg criteria]].<ref>{{WhoNamedIt|synd|2274|Spiegelberg's criteria}}</ref> While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an [[abdominal pregnancy]]. In such a situation the [[placenta]] sits on the intraabdominal organs or the [[peritoneum]] and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by [[laparotomy]]. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports.<ref>{{cite news | title='Special' baby grew outside womb | url=http://news.bbc.co.uk/1/hi/england/beds/bucks/herts/4197194.stm | date=2005-08-30 | publisher=BBC news | accessdate=2006-07-14}}</ref><ref>{{cite news | title=Bowel baby born safely | url=http://news.bbc.co.uk/2/hi/health/671390.stm | date=2005-03-09 |publisher=BBC news | accessdate=2006-11-10}}</ref><ref name="pmid17957101">{{cite journal |author = Zhang J, Li F, Sheng Q |title = Full-term abdominal pregnancy: a case report and review of the literature |journal = Gynecol. Obstet. Invest. |volume = 65 |issue = 2 |pages = 139–41 |year = 2008 |pmid = 17957101 |doi = 10.1159/000110015 |url = | issn = }}</ref> However, the vast majority of abdominal pregnancies require intervention well before fetal [[viability]] because of the risk of hemorrhage. ===Heterotopic pregnancy=== In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. Although rare, heterotopic pregnancies are becoming more common. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%.<ref>http://answers.google.com/answers/threadview?id=568935</ref> Successful pregnancies have been reported from ruptured [[tubal pregnancy]] continuing by the placenta implanting on abdominal organs or on the outside of the uterus. ===Persistent ectopic pregnancy=== A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a [[salpingotomy]], in about 15-20% the major portion of the ectopic may have been removed, but some trophoblastic tissue perhaps deeply embedded has escaped removal and continues to growth, generating a new rise in hCG levels.<ref>{{cite journal| doi=10.1016/S1074-3804(05)80774-1| author=Kemmann E, Trout S, Garcia A |title=Can we predict patients at risk for persistent ectopic pregnancy after laparoscopic salpingotomy?| journal=The Journal of the American Association of Gynecologic Laparoscopists | volume=1 |issue=2 |date=February 1994| pages=122–126 |url=http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7W6G-4KFTB5B-6&_user=10&_coverDate=02%2F28%2F1994&_rdoc=1&_fmt=high&_orig=article&_cdi=28550&_sort=v&_docanchor=&view=c&_ct=432&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=ebbee42acb01b64a9d7df19cba0ab1c0|accessdate=January 22, 2010| pmid=9050473}}</ref> After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic to assure their decline, also [[methotrexate]] can be given at the time of surgery prophyllactically. ==Signs and symptoms== Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability. Early signs include: * Pain in the lower abdomen, and inflammation (Pain may be confused with a strong stomach pain, it may also feel like a strong cramp) * Pain while urinating * Pain and discomfort, usually mild. A [[corpus luteum]] on the ovary in a normal pregnancy may give very similar symptoms. * Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. * Pain while having a bowel movement 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: * External bleeding is due to the falling progesterone levels. * Internal bleeding ([[hematoperitoneum]]) is due to hemorrhage from the affected tube. The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active [[Pelvic Inflammatory Disease]] (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID. More severe internal bleeding may cause: * Lower [[back]], [[abdomen|abdominal]], or [[pelvis|pelvic]] [[Pain and nociception|pain]]. * Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign. * There may be [[cramp]]ing or even tenderness on one side of the [[pelvis]]. * The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse. Ectopic pregnancy can mimic symptoms of other diseases such as [[appendicitis]], other gastrointestinal disorder, problems of the urinary system, as well as [[pelvic inflammatory disease]] and other gynaecologic problems. ==Causes== There are a number of risk factors for ectopic pregnancies. However, in as many as one third<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez/16099295 C.M. Farquhar, Ectopic Pregnancy, Lancet 366 (2005), p. 583]</ref> to one half<ref>[http://www.ncbi.nlm.nih.gov/sites/entrez/18232175 J Indian Med Assoc. 2007 Jun;105(6):308, 310, 312 passim]</ref> of ectopic pregnancies, no risk factors can be identified. Risk factors include: [[pelvic inflammatory disease]], [[infertility]], use of an [[intrauterine device]] (IUD), endometriosis, those who have been exposed to [[Diethylstilbestrol|DES]], tubal surgery, intrauterine surgery (e.g. [[D&C]]), [[smoking]], previous ectopic pregnancy, and [[tubal ligation]].<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=921 |title=BestBets: Risk Factors for Ectopic Pregnancy |format= |work= |accessdate=}}</ref> ===Cilial damage and tube occlusion=== Hair-like [[cilia]] located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy.<ref name="Lyons">{{cite journal |author=Lyons RA, Saridogan E, Djahanbakhch O |title=The reproductive significance of human Fallopian tube cilia |journal=Hum Reprod Update. |volume=12 |issue=4 |pages=363–72 |year=2006 |pmid=16565155 |doi=10.1093/humupd/dml012 }}</ref> Women with [[pelvic inflammatory disease]] (PID) have a high occurrence of ectopic pregnancy.<ref name="Tay">{{cite journal |doi=10.1136/ewjm.173.2.131 |author=Tay JI, Moore J, Walker JJ |title=Ectopic pregnancy |journal=West J Med. |volume=173 |issue=2 |pages=131–4 |year=2000 |pmid=10924442 |pmc=1071024 }}</ref> This results from the build-up of [[scar|scar tissue]] in the Fallopian tubes, causing damage to cilia.<ref name=speroff/> If however both tubes were completely blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy{{Citation needed|date=June 2009}}. Intrauterine adhesions (IUA) present in [[Asherman's syndrome]] can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the [[ostia]], ectopic tubal pregnancy.<ref name="Schenker">{{cite journal |author=Schenker JG, Margalioth EJ. |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility and Sterility |volume=37 |issue=5 |pages=593–610. |year=1982 |pmid=6281085|doi=}}</ref> <ref name="Klyszejko">{{cite journal |author=Klyszejko C, Bogucki J, Klyszejko D, Ilnicki W, Donotek S, Kozma J. |title=Cervical pregnancy in Asherman’s syndrome [article in Polish]. |journal=Ginekol Pol |volume=58 |issue= 1|pages=46–8. |year=1987 |pmid=3583040|doi=}}</ref> <ref name="Dicker:>{{cite journal |author=Dicker, D. Feldberg, D. Samuel, N. and Goldman, JA. |title=Etiology of cervical pregnancy. Association with abortion, pelvic pathology, IUDs and Asherman's syndrome. |journal=J Reprod Med |volume=30 |issue=1 |pages=25–7 |year=1985 |pmid=4038744 |doi=}}</ref> Asherman's syndrome usually occurs from intrauterine surgery, most commonly after [[D&C]].<ref name="Schenker">{{cite journal |author=Schenker JG, Margalioth EJ. |title=Intra-uterine adhesions: an updated appraisal |journal=Fertility and Sterility |volume=37 |issue=5 |pages=593–610. |year=1982 |pmid=6281085|doi=}}</ref> Endometrial/pelvic/genital [[tuberculosis]], another cause of Asherman's syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions.<ref name="Bukulmez">{{cite journal |author=Bukulmez O., Yarali H., Gurgan T. |title= Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis |journal=Human Reproduction |volume=14 |issue=8 |pages=1960–1. |year=1999 |pmid=10438408|doi=10.1093/humrep/14.8.1960}}</ref> [[Tubal ligation]] can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine{{Citation needed|date=June 2009}}. Reversal of tubal sterilization ([[Tubal reversal]]) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%.<ref name=speroff/> This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound. ===Other=== Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could act as a surrogate for other risk factors. Also, it has been noted that [[Tobacco smoking|smoking]] is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies.<ref name=speroff/> Women exposed to [[diethylstilbestrol]] (DES) in utero (aka "DES Daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women{{Citation needed|date=June 2009}}. It has also been suggested that pathologic generation of [[nitric oxide]] through increased [[iNOS]] production may decrease [[tubal ciliary]] beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy.<ref>{{cite journal |author=Al-Azemi M, Refaat B, Amer S, Ola B, Chapman N, Ledger W |title=The expression of inducible nitric oxide synthase in the human fallopian tube during the menstrual cycle and in ectopic pregnancy |journal=Fertil. Steril. |volume= 94|issue= 3|pages= 833–840|year=2009 |month=May |pmid=19482272 |doi=10.1016/j.fertnstert.2009.04.020 |url=}}</ref> ==Diagnosis== An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive [[pregnancy test]]. An [[ultrasound]] showing a [[gestational sac]] with fetal heart in the [[fallopian tube]] is clear evidence of ectopic pregnancy. An abnormal rise in blood [[β-human chorionic gonadotropin]] (β-hCG) levels may indicate an ectopic pregnancy. The threshold of discrimination of [[intrauterine pregnancy]] is around 1500 IU/ml of β-hCG. A high resolution, [[transvaginal ultrasound]] showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for β-hCG has been reached. An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on [[ultrasound]]. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the β-hCG level approximately 48hrs later and repeating the ultrasound. If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. A [[laparoscopy]] or [[laparotomy]] can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking [[fallopian tube]]. [[Culdocentesis]], in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy. [[Cullen's sign]] can indicate a ruptured ectopic pregnancy. ==Treatment== ===Medical=== Early treatment of an ectopic pregnancy with [[methotrexate]] is a viable alternative to surgical treatment<ref name="pmid17591007">{{cite journal |author=Mahboob U, Mazhar SB |title=Management of ectopic pregnancy: a two-year study |journal=Journal of Ayub Medical College, Abbottabad: JAMC |volume=18 |issue=4 |pages=34–7 |year=2006 |pmid=17591007 |doi=}}</ref> since at least 1993.<ref name="pmid2562613">{{cite journal |author=Clark L, Raymond S, Stanger J, Jackel G |title=Treatment of ectopic pregnancy with intraamniotic methotrexate&mdash;a case report |journal=The Australian & New Zealand journal of obstetrics & gynaecology |volume=29 |issue=1 |pages=84–5 |year=1989 |pmid=2562613 |doi=10.1111/j.1479-828X.1989.tb02888.x}}</ref> If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an [[abortion]], or the tissue may then be either resorbed by the woman's body or pass with a [[menstrual period]]. ===Surgical=== If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound.{{Citation needed|date=December 2009}} Surgeons use [[laparoscopy]] or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy ([[salpingostomy]]) or remove the affected tube with the pregnancy ([[salpingectomy]]). The first successful surgery for an ectopic pregnancy was performed by [[Robert Lawson Tait]] in 1883.<ref>{{cite web |url=http://www.emedicine.com/med/byname/Surgical-Management-of-Ectopic-Pregnancy.htm |title=eMedicine - Surgical Management of Ectopic Pregnancy: Article Excerpt by R Daniel Braun |accessdate=2007-09-17 |work=}}</ref> ==Complications== The most common complication is rupture with internal haemorrhage which may lead to hypovolaemic shock. Death from rupture is rare in women who have access to modern medical facilities. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy. ==Prognosis== ===Future fertility=== Fertility following ectopic pregnancy depends upon several factors, the most important of which is a prior history of [[infertility]].<ref name="isbn0-8247-0844-X">{{cite book |author=Togas Tulandi; Tan, S. L; Tan, Seang Lin; Tulandi, T. |title=Advances in Reproductive Endocrinology and Infertility: Current Trends and Developments |publisher=Informa Healthcare |location= |year=2002 |pages=240 |isbn=0-8247-0844-X |oclc= |doi= |accessdate=2009-12-21}}</ref> The treatment choice, whether surgical or nonsurgical, also plays a role. For example, the rate of intrauterine pregnancy may be higher following methotrexate compared to surgical treatment.<ref name="falcone">{{cite book |author=Hurd, William W.; Falcone, Tommaso |title=Clinical reproductive medicine and surgery |publisher=Mosby/Elsevier |location=St. Louis, Mo |year=2007 |pages=724 |isbn=0-323-03309-1 |oclc= |doi= |accessdate=}}</ref> Rate of fertility may be better following salpingostomy than salpingectomy.<ref name="falcone"/> ==Cases with live birth== There have been cases where ectopic pregnancy lasted many months and ended in a live baby delivered by [[laparotomy]]. On 19 April 2008 an English woman, Jayne Jones (age 37) who had an ectopic pregnancy attached to the omentum, the fatty covering of her large bowel, gave birth. The baby was delivered by a [[laparotomy]] at 28 weeks gestation. The surgery, the first of its kind to be performed in the UK, was successful, and both mother and baby survived.<ref>{{cite news |title=Miracle baby Billy grew outside his mother's womb | date=2008-08-31| publisher=Daily Mail | url =http://www.dailymail.co.uk/femail/article-1050942/Miracle-baby-Billy-grew-outside-mothers-womb.html| work = | pages = | accessdate = 2008-09-03 | language = | location=London | first=Laura | last=Collins}}</ref> On May 29, 2008 an Australian woman, Meera Thangarajah (age 34), who had an ectopic pregnancy in the ovary, gave birth to a healthy full term 6 pound 3 ounce (2.8&nbsp;kg) baby girl, Durga, via Caesarean section. She had no problems or complications during the 38-week pregnancy.<ref>{{cite news | first= | last= | coauthors= | title=Baby Born After Rare Ovarian Pregnancy | date=2008-05-30| publisher=[[Associated Press]] | url =http://ap.google.com/article/ALeqM5h7An_4HQLG6rSVO-h1eBIntgYOyAD90VRLKO1 | work = | pages = | accessdate = 2008-05-30 | language = }}</ref><ref>{{cite news | first=Rebekah | last=Cavanagh | coauthors= | title=Miracle baby may be a world first | date=2008-05-30 | publisher= | url =http://www.news.com.au/story/0,23599,23782145-2,00.html | work = | pages = | accessdate = 2008-05-30 | language = }}</ref> The case of Olivia, Mary and Ronan had an extrauterine fetus (Ronan) and intrauterine twins. All three survived. The intrauterine twins were taken out first.<ref>{{cite news |title=Doctors hail 'miracle' baby |date=2009-09-10 |newspaper=BBC News |url=http://news.bbc.co.uk/1/hi/health/443373.stm |accessdate=}}</ref> == In other animals == Ectopic gestation exists in other [[mammal]]s. In [[sheep]], it can go to term, with [[mammary]] preparation to [[parturition]], and [[childbirth|expulsion efforts]]. The foetus can be removed by [[caesarian section]]. Pictures of caesarian section of a euthanized [[ewe]], 5 days after parturition signs. <gallery> File:Poirtêye foû matrice pate.JPG|Leg of fetal lamb appearing out of the uterus during cesarian section. File:Poirtêye foû matrice saetch1.JPG|External view of fetal sac, necrotic distal part. File:Poirtêye foû matrice saetch2.JPG|Internal view of fetal sac, before resection of distal necrotic part. File:Poirtêye foû matrice saetch3.JPG|Internal view of fetal sac, the necrotic distal part is to the left. File:Poirtêye foû matrice saetch&coine.JPG|External side of fetal sac, proximal end, with ovary and uterine horn. File:Poirtêye foû matrice saetch ådfoû pwels.JPG|Resected distal part of fetal sac, with attached placenta. </gallery> ==References== {{reflist|2}} ==External links== * [http://www.ectopic.org.uk The Ectopic Pregnancy Trust] - Information and support for those who have suffered the condition by a medically overseen and moderated, UK based charity, recognised by the National Health Service (UK) Department of Health (UK) and [http://www.rcog.org.uk/ The Royal College of Obstetricians and Gynaecologists] * [http://www.ectopic.org.uk Brown discharge first trimester] - Information and support for pregnant women {{Pathology of pregnancy, childbirth and the puerperium}} [[Category:Medical emergencies]] [[Category:Obstetrics]] [[Category:Pregnancy]] [[Category:Pregnancy with abortive outcome]] [[Category:Health issues in pregnancy]] {{Link GA|zh}} [[fa:حاملگی نابجا]] [[ar:حمل خارج الرحم]] [[bs:Vanmaterična trudnoća]] [[bg:Извънматочна бременност]] [[ca:Embaràs ectòpic]] [[cs:Mimoděložní těhotenství]] [[de:Eileiterschwangerschaft]] [[es:Embarazo ectópico]] [[fr:Grossesse extra-utérine]] [[hr:Ektopična trudnoća]] [[is:Utanlegsfóstur]] [[it:Gravidanza ectopica]] [[lt:Ektopinis nėštumas]] [[ms:Kandungan luar rahim]] [[nl:Buitenbaarmoederlijke zwangerschap]] [[ja:子宮外妊娠]] [[pl:Ciąża pozamaciczna]] [[pt:Gravidez ectópica]] [[ru:Внематочная беременность]] [[sl:Zunajmaternična nosečnost]] [[sr:Ванматерична трудноћа]] [[sh:Vanmaterična trudnoća]] [[sv:Utomkvedshavandeskap]] [[ta:வேற்றிடச்சூல்]] [[wa:Poirtêye foû matrice]] [[zh:異位妊娠]]'