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Feature: Her pregnancy could have killed her

13-Jan-2011 (Thu) Mind Your Body, The Straits Times

By Joan Chew

Ms Avril Chua tested positive last April when she went for blood tests to check if she was pregnant. Yet, the gestational sac, the first sign of a pregnancy, could not be detected on the ultrasound scan. This was when her doctor suspected that it was an ectopic pregnancy.

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 percent 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 10ectopic 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.'

She lost both her fallopian tubes

Up till the moment she was wheeled into the operating theatre to remove an ectopic pregnancy that threatened her life, Zara (not her real name) was still pleading with her doctor not to do it.

She said: 'When the doctor said the baby could not be saved, I felt very sad as it would have been my first born.' As it turned out, the surgeon, Dr Anupriya Agarwal, a consultant at the department of obstetrics and gynaecology at National University Hospital, had to remove Zara's right fallopian tube as well as the foetus.

This incident happened in 2006 when Zara was 29.

Two years later, when Zara became pregnant again, the embryo implanted itself in her left fallopian tube. She was devastated and was again reluctant to terminate the pregnancy. However, her family persuaded her to undergo surgery to save her life.

If left untreated, her fallopian tube would rupture and she could die from internal bleeding.

She agreed - on condition that her fallopian tube not be removed. But during surgery, Dr Agarwal saw that it was too badly damaged to be saved.

Zara is not alone in her plight. Up to 20 per cent of women with an ectopic pregnancy develop another.

Zara gave up hope of ever becoming a mother. But Dr Agarwal persuaded her to consider in-vitro fertilisation (IVF). After a successful second cycle, Zara, now 33, will finally deliver a baby next month.

She said: 'It was the happiest moment of my life when I found out I was pregnant. I never thought I could conceive again without my fallopian tubes.'

The embryo was transferred to her uterus through the cervix, bypassing the fallopian tubes. Now Zara is making sure that the pregnancy goes well.

She has gone on no-pay leave from the shipping logistics company where she works and is doing only light housework at home, leaving the heavy chores to her husband of five years.

Zara wants other women who cannot conceive naturally to know that nothing is impossible with today's medical advancements.

She said chirpily: 'The bit of pain from IVF is all worth it. After all, no pain, no gain.'

In pain for more than 16 hours

In 2006 when Mrs Cynthia Leong was 16 weeks pregnant, she was woken by a sharp, stabbing pain in her abdomen one morning.

She called her doctor, who said that she could have torn a muscle and told her to rest in bed.

But Mrs Leong felt that the pain was unusual and feared it would endanger her baby, so she checked herself into KK Women's and Children's Hospital by 8am that morning.

The pain did not go away even with painkillers. She said: 'The pain was continuous and grew more intense. Whenever I moved, I would scream in pain.'

Three ultrasound scans showed her foetus was in the right position in the uterus.

As doctors decided it was not a gynaecological problem, she was transferred to Tan Tock Seng Hospital that night to be examined for other conditions like appendicitis and stomach ulcer.

However, even after an X-ray examination, no one could determine the reason for the pain. Her condition took a turn for the worse at midnight, when her blood pressure plummeted to a dangerously low level.

She was rushed into emergency surgery and doctors finally saw the ruptured ectopic pregnancy. The foetus was in her right fallopian tube and buried deep in the wall of the uterus.

The surgeon, Dr Christopher Ng, noted it was a rare form of ectopic pregnancy, known as cornual pregnancy. This condition is more difficult to diagnose than other ectopic pregnancies as the foetus may appear to be in the right place in the mother's uterus on an ultrasound scan.

Dr Ng, an obstetrician and gynaecologist who now works at GynaeMD Women's and Rejuvenation Clinic in Camden Medical Centre, said he has seen fewer than 10 such cases in his 13 years of practice.

He said Mrs Leong had massive internal bleeding and was in danger of going into shock. During surgery, he removed her ectopic pregnancy, part of her uterus and right fallopian tube.

Six months after the incident, she was pregnant again and gave birth to a healthy baby boy through Caesarean section in 2007.

She said: 'I count my blessings that I was able to survive that devastating period.'

All stories by Joan Chew

Case of the S'pore woman en route to Amsterdam

A 28-year-old Singaporean had a close brush with death last month when she suffered complications from an ectopic pregnancy while en route to Amsterdam for a holiday with her husband.

After an emergency landing in Bucharest, she was rushed to Romania's Elias Hospital with nearly no pulse or blood pressure. Doctors there discovered that the embryo had developed outside her womb and part of her uterus had to be removed. Her husband said that a medical scan prior to the trip had given her the all-clear. Doctors believe that her ectopic pregnancy was not discovered because it had developed close to the uterus. Dr Christopher Ng, obstetrician and gynaecologist at GynaeMD Women's and Rejuvenation Clinic in Camden Medical Centre, said it may have been a cornual pregnancy, also known as an interstitial pregnancy.

'This is a rare type of ectopic pregnancy which occurs when the fertilised egg implants itself in the part of the fallopian tube that is buried deep in the wall of the uterus,' he said.

An ultrasound scan could show the foetus implanted in the uterus, causing the doctor to miss the diagnosis.

'It is more dangerous than other forms of ectopic pregnancies because it tends to rupture later and with potentially more severe haemorrhage,' he said.

Dr Benjamin Tham, obstetrician and gynaecologist at WC Cheng & Associates at Thomson Medical Centre, said another possibility was a heterotrophic pregnancy, in which there are two fertilised eggs - one inside the uterus and the other outside.

The abnormal pregnancy outside the uterus ruptures.

He said the incidence of heterotrophic pregnancies is very rare, at one in 30,000 pregnancies. However, it may rise to one in 7,000 pregnancies because of assisted reproduction, he added.