The word ectopic means “out of the place”. Ectopic pregnancy occurs when a fertilized ovum (a blastocyst) becomes implanted on any other tissue other than uterine lining or out of the uterine cavity (for example the fallopian tube, ovary, abdomen, cervix or scar tissue from previous caesarean section). The most common site of ectopic implantation is fallopian tube. The incidence of ectopic pregnancy is difficult to estimate but on average it is approximately 1 in 300 to 1:150 deliveries. The incidence of ectopic pregnancy and risk of death due to ectopic pregnancy are decreasing. However, ectopic pregnancy remains the leading cause of pregnancy related death in the first trimester. The common site of ectopic pregnancy are in abdominal (0-1%), in ampulla (55%), in isthmus (25%), in fimbriated end (17-4%), and in ovary (0-5%).
Possible causes of ectopic pregnancy include:
- peritubal adhesions (after pelvic infection, endometriosis, appendicitis)
- structural abnormalities of fallopian tube (rare and usually related to DES exposure),
- previous ectopic pregnancy, previous tubal surgery,
- multiple previous induced abortions (particularly if followed by infection),
- tumors that distort the tube, and IUD (intra-uterine device) and progestin only contraceptives.
- PID (pelvic inflammatory disease) appears to be the major risk factor.
- Improved antibiotic therapy for PID usually prevents total tubal closure but may leave a stricture or narrowing, predisposing to ectopic implantation.
The odds of recurrent ectopic pregnancy are three times higher of an infectious pathology caused the first ectopic pregnancy. Risk factors are important, but all women need to be educated about early treatment and have high index of suspicion in the case of a period that does not seem normal, the presence of pain or pain with a suspected pregnancy. Women may have fatal haemorrhage with ruptured ectopic pregnancies if they delay seeking medical attention or if their health care provider are not alert to the possibility of this diagnosis. The delayed condition can result various complications involving death due to haemorrhage.
Signs and symptoms vary depending on whether tubal ruptured has occurred. Clinically, ectopic pregnancy is three distinct types.
Acute or Ruptured Ectopic
- Short period of amenorrhoea. Delay in menstruation from 1 to 2 weeks followed by slight vaginal bleeding (spotting) or a report of a slightly abnormal period suggests the possibility of an ectopic pregnancy.
- Symptoms may begin late, with vague soreness on the affected side (probably due to uterine contraction and distension of tube).
- May proceed to sharp colicky pain.
- Gastrointestinal symptoms, dizziness or light-headedness may occur.
- Patients may mistaken spotting for menstrual bleeding, especially if a recent period occurred and was normal.
- When the tube ruptures, the ovum is discharged into the abdominal cavity and the woman experiences agonizing pain, dizziness, faintness, nausea and vomiting due to the peritoneal reaction to blood escaping from the tube.
- Features of hypovolemic shock are evident by rapid and feeble pulse, hypotension, cold and clammy extremities, pallor, restlessness and sweating.
- Later the pain becomes generalised in the abdomen.
- Discomfort om the side of the flank which is continuous or at time colicky in nature.
- Uterus is slightly smaller than the weeks of amenorrhoea.
- A pulsatile small, well circumscribed tender mass may be felt through one fornix separated from the uterus.
Sub acute or chronic
- Abdominal pain present with varying degrees.
- Vaginal bleeding appears sooner or later following the pain .
- Bladder irritation- dysuria, frequency or even retention of urine.
- Patient looks ill (pallor, fever, tachycardia).
- On abdominal examination-tenderness and muscle guard on the lower abdomen especially on affected side. A mass can be felt.
Ectopic pregnancy must be diagnosed promptly to prevent life-threating haemorrhage, the major complication of rupture.
- During vaginal examination, a large mass of clotted blood that has collected in the pelvis behind the uterus or a tender adnexal mass may be palpable, although there are often no abnormal findings.
- If an ectopic pregnancy is suspected, the patient is evaluated by sonography and human chorionic gonadotropin (hCG) levels. If the Ultrasonography results are inconclusive, the hCG test is repeated.
- The hCG levels double in early pregnancies every 3 days but are reduced in abnormal or ectopic pregnancies.
- Serum progesterone levels are also measured. Levels less than 5ng/ml are considered abnormal; levels greater than 25ng/ml are associated with a normally developing pregnancy.
- Detectable Fetal heart movement outside the uterus on ultrasound is firm evidence of an ectopic pregnancy.
- An ultrasound study is not definitive and the diagnosis must be made with combined diagnostic aids (beta-hCG and progesterone levels, ultrasound, pelvic examination and clinical judgement).
- Laparoscopy can be used because the physician can visually detect an Unruptured tubal pregnancy and thereby circumvent the risk of its rupture.
- HB, cbc (complete blood count) and blood grouping and other pre-operative investigation.
Management: The principle of acute ectopic is resuscitation and laparotomy.
When the surgery is performed early, almost all patients recover rapidly; if tubal rupture occurs mortality increases. The type if surgery is determined by the size and extent of tubal damage. Conservative surgery includes “milking” an ectopic pregnancy from the tube. Resection of the involved fallopian tube with end-to-end anastomosis may be effective. More extensive surgery includes removing the tube alone (salpingectomy) or with the ovary (salpingo-oophorectomy). Depending on the amount of blood loss, blood component therapy and treatment of haemorrhagic shock may be necessary before of after the surgery. Surgery may also be indicated in women unlikely to comply with close monitoring to obtain the monitoring needed with nonsurgical management.
Methotrexate (Trexall), a Chemotherapeutic agent and folic acid antagonist, may be used after surgery to treat any remaining embryonic or early pregnancy tissues, as indicated by a persistent or increasing beta-hCG level. The beta-hCG test is repeated after 2 weeks prior to surgery to ensure that the level is decreasing.
Another option is the use of methotrexate without surgery. Because methotrexate stops the pregnancy from progressing by interfering with DNA synthesis and multiplication of cells, it interrupts early, small, Unruptured ectopic pregnancies. The patient must be hemodynamically stable, have no active renal or hepatic disease, have no evidence of thrombocytopenia or leukopenia and have Unruptured ectopic pregnancy with no Fetal cardiac activity. The medication is administered intramuscularly or orally. Some patients may be treated with intra tubal injection of methotrexate. Complete blood count and tests of liver and renal function are conducted to monitor the patient; blood grouping is performed in anticipation of the need for transfusion.
Until the pregnancy is resolved, the patient is advised to refrain from alcohol, intercourse and vitamins containing folic acid because these may exacerbate the adverse effects of methotrexate. Abdominal pain may occur within 5 to 10 days and may indicate termination of pregnancy. Side effects of methotrexate include abdominal cramping, mucositis, and renal and hepatic damage. Allergic reactions have occurred in patients receiving high doses.
Home-based care and management
If the patient has experienced life-threating haemorrhage and shock, these complications are addressed and treated before any in-depth teaching can begin. Procedures are explained in terms that the distressed and apprehensive patient can understand. The patient’s partner and close family members are included in teaching and explanations when possible. The patient is informed about possible complication and instructed to report early signs and symptoms. Emphasise on healthy sexual activity, dietary requirements and rest.