What You Need to Know About Ectopic Pregnancy
Ectopic pregnancy is defined as pregnancy that implants outside of the lining of the womb. It could be located in the fallopian tube, ovary, abdomen, or cervix. However, tubal pregnancy accounts for 97.7% of cases.
The World Health Organization (WHO) estimates that 585,000 women die every year as a result of complications related to pregnancy, delivery and post-delivery period. This is higher in developing countries than in developed countries.
Ectopic pregnancies are responsible for 10% of maternal mortality (pregnancy related death) in the first trimester (3 months) of pregnancy.The rate (risk) of ectopic pregnancy increases with age regardless of race and is highest for women between the age of 35 and 44.
These are factors that predispose a woman to having Ectopic pregnancy, the commonest being Pelvic inflammatory disease, uterine abnormalities, previous tubal pregnancy, illegal abortion,previous tubal surgery, certain contraceptive failures like IUD.
Other rare risk factors include cigarette smoking, ovulation induction and transmigration of the ovum as it passes down the fallopian tube. In about one-fourth of tubal pregnancies, the corpus luteum, which is where the ovum came from that resulted in the pregnancy, is found on the other ovary, not on the same side as that of ectopic pregnancy.
There must be a high index of suspicion, as clinical presentation or symptoms may differ depending on the location of the ectopic pregnancy. Also symptoms may mimic other clinical entities like spontaneous miscarriage. Due to the fact that symptoms differ, based on the location of the ectopic pregnancy, Doctors are always extra careful before concluding that the symptoms a patient presents with are suggestive of ectopic pregnancy.
Most women with ectopic pregnancy will have a missed period, spotting par vagina with associated abdominal cramps or lower abdominal pain. In cases of tubal rupture patient can present in shock with marked lower abdominal pain.
Advancement in clinical technology during the past 20 years has resulted in earlier diagnosis of ectopic pregnancy. The availability of a highly specific immunoassay for hCG and high-resolution ultrasonography has resulted in the ability to diagnose ectopic pregnancy in its earliest stages.
Pregnancy can now be diagnosed from the 25th day of the menstrual cycle (this is before a missed period).
Other diagnostic measures used previously include: culdocentensis; serum progesterone; Dilatation and Curretage. All these have their limitations.
This is typically divided into three broad umbrella groups which include: expectant management, medical management and surgical management.
Expectant Management. Some patients with ectopic pregnancy undergo spontaneous absorption and require no therapy. Hence, expectant management entails watchful waiting in patients with an un-ruptured tubal ectopic, with a clinical suspicion that ectopic gestation may be dying off. These patients are admitted in the hospital from the time of diagnosis to complete resolution of ectopic. This entails repeated tests, serial Beta hCG level assay and scans (Transvaginal Ultrasound Scan). This is to ensure the pregnancy is not thriving, instead of resolving, otherwise it will eventually rupture.
At present, it is considered better to remove an un-ruptured ectopic pregnancy at the time of first laparoscopy (Diagnostic Key Hole or Minimal Access Surgery) to avoid the additional expense of hospitalization, serial hCG assays, and a second surgery later.
Medical Management. This may also play a role in carefully selected patients. It entails the injection of medical substances like methotrexate, urea or high concentration of dextrose into the gestational sac to cause death of the embryo. These groups of patients are also closely monitored with serial Beta hCG assay and Transvaginal scan. However, there may be recourse to surgery if the embryo persists.
Surgery Management. Surgery can be conservative (laparoscopy) or open surgery.
Conservative surgical treatment of ectopic pregnancy is well established, and laparoscopic salpingostomy is the preferred operative method in un-ruptured cases. This is available in Kelina Hospital.
This has the advantage of cosmesis i.e no big scars on the abdomen, short hospital stay with lower risk of intra-operative adhesions, faster recuperation and earlier return to work. This is desirable to most patients especially single ladies who prefer their abdomen to remain unscarred.
The type of surgery performed also depends on the extent of affectation of the tube or location of the ectopic in question.
Open surgery is advocated in the face of tubal rupture and overt hemorrhage, salpingectomy (removal of the tube) may be necessary to provide rapid treatment and to prevent serious morbidity and mortality.
Thanks for reading
Dr. Olufolake A. Oni