Ectopic Pregnancy - Signs, Symptoms And Treatment

Alternative names :- Tubal pregnancy; Cervical pregnancy; Abdominal pregnancy

Ectopic pregnancy is the implantation of a fertilized ovum outside the uterine cavity. The most common site is the fallopian tube, with more than 90% of ectopic implantations occurring in the fimbria, ampulla, or isthmus. Other possible sites include the interstitium, tubo-ovarian ligament. ovary, abdominal viscera. and internal cervical os. In whites, ectopic pregnancy occurs in 1 in 200 pregnandes; in nonwhites, in 1 in 120. The prognosis is good with prompt diagnosis. appropriate surgical intervention and control of bleeding: rarely, in cases of abdominal implantation, the fetus may survive to term. Usually, a subsequent and successful intrauterine pregnancy is achieved.

What causes Ectopic Pregnancy ?

Conditions that prevent or retard the passage of the fertilized ovum through the fallopian tube and into the uterine cavity include:

• diverticula - the formation of blind pouches that cause tubal abnormalities
• endometriosis - the presence of endometrial tissue outside the lining of the uterine cavity
• endosalpingitis - an inflammatory reaction that causes folds of the tubal mucosa to agglutinate, narrowing the tube
• pelvic inflammatory disease - an infection of the oviducts and ovaries with adjacent tissue involvement
• previous surgery - tubal ligation or resection or adhesions from previous abdominal or pelvic surgery
• tumors pressing against the tube.

Ectopic pregnancy may result from congenital defects in the reproductive tract or ectopic endometrial implants in the tubal mucosa. The increased prevalence of sexually transmitted tubal infection may also be a factor.

Signs and symptoms of Ectopic Pregnancy

Ectopic pregnancy sometimes produces symptoms of normal pregnancy or sometimes no symptoms other than mild abdominal pain, thus, making diagnosis difficult. Characteristic clinical effects after fallopian tube implantation include amenorrhea or abnormal menses, followed by slight vaginal bleeding, and unilateral pelvic pain over the mass.

Rupture of the fallopian tube, however, causes life-threatening complications, including hemorrhage, shock, and peritonitis. The woman usually experiences sharp and severe lower abdominal pain, possibly radiating to the shoulders and neck, commonly predicated by activities that increase abdominal pressure such as a bowel movement. She may also feel extreme pain upon motion of the cervix and palpation of the adnexa during a pelvic examination.

Diagnosis information

Clinical features, patient history, and the results of a pelvic examination suggest ectopic pregnancy. The following tests may be used to confirm it:

• Serum pregnancy test shows presence of human chorionic gonadotropin.
• Real-time ultrasonography determines extrauterine pregnancy (performed if serum pregnancy test is positive).
• In culdocentesis, fluid is aspirated from the pouch of Douglas through the posterior vaginal fornix to detect free or nonclotting blood in the peritoneum (sometimes performed ifultrasonography fails to detect a gestational sac in the uterus).
• Laparoscopyor laparotomy is used to diagnose and treat an ectopic pregnancy by either removal of the tube (salpingectomy) or removal of the pregnancy with preservation of the tube (salpingostomy).Decreased hemoglobin level and hematocrit due to blood loss support the diagnosis. Differential diagnosis must rule out uterine abortion, appendidtis, ruptured corpus luteum cyst, salpingitis, and torsion of the ovary.

Treatment of Ectopic Pregnancy

If culdocentesis is positive or the patient has peritoneal signs consistent with a surgical abdomen, laparoscopy and laparotomy are indicated. (Note: If the fallopian tube hasn't ruptured, laparoscopy is performed; if the tube has ruptured, laparotomy is performed.) The ovary is preserved as a rule; however, ovarian pregnancy may necessitate oophorectomy. Interstitial pregnancy rarely may require hysterectomy; abdominal pregnancy requires a laparotomy to remove the fetus, except in rare cases, when the fetus survives to term or calcifies undetected in the abdominal cavity.

Supportive treatment includes transfusion with whole blood or packed red cells to replace excessive blood loss,administration of broadspectrum antibiotics I. V. for septic infection, and administration of supplemental iron by mouth or I.M. (using the Z-trackmethod of injection).

An alternative treatment to surgery is a medicine called methotrexate (Maxtrex) , which decreases the growth of cells in the ectopic pregnancy (unlicensed use). As a result the pregnancy shrinks and eventually disappears. The advantage of methotrexate is that it avoids the need for surgery but success rates with methotrexate tend to be slightly lower than with surgery. Occasionally, both surgery and methotrexate will be necessary.

Who's at Risk for an Ectopic Pregnancy?

The risk of ectopic pregnancy is highest for women who are between 35 and 44 years old and have had:

• PID
• a previous ectopic pregnancy
• surgery on a fallopian tube
• infertility problems or medication to stimulate ovulation

Some birth control methods can also increase your risk of ectopic pregnancy. If you get pregnant while using progesterone-only oral contraceptives, progesterone intrauterine devices (IUDs), or the morning-after pill, you're more likely to have an ectopic pregnancy.

Special considerations or prevention

Patient care measures include careful monitoring and assessment of vital signs and vaginal bleeding, preparing the patient with excessive blood loss for emergency surgery as well as providing her with blood and fluid replacement, and offering the patient and the family emotional support and reassurance.

• Record the location and character of the pain and administer analgesics. (Remember, however, that analgesics may mask the symptoms of intraperitoneal rupture of the ectopic pregnancy.)
• Check the amount, color, and odor of vaginal bleeding. Ask the patient the date and characteristics of her last menstrual period.
• Observe for signs of pregnancy (enlarged breasts, soft cervix).
• Provide a quiet, relaxing environment, and encourage the patient to freely express her feelings of fear, loss, and grief.

To prevent ectopic pregnancy:

• Advise prompt treatment of pelvic infections to prevent diseases of the fallopian tube.
• Inform patients who have under gone surgery involving the fallopian tubes or those with confirmed pelvic inflammatory disease that they're at increased risk for ectopic pregnancy.
• Avoiding risk factors for PID -- multiple partners, intercourse without a condom, and sexually transmitted diseases (STDs)