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Ectopic Pregnancy

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Ectopic Pregnancy 12 Ectopic pregnancy Pascal R. Kolk INTRODUCTION The difficulty with all these figures is that in low-resource settings, the registration of women Ectopic pregnancy is defined as a pregnancy in having an ectopic pregnancy is far from complete. which the implantation of the embryo occurs out- Most of the data mentioned in research and publi- side the uterine cavity, most frequently in one of cations are hospital-based figures. Many women the two fallo pian tubes or, more rarely, in the abdo- with an ectopic pregnancy will survive, and thus minal cavity or the cervix1. Ectopic pregnancy is not visit a hospital; after tubal abortion, blood loss one of the frequent emergencies encountered in and symptoms may cease. The incidence of un- obstetrics and gynecology and is a common condi- detected ectopic pregnancy is therefore unknown. tion through out the world. It is important to have Only a limited number of women will be able (due at least a basic knowledge about this condition and to different factors) to reach a health facility and to recog nize its symptoms. When an ectopic preg- will be diagnosed correctly and in time with having nancy ruptures it is a medical emergency and is an ectopic pregnancy. Women who in the worst a life-threatening condition. One study in Lagos case die of a ruptured ectopic pregnancy before showed that ruptured ecto pic pregnancy was they can reach a health facility will in most cases responsible for almost 50% of all gynecologic not be counted in the maternal mortality figures. emergencies2. Hence early diagnosis, prior to rupture and According to the World Health Organization hemor rhage, is extremely important. Ideally one (WHO), incidence in the developing world varies should recognize every ectopic pregnancy before it between one ectopic pregnancy per 50–200 preg- ruptures and becomes a life-threatening condition. nancies3,4. A study conducted in Ghana showed The most important thing is to keep in mind that a incidence rates as high as one ectopic pregnancy in woman with certain complaints might have an every 44 deliveries5. Ectopic pregnancy is a major ecto pic pregnancy and needs to be seen urgently by cause of maternal death around the world, with a health professional in a clinic preferably with a case fatality rates in the developing world (hospital- theatre and a skilled doctor who can perform a based figures) of 1–4%4. This is 10 times higher salpingectomy. compared with developed countries4. In some Early recognition is of course important to pre- countries, up to 9% of all maternal deaths are caused vent maternal death (Figure 1). In addition, early by ectopic pregnancies4,6,7. recognition can prevent hemorrhagic shock, exces- As is stated in William’s Obstetrics: ‘The risk of sive tubal damage, acute surgery and blood trans- death from an extrauterine pregnancy is greater fusion. Further, even when a woman survives it than that for pregnancy that either results in a live might have a major impact on the rest of her life, birth or is intentionally terminated’8. An extra- especially if her fertility is significantly reduced after uterine pregnancy is 50 times more likely to result an ectopic pregnancy1. in a maternal death than a first-trimester abortion So the best way would be to prevent women and 10 times more likely than delivery in the third from having an ectopic pregnancy. trimester9. 115 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS Isthmic 12% Interstitial 2–3% Ampullary 70% Table 1 Main risk factors for ectopic pregnancy Pelvic inflammatory disease Sexually transmitted disease Multiple sexual partners Smoking Previous ectopic pregnancy Fimbrial 11% Abdominal 1% Sterilization Ovarian 3% Previous induced abortion CS scar and cervical <1% levels and higher gestational age were significant Figure 1 Implantation sites of an ectopic pregnancy risk factors for an ectopic to rupture, but keep in mind that there is no threshold of hCG level for tubal rupture14. Key points • Ectopic pregnancy is an emergency condition. Intrauterine device • It is a major cause of maternal death. As any contraceptive method reduces the overall • It is important to recognize it at an early stage. pregnancy rates it will also protect against an ecto- pic pregnancy. So, in general, an intrauterine device RISK FACTORS AND PREVENTION (IUD) will not increase the risk of an ectopic preg- As mentioned earlier, ectopic pregnancy is a life- nancy compared with not using any contraceptive threatening condition and therefore early recogni- method. However, when a woman with an IUD tion and proper treatment is very important. gets pregnant there is a significantly higher chance However, prevention is even more important. You of the pregnancy being an ectopic11,15. There might should always bear in mind that there are several be a bit higher chance of getting an ectopic after risk factors contributing to developing an ectopic the use of an IUD in the past15. The study con- pregnancy. The main risk factors are shown in ducted in Lagos showed an increased risk of almost Table 12,8–11. four times after the previous use of an IUD; how- Research in Zimbabwe1,12 compared a group of ever this seems to be exaggeratedly high2. women who had an ectopic pregnancy with As you can see by focusing on prevention of women with an intrauterine pregnancy. Previous STIs and unwanted pregnancies a reasonable infection with Chlamydia trachomatis was much number of ectopic pregnancies can be prevented. more common in the group with an ectopic preg- As with STI and HIV/AIDS prevention, proper nancy. Other studies also showed a relationship sexual education at all ages starting at a young age is with an infection with Neisseria gonorrhoeae. Several most important. other studies (descriptive) and some case reports describe a possible role for endometriosis, tubercu- Key points losis and Schistosoma haematobium infection1. • Know the risk factors for an ectopic pregnancy: A case–control study was carried out in Lagos, pelvic inflammatory disease (PID), STI, multiple Nigeria2. Age, marital/socioeconomic status and sexual partners, previous ectopic pregnancy, parity were not significant risk factors for ectopic sterilization and previous induced abortion. pregnancy. However, an early age of sexual debut • Ectopic pregnancy is linked to STIs. increased the risk of ectopic pregnancy almost two- • Sexual education is important at all ages, in fold, previous induced abortion increased the risk particular at young age. 14-fold and a sexually transmitted infection (STI) nine-fold. The use of condoms was protective2. SIGNS AND SYMPTOMS In one study, the risk factors for an ectopic to rupture were a previous history of ectopic preg- The signs and symptoms of an ectopic pregnancy nancy and parity13. Other research found that can be subtle or very acute in the case of a ruptured higher β-human chorionic gonadotropin (hCG) ectopic pregnancy, depending on the amount of 116 Ectopic Pregnancy internal hemorrhage. You can make a difference in heart rate) with a painful abdomen which can show an acute and a subacute presentation. This differ- signs of an acute abdomen: guarding and rebound ence is caused in most cases by the fact that there is tenderness. If you do want to perform a vaginal a ruptured or unruptured ectopic pregnancy. In exam (see Chapter 1 on how to do this), do it care- most cases it means the difference between investi- fully, because it can cause an unruptured ectopic to gating the patient more thoroughly with more rupture. You may find cervical motion tenderness exten sive diagnostic procedures (if possible) or the with a soft small uterus and adnexal tenderness. need of performing urgent surgery. Some women The patient can be anemic so if she is stable you present after they have had a ‘miscarriage’: i.e. they might want to give her a blood transfusion. As the lost the so-called decidual cast (decidualized endo- patient is stable there is time to perform diagnostic metrium that is sometimes expelled in ectopic preg- tests (see Chapter 9). nancy and resembles a spontaneous miscarriage). The diagnosis of an ectopic pregnancy can how- ever be difficult. Usually women will have experi- Acute presentation enced a period of amenorrhea, but sometimes the Most likely the woman has a ruptured ectopic patient thinks she cannot be pregnant: either be- pregnancy. This is a medical emergency. Most women cause she has not yet missed her period or she does will present at a health facility after having a period not know the exact date, she experiences patho- of amenorrhea, complaining of (severe) abdominal logical bleeding due to the ectopic when she pain, fainting and often vaginal bleeding. Typically, expects to have her normal period or she has a the pain suddenly became worse. As a result of levonorgestrel (LNG)-IUD and is amenorrheic. blood in her abdomen she can also complain of Up to 9% of women with ectopic pregnancy report shoulder pain. no pain and one-third lack adnexal tenderness8. Physical examination Her abdomen is painful, rigid with rebound tenderness and guarding. Signs of Key points anemia (paleness) and shock are present in most The main symptoms are: cases (tachycardia and hypotension). • Amenorrhea If a patient presents with the above-mentioned com- • Abdominal pain plaints and signs she needs an immediate intravenous • Abnormal bleeding (IV) line with fluid substitution while organizing • Abdominal and pelvic tenderness urgent surgery and blood transfusion if she is in • Shock. severe shock. If she is hemodynamically stable but shows signs of hypotension and anemia she should Classic triad of : still have further diagnostics: at least a pregnancy test • Amenorrhea (98.0%) before operation; if further investigation is not delay- • Abdominopelvic pain (92.2%) ing surgery unnecessarily she should have a vaginal • Vaginal bleeding (62.7 %)10.
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