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Pregnancy outside the womb

Sunday, May 18, 2014    

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ECTOPIC pregnancy is any pregnancy implanted outside of the womb. It occurs in approximately two per cent of all pregnancies in the USA and one in every 24-28 pregnancies in Jamaica.

It is one of the most common gynaecological emergencies with the incidence continuing to increase over the last two decades. The mortality rate however, has been significantly reduced, but it remains the leading cause of death in women in the first three months of pregnancy.

Up to 95 per cent of ectopic pregnancies occur in the fallopian tubes, but can also be found in the cervix, ovaries and abdomen.

In normal pregnancies the sperm meets the egg in the fallopian tube where fertilisation takes place, and by day six the blastocyst travels down and is implanted in the uterine cavity. Anything that delays or interferes with the transportation of the blastocyst may result in an ectopic pregnancy. It is also possible, but rare, to have a normal pregnancy and an ectopic pregnancy at the same time (heterotopic pregnancy), especially if fertility measures are being used.

RISK FACTORS

The risk factors for ectopic pregnancy are linked to the problems that affect the normal tubal transport. These include tubal surgery such as in tubal ligation also known as "tie off", or tubal reconstruction , tubal tumours, tubal infection - for example with gonorrhea and chlamydia - pelvic inflammatory disease, previous ectopic pregnancy, smoking, drugs (diethylstilbestrol) and use of intrauterine device for contraception.

Ectopic pregnancy is dangerous as it mimics the normal pregnancy in the early stages. It can even result in deadly consequences if the woman tries to do an abortion without a prior ultrasound. In that case, the attempted evacuation of products of conception will be contents of the uterus instead, while the pregnancy remains for example in the tubes causing massive internal bleeding and subsequently death if medical attention is not sought.

SIGNS AND SYMPTOMS

Early ectopic pregnancy may present with light vaginal bleeding and abdominal pain, often, but not always, after the menstrual period is missed. If the pregnancy progresses the abdominal pain worsens and the patient may start having heavier vaginal bleeding, dizziness and light-headedness, fainting, shoulder tip pain or may show signs of shock such as low blood pressure, rapid pulse, cool clammy skin, as well as acute blood loss.

It is diagnosed by the history and physical examination of the patient along with the positive pregnancy test for the hormone human chorionic gonadotropin and the ultrasound showing an empty uterus or the presence of the foetus outside of the uterus.

If no foetus has been detected and the pregnancy test is positive, then repeat blood tests for hCG levels or progesterone and repeat ultrasounds will be done.

WHAT'S NEXT?

After an ectopic pregnancy has been diagnosed, the options can be medical or surgical as guided by the obstetrician. Medical management employs drugs such as methotrexate, which interferes with DNA synthesis of the foetus. It is given with strict indications such as tubal pregnancy less than 5cm without cardiac activity, stable patients, able to comply with treatment, and desirous of having children.

If the ectopic has ruptured the tubes and the patient is unstable, then surgery is indicated. This is usually laparotomy which is a cut into the abdomen and the tube removed or the tube opened and the pregnancy removed, but laparoscopy has also been done in some hospitals. Laparoscopy is where minimal invasion of the abdomen is done as the surgery is done through laparoscopes resulting in faster recovery, shorter hospitalisation, reduced costs, less bleeding and adhesion formation in the abdomen.

Warning signs should not be ignored. If the menstrual period is late or pregnancy is suspected and there is vaginal bleeding and or abdominal pain, medical attention should be sought and a pregnancy test and an emergency ultrasound should be requested by the physician.

Dr Romayne Edwards is a consultant emergency physician at the University Hospital of the West Indies and an associate lecturer at the University of the West Indies.

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