Ectopic PregnancyAssessment and Management of Ectopic Pregnancy The incidence of ectopic pregnancy is on the rise. It occurs in 2% of pregnancies. Ectopic pregnancy takes place when a fertilized ovum becomes implanted on any tissue other than the uterine lining, such as the fallopian tube, abdomen, ovary, or cervix. The most common site of ectopic implantation, however, is the fallopian tube. As the fertilized ovum increases in size, the tube becomes more and more distended until finally, from 4 to 6 weeks after conception has occurred, rupture takes place and the ovum is discharged into the abdominal cavity. The symptoms may start with attacks of colicky pain on the affected side due to distention of the fallopian tube. When “tubal” rupture occurs, the patient experiences agonizing pain, faintness, shock and air hunger. It is recognized at once that the patient is desperately ill; all the signs of hemorrhage—rapid, “thready pulse,” subnormal temperature, restlessness, pallor, sweating—are in evidence. Causes of Ectopic Pregnancy The possible causes of ectopic pregnancy include structural abnormalities of the fallopian tube, tumors that distort the tube, IUD, and progestin-only contraceptives. Previous ectopic pregnancy can also cause another case of ectopic pregnancy. Statistical reports show the risk of recurrence is 7% to 15%. However, studies show that PID or pelvic inflammatory disease appears to be the major risk factor for ectopic pregnancy. Improved antibiotic therapy for PID usually prevents total tubal closure but may leave a stricture or narrowing, predisposing the woman to ectopic implantation. The odds of recurrent ectopic pregnancy are three times higher if an infectious pathology was the cause of the first one. If a woman has a second ectopic pregnancy, assisted reproduction is considered. Clinical Diagnosis By vaginal examination, the surgeon is able to feel a large mass of clotted blood that has collected in the pelvis behind the uterus. If an ectopic pregnancy is suspected, the patient is evaluated by sonography and the “beta subunit” of “human chorionic gonadotropin” (hCG) levels. Ultrasound can detect a pregnancy between 5 and 6 weeks from the last menstrual period. Detectable fetal heart movement outside the uterus on ultrasound is firm evidence of an ectopic pregnancy. In some cases, an ultrasound study is not definitive and the diagnosis must be made with combined diagnostic aids, such as pelvic examination, hCG level, clinical judgment, and ultrasound. Occasionally, the clinical picture makes the diagnosis relatively easy. However, when the clinical signs and symptoms are questionable, (which is often the case) other procedures have value. These signs and symptoms are not as obvious as the regular signs and symptoms of pregnancy. Laparoscopy is used because the physician can visually detect an unruptured tubal pregnancy and thereby avoid the risk of its rupture. In Treating Ectopic Pregnancy The treatment of ectopic pregnancy is always surgical. It involves the removal of the tube, through an operation known as salpingectomy, and the ovary if necessary, on the affected side. However, many patients are in such a shocked condition that immediate operation cannot be performed. Measures then should be instituted to combat the shock and hemorrhage. When the operation is performed early, practically all such patients recover with remarkable rapidity, but without operation, the mortality is 60% to 70%. After operation, the treatment is the same as that for any laparotomy, plus transfusions to combat the acute anemia. Surgical Management When surgery is performed early, almost all patients recover rapidly. If tubal rupture occurs, mortality increases. The type of surgery is determined by the size and extent of local tubal damage. Surgery may also be indicated in women unlikely to comply with close monitoring or those who live too far away from a health care facility to obtain the monitoring needed with non-surgical management. Another option is the use of methotrexate without surgery. Because this medication stops the pregnancy from progressing by interfering with DNA synthesis and the multiplication of cells, it interrupts early, small, unruptured tubal pregnancies. Emotional and Psychological Impact The major goals for the patient may include relief of pain; acceptance and resolution of grief and pregnancy loss; increased knowledge about ectopic pregnancy, its treatment, and its outcome; and absence of complications. However, the emotional and psychological impact of ectopic pregnancy cannot simply be underrated. This is because the patient’s distress levels may vary. If the pregnancy is wanted, loss may or may not be expressed verbally by the patient and her partner. The impact may not be fully realized until much later. On the other hand, even if the pregnancy was unplanned, a loss has been experienced, and a grief reaction may follow. Severe and persistent psychological distress may require referral for psychological counseling. Indeed, careful assessment and management of ectopic pregnancy is essential to detect the development of complications and other imminent problems, which can either be psychological or sociological problems.
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