It is the leading cause of pregnancy related death in the first trimester- Ectopic pregnancy

Emobileclinic Trending Topic: Etopic Pregnancy

Emobileclinic Specialist

Ectopic pregnancy is an ovum ferterization implant that occur in an area other than the endometrial linning of the uterus. Ectopic pregnancy is a significant cause of maternal morbidity and mortality as well as fetal loss.It is the leading cause of pregnancy related death in the first trimester (first 3 months of pregnancy)

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The development of sensitive B-hCG assays,along with increasing use of ultrasound and laparoscopy ,has allowed for early diagnosis of ectopic pregnancy. This has resulted in a decrease in both maternal morbidity and mortality.The etiology of ectopic pregnancy is not well understood.

However several risk factors have been found to be associated with ectopic pregnancy.

*Tubal Factor
Ectopic pregnancy is 5-10 times common in women who had salpingitis. Up to 50% would have had salpingitis previously and in most of these patients ,the uninvolved tube is also abnormal. Other tubal factors that interfree with the progress of the fertilized ovum include adherent folds of tubal lumen due to salpingitis isthmica nodosa ,developmental abnormalities of the tube or abnormal tubal anatomy due to DES exposure in utero, previous tubal surgery including tubal ligation with 16-50% ectopic pregnancy rate if pregnancy occus after tubal ligation, conservative treatment of an unruptured ectopic with a recurrent ectopic rate of a 4%- 16% and tubal anastomosis with 4% ectopic rate. Adhesion from infection or previous abdominal surgery,endometriosis and even leiomyomas have been associated with ectopic pregnancy. Most of these abnormalities are bilateral and irreversible.

*Zygote Abnormalities
A variety of zygote abnormalities have been reported in ectopic pregnancy, including chromosomall abnormalities, gross malformations and neural tube defects. It is believed that these abnormal preembryos are more likely to result in abnormal or ectopic implantation.

Oarian factors
This may result in the development of ectopic pregnancy through ferterlization of an unextruded ovum ,transmigration of The ovum into the contralateral tube with subsequent delayed and faulty implantation, and postmidcycle ovulation and fertilization.

Exogenous Hormones
Abnormal hormonal stimulation and or exogenous hormones may play a role in etopic gestation. Examples; of pregnancies occurring in women taking progestin-only oral contraceptive, 4-6% are ectopic pregnancies.This may be due to progesterone’s smooth muscle relaxant effects and subsequent ”ovum trapping.” Patients with DES exposure are also at risk , as are patients under going ovulation induction.

Other factors
Intrauterine device (IUD) users are also at risk of ectopic pregnancy if pregnancy occurs ,although the risk of ectopic pregnancy is still lower than if no contraceptive method is used .Whether the IUD prevents intrauterine but not ectopic pregnancy or whether an associated salpingitis is responsible for this increased risk is unclear. Smoking and increasing age are also associated with ectopic pregnancy. Multiple previous elective abortion are also felt to be at risk factor for ectopic pregnancy as post abortal infection may lead to salpingitis.
Some additional factors are; infertility, multiple sexual partners,previous genital infection ,vaginal douching, early age at first intercourse( age less than 18).

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Time of Rupture

Rupture is usually spontaneous. Isthmic pregnancies tend to rupture earliest at 6 to 8 weeks’ gestation, due to the small diameter of this portion of the tube.Ampullary pregnancies rupture later,generally at 8- 12 weeks.Interstitial pregnancies are the last to rupture, usually at 12 to 16 weeks, as myometrium allows more room to grow than the tubal wall .Interstitial rupture is quite dangerous as its proximity to uterine and ovarian vessels can result in massive hemorrhage .

Classifications & Incidence

*Tubal constitute 95% of ectopic pregnancy which also is subclassified into ampullary,isthmic,fimbrial and interstitial.

* Others are cervical, ovarian and abdominal- primary abdominal pregnancies have been reported,but most abdominal pregnancies are secondary pregnancies,from tubal abortion or rupture and subsequent implantation in the bowel,omentum,or mesentery

*Intraligament

* Heterotopic pregnancy: An ectopic pregnancy which occur in combination with an intrauterine pregnancy in 1 in 15,000-40,000 spontaneous pregnancies and in up to 1% of patients undergoing in vitro ferterlization.
*Bilateral ectopic : These pregnancies have occasionally been reported.

Symptoms of Ectopic

-Pain -usually abdominal or pelvic
-Abnormal uterine Bleeding – usually spotting, occurs in roughly 75% of cases and represent s decidual sloughing.
-Amenorrhea- Secondary amenorrhea is variable. Approximately half of women with ectopic pregnancies have some spotting at the time of their expected menses, and thus do not realise they are pregnant .
-Syncope- Dizziness, lightheadedness, and or syncope is present in one – third to one- half of cases.
-Decidual cast- A decidual cast is passed in 5 -10% of ectopic pregnancies,and may be mistaken for products of conception.

Prevention & Treatment

Early diagnosis of unruptured tubal pregnancy by maintaining a high index of suspicion, and liberally using B-hCG titers, ultrasound, and laparoscopy will minimize potential problems from hemorrhage, infertility and extensive surgery.
Immediate surgery is needed when the diagnosis of ectopic pregnancy with hemorrhage is made.Blood products are also needed for transfusion. There is no place for conservative therapy in a hemodynamically unstable patients.
The extent of surgery depends on the degree of the damage to the uterus and adnexae.Preservation of the ovary is attempted if feasible. Conservative surgery i. e Preservation of the fallopian tube may be achieved in patients with an ampullary pregnancy who wishes to preserve fertility.A linear salpingostomy may be performed, and this can also be achieved through a laparoscope when pregnancy is less than 3cm ,unruptured and eazily accessible .

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