ECTOPIC PREGNANCY
On my usual patient reviews and discussion with my colleague, we went through the case of a pregnant patient who had vaginal bleeding and a regular pelvic ultrasound was done. It showed thickening of the uterus wall and retained products of conception . A diagnosis of incomplete abortion (miscarriage) was done and dilation and curretage done. The patient went home stable, her next review 2 weeks later was unremarkable and she went home happy . Four weeks later, the patient came in with sudden severe abdominal pain and abdominal distension. The abdomen was very tender to touch . And urgent ultrasound was ordered and blood was seen in the abdomen (peritoneum). The uterus was normal and non-gravid , the Fallopian tubes and ovaries were normal. So what is the diagnosis?????? Her pregnancy test remained positive all along. Further scanning of the rest of the abdomen showed an alive 4 months male fetus, with a regular heart beat and movements growing up in the intestines with placenta attached to the large intestine. The placenta had detached slightly and was slowly bleeding. A final diagnosis of ABDOMINAL ECTOPIC PREGNANCY was made and emergency surgery was done just on time and the mother's life was saved. The baby was removed alive but died shorty after due to severe prematurity.
When I was growing up in Machakos, a neighbour lost her life to undiagnosed ruptured ectopic pregnancy. I heard the aunties say that she had lost her life to 'mimba ya mishipa' (pregnancy of the tubes) and it made no sense to me because I thought 'mishipa' only meant 'veins.' 'How can there be pregnancy in the veins?' It confused me at my tender age of 12.
What is ectopic pregnancy? It basically refers to pregnancy that embeds and develops in other places other than the uterus. The most common location is the Fallopian Tubes followed by the Ovaries. The third and least common location is the abdomen as outlined in the first case above.
The causes of ectopic pregnancy are directly related to any factor that causes disruption of the inner lining of the Fallopian tubes and hence delayed passage of a fertilized ovum along the tube. As we all know, fertilization takes place in the tubes then the fertilized egg travels down to implant at the uterus. The factors that cause above disruption include infections of the tubes i.e Salpingitis, chronic inflammation of the tubes as in Tuberculosis of the tubes, abnormalities of the tubes like abnormal lengths and prior tube surgeries. Research shows a high risk in patients with intrauterine copper-T devices for contraception and women who take progesterone only contraceptives. Women with a previous history of ectopic pregnancy are at a higher risk of developing a second ectopic pregnancy.
17 out of 100 women in Kenya will get ectopic pregnancy in their reproductive life. This clearly indicates that incidence is high and that all women of child-bearing age should be armed with knowledge of this very dangerous condition yet very easy to diagnose if proper steps are taken.
The symptoms are usually noticeable latest by 2 months of pregnancy unless in unique cases like the one above. The woman would report missed menstrual periods and severe one sided Lower abdominal pain,irregular minimal vaginal bleeding ( the pain precedes the bleeding), then severe abdominal pains. The patient may present in shock,collapsing , having air-hunger, paleness, rapid heart beat , increased thirst or even unconscious after collapsing. Shock occurs in women undergoing bleeding following a ruptured ectopic pregnancy. Most women are usually not aware that they are pregnant. A ruptured ectopic pregnancy can kill in as little as two hours.
ABDOMINAL PREGNANCY . This happens when the embryo perforates the tube into the abdominal cavity but the amniotic sac remains intact. The embryo continues to grow and a placenta site is established on one of the abdominal structures like the intestines. Pregnancy can continue growing to term but mostly gives way and causes severe bleeding.
I remember watching an Indian medical documentary where a fetus that had stayed in the mother's abdomen for 50 years was removed. It was actually a fetus in the form of mummified stone. This is called a LITHOPAEDION. It occurs when the fetus in an abdominal pregnancy dies, the placenta site thromboses and doesn't bleed, absorption of amniotic fluid occurs and mummification of the fetus occurs by deposition of lime salts. This can stay for many years.
Diagnosis of ectopic pregnancy is mostly clinical through thorough abdominal and per-vaginal examination supported by ultrasound scan and a positive blood pregnancy test in the absence of a fetus in the womb.
Treatment is usually emergency operation to remove the fetus and control the bleeding. The affected tube may be cut ( salpingectomy) and ligated to control bleeding or simply repaired depending on the severity. If the pregnancy is towards the outer end of the tube, it might be milked out if no rupture has occurred to save the tube.
The topic is so wide and intense , I only covered a small portion and I tried to use layman's language as much as possible to sensitize people on this potentially dangerous condition. No mother should lose life to ectopic pregnancy. Spread the word and let me know what you think. Any questions will be answered promptly because I have left a big part to avoid boring you with medical jargon. If you are sexually active and get the above symptoms, seek medical advice quick before it's too late. Thank you
