Thesis on "Ectopic Pregnancy: Etiology, Modern Diagnosis and Treatment"

Thesis 18 pages (5051 words) Sources: 10

[EXCERPT] . . . .

Ectopic Pregnancy: Etiology, Modern Diagnosis and Treatment

An ectopic pregnancy is an abnormal kind of pregnancy, which occurs outside the uterus or womb (Chen 2008). The term "ectopic" was adapted from the Greek word, ektopos, which means "out of place (Sepilian & Wood 2009). Studies showed that approximately 1-2% of pregnancies are ectopic and 97% of these occur in the fallopian tube (Moeller et al. 2009 as qtd in Kovacs 2010). An ectopic pregnancy develops initially but when there is no more room for it to expand, it can rupture the tube. In rare cases, pregnancy occurs in the ovary, the stomach or the cervix. A condition blocks or slows down the normal travel of a fertilized egg through the fallopian tube to the uterus (Chen). It is seen as an error or flaw of the human reproductive physiology, which allows the fertilized egg to implant itself and grow outside the uterus, its natural location (Sepilian & Wood 2009). Most experts believe that the fertilized egg gets stuck on its way to the uterus and the fallopian tube is scarred, damaged or misshapen (Mayo Clinic Staff 2010). The specific cause remains a mystery. The embryo draws blood supply from the site of implantation. As it enlarges and expands, the site can no longer accommodate it and ruptures. Only the uterine cavity has the natural capacity to expand. The embryo thus ultimately dies. It can also result in massive internal hemorrhage that threatens the mother's life unless promptly and correctly diagnosed and treated (Sepilian & Wood).

History, Incidence and Frequency

Ectopic pregnancy was first recognized in the 11th century and considered fatal until the 18th century (Sepilian & Wood 2009). John Bard holds the distinction of being the first to successfully treat ectopic pregnancy through surgery in New York City in 1759. The survival rate was very low up to the 19th century at 5 out of 30 by surgery. By the 20th century, great scientific improvements, such as anesthesia, antibiotics and blood transfusion, decreased maternal mortality rate due to ectopic pregnancy. There were 200-400 recorded deaths per 10,000 people from ectopic pregnancy in the early part of the 20th century. The Centers for Disease Control and Prevention reported 17,800 in 1970 and this increased to 108,800 in 1992 (Sepilian & Wood).

A gradual increase in the rate of ectopic pregnancies has been observed in the last three decades (Selway 2006). Many of these are outpatient clients, but roughly 19-20 per 1000 persons are documented (Selway). The incidence has risen six times since 1970, and at present, 2% of all pregnancies are ectopic ( Sepilian & Wood 2009). There were approximately 108,800 cases reported in 1992 and more than 58,000 of these were hospitalized and cost approximately $1.1 billion. It is the leading pregnancy-related cause of death during the first trimester in the country at 9%. Long-term adverse effect is the woman's ability to reproduce (Sepilian & Wood).

Etiology

Certain factors are believed to contribute to the risk of ectopic pregnancy (Sepilian & Wood 2009, Chen 2008). These are pelvic inflammatory disease, history of prior ectopic pregnancy or pregnancies, tubal surgery, conception after tubal ligation, fertility drugs or assisted reproductive technology, the use of intrauterine device or IUD, increasing age, smoking, salpingitis isthmica nodosum, exposure to diethylstilbestrol, a T-shaped uterus, prior abdominal surgery, failure with progestin-only contraception, and a ruptured appendix. Theoretically, anything that impedes the transfer of the fertilized egg to the endometrial cavity or uterus can lead to an ectopic gestation or pregnancy. Previous pelvic infection offers the most logical explanation to the increased frequency of ectopic pregnancies. However, most patients have no identifiable risk factors (Sepilian & Wood, Chen).

Pelvic Inflammatory Disease or PID

The most common cause is of a broad range of PIDs from cervicitis to salpingitis and florid PID is the infective agent Chlamydia Trachomatis (Sepilian & Wood 2009). More than 50% of those infected are not aware of the exposure. Other infective agents are Neisseria Gonorrhea and salpingitis. Salpingitis increases the risk of ectopic pregnancy to as many as four times. Successive PDIs also increasingly raise the probability of tubal damage (Sepilian & Wood).

History of Prior Ectopic Pregnancies or Pregnancy

A single prior history of ectopic pregnancy increases the likelihood of another from 7 to 13 times, a 50-80% intrauterine gestation and 10-25% future tubal pregnancy (Sepiilian & Wood 2009, Chen 2008).

History of Tubal Surgery and Conception after Tubal Ligation

Records showed that prior tubal surgery increases the risk of ectopic pregnancy according to the degree of damage and bodily change (Sepilian & Wood 2009, Chen 2008). These surgeries include salpingostomy, neosalpingostomy, fimbrioplasty, tubal reanastomosis and lysis of peritubal or periovarian adhesions. Pregnancy after tubal ligation also raises the risk of ectopic gestation at 35-50%, reports said. These reports also said that ectopic pregnancies follow tubal sterilizations 2 or more years after rather than immediately (Sepilian & Wood, Chen).

Fertility Drugs or Assisted Reproductive Technology

The use of clomiphene citrate or the injectable gonadotropin to induce ovulation has been blamed for the increased risk of ectopic pregnancy up to four times, a recent study found (Sepilian & Wood 2009). The study implied the enhancement of multiple eggs and high hormone levels to ectopic pregnancy. Another study found that infertile patients with luteal phase defects are more highly prone to developing ectopic pregnancy than those whose infertility is caused by anovulation. On the other hand, the use of assisted reproductive techniques can increase the risk of ectopic pregnancy and heterotopic pregnancies in different parts of the body. Examples of these techniques are in vitro fertilization and gamete intrafallopian transfer. This was the conclusion of a study of 300 clinical pregnancies through in vitro fertilization wherein ectopic pregnancy rate was 4.5%. Other studies also showed that pregnancies achieved through in vitro fertilization or gamete intrafallopian transfer can result in heterotopic gestation at 1%. The incidence occurs in 1 out of 30,000 pregnancies from normal spontaneous conceptions (Sepilian & Wood).

Use of Progesterone IUD

The presence of this device has always been suspected as a risk factor of ectopic pregnancy (Sepilian & Wood 2009, Chen 2008). The modern copper IUD does not entail this risk. Nonetheless, the probability of ectopic pregnancy remains when the women gets pregnant at a 3-4% risk (Sepilian & Wood, Chen).

Increasing Age

Ectopic pregnancy occurs mostly in women aged 35-44 years old at a three-to-four times the risk among those aged 15-24 (Sepilian & Wood 2009). The myoelectrical activity in the fallopian tube responsible for tubal motility may slow down with age and lead to abnormal gestation (Sepilian & Wood).

Smoking

Studies showed an elevated risk of ectopic pregnancy at 1.6 to 3.5 times among smokers as compared to non-smokers (Sepilian & Wood 2009). Laboratory research on both human and animal subjects identified several mechanisms by which smoking contributes to ectopic pregnancies. These include delayed ovulation, altered tubal and uterine motility and altered immunity (Sepilian & Wood).

Salpingitis Isthmica Nodosum

These are microscopic substances of tubal epithelium fund in the myosalpinx or below the tubal serosa (Sepilian & Wood 2009). Studies of the fallopian tubes of 50% of patients who underwent salpingectomy for ectopic pregnancy had these microscopic substances. Their origin or cause is not clear. But their assumed mechanisms include post-inflammatory and congenital and acquired tubal alterations (Sepilian & Wood).

Other Risk Factors

These include previous exposure to diethylstilbestrol, a T-shaped uterus, previous abdominal surgery, failure of progestin-only contraception and ruptured appendix (Sepilian & Wood 2009).

Symptoms

These include abnormal vaginal bleeding, amenorrhea or lack of menstruation, breast tenderness, low back pain, mild cramps on one side of the pelvis, nausea, and pain in the pelvic area (Chen 2008). When the site ruptures and bleeds, symptoms include fainting, pain in the shoulder area and sharp and sudden pain in the lower abdomen. Shock may follow internal bleeding from rupture. It is the first symptom of almost 20% of ectopic pregnancies (Chen). Quite often, there will be no symptoms or indication of pregnancy (Mayo Clinic Staff 2010). If any, they resemble those of any pregnancy, such as a missed period, breast tenderness, nausea and fatigue. But a pregnancy test will yield positive results. The first signs of an ectopic pregnancy can be light vaginal bleeding, pain in the lower abdomen and cramps on one side of the pelvis. Symptoms of a ruptured fallopian tube include sharp and stabbing pain in the pelvis, abdomen, shoulder or neck; dizziness; and lightheadedness (Mayo Clinic Staff).

Only about 50% of all patients display the typical symptoms of ectopic pregnancy (Sepilian & Wood 2009). Instead, they report symptoms common to early pregnancy. These include nausea, breast fullness, fatigue, low abdominal pain, heavy cramps, shoulder pain and dyspareunia. In addition, only 40-50% of them report or exhibit vaginal bleeding, palpable adnexal mass at 50%, and abdominal tenderness at 75%. About 20% of those with ectopic pregnancies are hemodynamically compromised. This suggests rupture. Modern diagnostic techniques can now diagnose most ectopic pregnancies before rupturing (Sepilian & Wood).… READ MORE

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