Ectopic pregnancy
Ectopic pregnancy is the implantation of the fertilized ovum outside the uterine cavity. The most common site is the fallopian tube (more than 90% of ectopic implantations occur in the fimbria, ampulla, or isthmus), but other possible sites include the interstitium, tubo-ovarian ligament, ovary, abdominal viscera, and internal cervical os. (See Implantation sites of ectopic pregnancy, page 960.) The prognosis is good with prompt diagnosis, appropriate surgical intervention, and control of bleeding; rarely, in cases of abdominal implantation, the fetus may survive to term. Usually, a subsequent intrauterine pregnancy is achieved.
Causes and incidence
Conditions that prevent or retard the fertilized ovum’s passage through the fallopian tube and into the uterine cavity include:
❑ diverticula, the formation of blind pouches that cause tubal abnormalities
❑ endometriosis, the presence of endometrial tissue outside the lining of the uterine cavity
❑ endosalpingitis, an inflammatory reaction that causes folds of the tubal mucosa to agglutinate, narrowing the tube
❑ pelvic inflammatory disease (PID), an infection of the oviducts and ovaries with adjacent tissue involvement
❑ previous surgery (tubal ligation or resection, or adhesions from previous abdominal or pelvic surgery)
❑ tumors pressing against the tube.
Ectopic pregnancy may result from congenital defects in the reproductive tract or ectopic endometrial implants in the tubal mucosa. The increased prevalence of sexually transmitted tubal infection may also be a factor. In whites, it occurs in 1 in 200 pregnancies; in nonwhites, in 1 in 120.
Signs and symptoms
Ectopic pregnancy sometimes produces symptoms of normal pregnancy or no symptoms other than mild abdominal pain, making diagnosis difficult. Characteristic clinical effects after fallopian tube implantation include amenorrhea or abnormal menses, followed by slight vaginal bleeding, and unilateral pelvic pain over the mass. Rupture of the tube causes life-threatening complications, including hemorrhage, shock, and peritonitis. The patient experiences sharp lower abdominal pain, possibly radiating to the shoulders and neck, often precipitated by activities that increase abdominal pressure, such as a bowel movement; she feels extreme pain upon motion of the cervix and palpation of the adnexa during a pelvic examination.
Diagnosis
Clinical features, patient history, and the results of a pelvic examination suggest ectopic pregnancy. The following tests help confirm it:
❑ Serum pregnancy test shows presence of human chorionic gonadotropin.
❑ Real time ultrasonography determines extrauterine pregnancy (performed if serum pregnancy test is positive).
❑ In culdocentesis, fluid is aspirated from the pouch of Douglas through the posterior vaginal fornix to detect free or nonclotting blood in the peritoneum (sometimes performed if ultrasonography fails to detect a gestational sac in the uterus).
❑ Laparoscopy or laparotomy is used to diagnose as well as to treat an ectopic pregnancy by either removal of the tube (salpingectomy) or removal of the pregnancy with preservation of the tube (salpingostomy).
Decreased hemoglobin levels and hematocrit due to blood loss support the diagnosis. Differential diagnosis must rule out uterine abortion, appendicitis, ruptured corpus luteum cyst, salpingitis, and torsion of the ovary.
Treatment
If culdocentesis is positive or the patient has peritoneal signs consistent with a surgical abdomen, laparoscopy and laparotomy are indicated. The ovary is preserved as a rule; however, ovarian pregnancy may necessitate oophorectomy. Interstitial pregnancy may rarely require hysterectomy; abdominal pregnancy requires a laparotomy to remove the fetus, except in rare cases, when the fetus survives to term or calcifies undetected in the abdominal cavity.
Supportive treatment includes transfusion with whole blood or packed red cells to replace excessive blood loss, administration of broad-spectrum antibiotics I.V. for septic infection, and administration of supplemental iron by mouth or I.M.
Methotrexate I.M. is also a therapeutic option in stable patients, avoiding surgery in most cases.
Special considerations
Patient care measures include careful monitoring and assessment of vital signs and vaginal bleeding, preparing the patient with excessive blood loss for emergency surgery, and providing blood replacement and emotional support and reassurance.
❑ Record the pain’s location and character, and administer analgesics as ordered. (Remember, however, that analgesics may mask the symptoms of intraperitoneal rupture of the ectopic pregnancy.)
❑ Check the amount, color, and odor of vaginal bleeding. Ask the patient the date of her last menstrual period and to describe this period’s character.
❑ Observe for signs of pregnancy (enlarged breasts, soft cervix).
❑ Provide a quiet, relaxing environment, and encourage the patient to freely express her feelings of fear, loss, and grief.
To prevent ectopic pregnancy:
❑ Advise prompt treatment of pelvic infections to prevent diseases of the fallopian tube. Inform patients who have undergone surgery involving the fallopian tubes or those with confirmed PID that they’re at increased risk of ectopic pregnancy.
❑ Tell the patient who’s vulnerable to ectopic pregnancy to delay using an intrauterine device until after she has completed her family.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
Other Book Chapters Related to Pregnancy symptoms
Read excerpts from these other book chapters related to Pregnancy symptoms:
Medical Books Excerpts
- AMENORRHEA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Amenorrhea
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Amenorrhea
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Amenorrhea
- "Professional Guide to Diseases (Eighth Edition)" (2005)
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- Amenorrhea
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Amenorrhea
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Amenorrhea
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Pregnancy symptoms
» Next page: Abdominal distention (Professional Guide to Signs & Symptoms (Fifth Edition))
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