Chapter 3 DISCUSSION

This chapter discusses the answers of the questions following the same sequence in the Statement of the Problem.

I. What is Ectopic Pregnancy?

Ectopic Pregnancy is a complication in pregnancy where the blastocyst is implanted outside the womans womb or called uterus. It is also called extrauterine pregnancy.

Normally, after fertilization the embryo implants itself in the uterus where it begins to grow and develop. However, embryo has the possibility to attach elsewhere along its path before it goes through the uterus and grows and develops in an abnormal site. This kind of pregnancy is not viable. Any other sites aside from the uterus cannot provide enough nutrients and other things needed by the embryo to normally grow and develop. Ectopic pregnancy may occur in the fallopian tube, abdomen, ovaries and cervix.

When undiagnosed and untreated, this can lead to hemorrhage which can be the cause of the mothers death.

HISTORY

Ectopic pregnancy was first diagnosed by an Arab writer, Albucassis in 963 AD. The ectopic pregnancy as a complication in pregnancy was first discussed in Mauriceaus textbook of obstetrics in 1694. The first documented treatment was done by John Bard of New York. In 1759, John Bard, Dr. Huck, an army of surgeon, had correctly diagnosed an extrauterine pregnancy. It was written that at the operation, He removed the macerated fetus and considerable pus but no trace of placenta. In the late nineteenth century was an era of diagnosis and treatment for ectopic pregnancy. It was pioneered by Parry and Lea in 1876 when they published their book Extrauterine Pregnancy: Its Causes, Species and Treatment. The first successful operative treatment was done by Lawson Tait in 1883. Tait followed the study conducted by Parry and Lea. He also reported that he had performed salpingectomy on four women who suffered with ectopic pregnancy and all survived. Until now, there are still studies on newer methods in treating ectopic pregnancy.

II. What are the common causes of Ectopic Pregnancy?

Ectopic pregnancy has many theories in its formation and cause, some explained by science and some not. No one can really determine why ectopic pregnancy occurs back then but along side of long study and research, they have come with few common causes of ectopic pregnancy.

One theory, with no scientific support, is that functional disturbances the patient is experiencing result in tubal spasm. Tubal spasm means that there might have been contractions in the fallopian tube that made it possible to happen. Is this occurs of the

fertilized egg, the temporary blockage might cause ectopic pregnancy. This theory is not yet proven.

The fallopian tubes are five- to six-inches long and have funnel-shaped endings. They are designed to pick up the egg from the ovary and transport it to the womb. The embryo is transported through the tube by a combination of the contractions of the muscles surrounding the tube and the movement of fine, hair-like cells lining the tube. After fertilization occurs inside the tube, these "squeeze and sweep" the embryo out of the fallopian tube and into the uterus

The most common causes of tubal damage are:

The major cause of ectopic pregnancy is salpingitis. Salpingitis is the inflammation of the fallopian tube. Salpingitis Istmica Nodosa (Tubal Diverculum) is also known as diverticulosis of fallopian tube. It is the thickening of the narrow part of the uterine tube due to inflammation. When the sperm enters the vaginal cavity, it passes through the uterus fallopian tube up to the ovary where it will fertilize the egg. Normally, it will go the uterus but due to salphingitis, it is stuck in the fallopian tube. There are two kinds of salpingitis acute and chronic. The symptoms usually appear after a menstrual period. The most common are Abnormal smell and color of vaginal discharge, pain coming and going in periods, abdominal pain, vomiting and bloating. Salphingitis can be diagnosed through hysterosalpingography. It is commonly treated by antibiotics.

Maternal smoking can be one cause of having ectopic pregnancy. It can risk four to five times than non-smoking women during the pregnancy. This may due to the nicotine which is the poisonous alkaloids in cigarettes. It is a kind of stimulants which induce temporary improvement function whether mentally or physically. Nicotine stimulates the contractions in the fallopian tube resulting temporary blockage of the embryo. Inhalation of cigarette smoke greatly affects the lungs, can also enter the bloodstream and somewhat may affect the reproductive tract.

Previous pelvic infection. The infections most likely to cause fallopian tube problems are sexually transmitted diseases (STDs), such as gonorrhea and Chlamydia. These STDs can be especially dangerous for women, because they may not cause any symptoms until the disease has traveled into the abdominal cavity and infected the reproductive organs. This can lead to serious condition called pelvic inflammatory disease, or PID. Mild pelvic infections can destroy the delicate hairlike cells lining the fallopian tubes. Severe infections can scar the tubes, causing them to become blocked. Symptoms of PID include abdominal pain, irregular periods, abnormal vaginal discharge, and pain during urination and intercourse. Women who have had pelvic infections have a five times greater risk of ectopic pregnancy.

The use of an intrauterine contraceptive device can cause ectopic pregnancy. It is an object placed in the uterus to prevent pregnancy. IUD's can place a woman at an increased risk of pelvic infection, scarring of the fallopian tubes.

Endometriosis is a medical condition that causes uterine tissue to grow outside the womb and attach itself to internal organs. It can cause damage and scarring to the fallopian tubes, raising the risk of ectopic pregnancy. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones. These endometrial like cells in areas outside the uterus are influenced by hormonal changes. The pain and worsening of menstruation cycle are one of the common symptoms of endometriosis.

Some surgeries within the pelvic, abdominal area or particularly surgery involving the reproductive system increases the chance of having ectopic pregnancy. In particular, when pregnancy occurs after an unsuccessful tubal sterilization, there is a 50 percent chance that it will be ectopic. Reversing tubal ligation can cause ectopic pregnancy this is because the tube may be narrowed at the spot where it was rejoined.

III. How to diagnose Ectopic Pregnancy?

Many women with ectopic pregnancy see their doctors after having bleeding or cramping in early pregnancy. Sometimes these symptoms occur even in normal pregnancies, but at times,

they can be signs of miscarriage or ectopic pregnancy. Physicians may suspect an ectopic pregnancy if there is an abnormal lump located in the tubal area. In diagnosing ectopic pregnancy it requires, observation and physical examination.

Culdocentesis is one of the first tests available for the diagnosis of ectopic pregnancy. This test refers to the extraction of fluid from the recto uterine pouch posterior to the vagina through a needle. It can also be a test in identifying pelvic inflammatory diseases. According to one study that although positive culdocentesis often indicates the presence of an ectopic pregnancy, it does not mean the pregnancy has ruptured. In fact, 65 percent of unruptured ectopic pregnancies will have a positive culdocentesis.

Human Chorionic Gonatropin (hCG) is a glycoprotein hormone produced during pregnancy that is made by the developing embryo after conception and later by the syncytiotrophoblast. All women of reproductive age with signs or symptoms of pregnancy should be screened through a urine hCG test. Stovali said that this technology allows for an easy method to screen for pregnancy. When positive, quantitative methods are then performed. Using the sensitive radioassays, which are readily available from several manufacturers, hCG is detectable in maternal serum within 8 days after the luteinizing hormone surge, The level rises exponentially to peal at about 8 to 10 weeks gestation and thereafter falls between 16 to 24 weeks. In general, hCG increase more slowly in ectopic compared to the normal pregnancies.

Progesterone concentrations are much lower than with those with viable pregnancies. In normal pregnancy, the progesterone level are greater than 25 ng/ml and <5.0 level identifies a nonviable pregnancy. This test will not exactly confirm the location of the pregnancy (intrauterine of extrauterine), patients are still advised to require follow up tests through hCG titers and ultrasound.

Vaginal Ultrasound is to visualize a gestational sac at a much lower hCG titer that with transabdominal scanning. Vaginal ultrasound can also image oviducts and ovaries such that masses and their dimensions can be defined with increasing reliability. If the patient has a rising hCG titer >2000mIU/ml and no intrauterine gestational sac is identified, this patient is considered to have an extrauterine pregnancy and can be treated without any further testing.

IV. What are the treatments or medications for Ectopic Pregnancy?

Unruptured tubal pregnancy can be treated medically or surgically. A recent study showed that the standard or most common treatment is surgical, laparoscopic salpingostomy, however, factors such as the length of amenorrhea, the level of hCG and the womans fertility status can lead to alternative treatments.

MEDICAL MANAGEMENT

Methotrexate is a cytotoxic agent which may be used either systematically, by intramuscular injection or by localized injection into the ectopic pregnancy. As said in the book

by Rosevear, Methotrexate is antimetabolite that interferes with the synthesis of DNA by inhibiting the action of dihydrofolate reductas in the conversion of dihydrofolic acid into tetrahydrofolic acid. It interrupts the synthesis of the purine nucleotide thymidylate and the amino acids serine and methionine. Because methotrexate has been usedextensively for the treatment of trophoblastic disease, its safety with respect to future reproductive performance has been established. The dose used in the treatment of ectopic pregnancy is much less than that for trophoblastic disease. There is no increase in the number of spontaneous miscarriages or the rate congenital anomalies after its use.

Methotrexate treatment can be given as a single shot or as several injections. If an ectopic pregnancy continues after 2 or 3 doses of methotrexate, surgical treatment is needed to remove the ectopic pregnancy.

During the week of methotrexate injections, your pregnancy hormone levels or hCG are tested several times. The physician will look for a drop in hCG levels, which is a sign that the pregnancy is ending.

If hCG levels have dropped enough after 1 week, a patient is tested on a weekly basis until they are low enough to suggest that the pregnancy has safely ended. This usually takes about a month but can take more than 3 months.

If the patients hCG levels aren't dropping enough after 1 week, a patient will be given another dose of methotrexate. The patients hCG levels will be watched as they were after the first dose.

If the patients hCG levels continue at higher levels, or if the doctor becomes concerned about tubal rupture, surgery will be needed to remove the ectopic growth.

Methotrexate can be used to end an early ectopic pregnancy. It also prevents the growth of any embryonic or fetal cells that are left behind after surgery to end an ectopic pregnancy.

SURGICAL TREATMENT

William B. Strommer was the first author to describe conservative surgical procedure for the treatment for the tubal pregnancy. In 1953, he presented a case report of a saloinggotomy performed on a 23-year-old who had unruptured tubal pregnancy in her only remaining tube. The patient went in to have two intrauterine gestations after Strommes salpingotomy. (Thomas G. Stovall, M.D, 1993)

Based on the study of Seifer, D.B. that even with rising trends in endoscopic surgery in the United States, laparotomy still remains the majority treatment for ectopic pregnancies including salpingostomy and salpingectomy. Never the less, over the years the endoscopic approach has certainly grown dramatically.

Laparotomy is more invasive the laparoscopy. Laparoscopy is chosen by surgeons because it is safer. It is a minimally invasive procedure used as a diagnostic tool and surgical procedure that is performed to examine the abdominal and pelvic. On the other hand, laparotomy is an open surgical exploration of the abdomen in order to view its internal organs, including the stomach organs that make up the female reproductive system. The procedure is used for exploratory purposes, to take samples of abdominal tumors for cancer staging, to make or confirm a diagnosis, and to repair internal organs damaged due to disease or trauma.

There is still some controversy whether which is the better approach. Certainly there are dictates whether laparotomy or laparoscopy should be performed in order to remove an ectopic pregnancy either by salpingostomy or salpingectomy. The three things that are looked at in order to make the decision are: a) size of the ectopic pregnancy, b) amount of hemoperitoneum, and c) stability of the patient. Depending on surgical skills and availability of equipment, all of these remain relative contradictions in making the decision rather than absolutes.

Salpingostomy is a surgical incision into a fallopian tube. This procedure may be done to repair a damaged tube or to remove an ectopic pregnancy. Salpingostomy may be performed via laparotomy or laparoscopy, under general or regional anesthesia. A laparotomy is an incision made in the abdominal wall through which the fallopian tubes are visualized. If the tube has already ruptured as a result of an ectopic pregnancy, a salpingectomy will be performed to remove the damaged fallopian tube. If rupture has not occurred, a drug called vasopressin is injected into the fallopian tube to minimize the amount of bleeding. An incision (called a linear salpingostomy) is made through the wall of the tube in the area of the ectopic

pregnancy. Salpingectomy is the surgical removal of one or both fallopian tubes. The fallopian tubes serve as a passageway for an ovum to travel from the ovary to the uterus. In a unilateral salpingectomy, only one fallopian tube is removed; in a bilateral salpingectomy, both fallopian tubes are removed. (Seifer, D.B et. al, 1990)

In regards to the management of patients, whether a salpingostomy or salpingectomy should be performed, there are a number of criteria. These include: 1) status of the contra-lateral tube, 2) status of the ipsilateral tube, 3), desire for future child bearing, 4) salvagability of the tube, and 5) other pelvic anatomic pathology i.e. adhesions. (Seifer, D.B et. al, 1990)

The first decision of course is whether the tube should be salvaged or not. This implies a number of important facts, primarily does the patient want the tube salvaged or not; and if the patient wants the tube salvaged, and can that tube be salvaged. The latter is based on appearance of the tube itself, appearance of the contra-lateral tube, and other pelvic pathology. In a worst case scenario, if the contra-lateral tube is damaged more greatly than the tube with the ectopic pregnancy and there is a fair of amount of peritubal adhesions and other modes of treatment i.e. IVF are not available to this patient, then salpingostomy, although not highly successful in regards to future pregnancies, should be what is embarked upon. (Seifer, D.B et. al, 1990)

On the other hand it becomes a folly to salvage tubes with ectopic pregnancies if there is only a slim chance of that tube functioning; and in that case a salpingectomy should be performed.

In regards to technique, these have been well described. For salpingostomy, an incision is made in the antimessenteric side of the tube after injection with the ectopic itself and into the feeding vessels in the broad ligament, and then the products of conception are removed. For salpingectomy using a multiple clip apparatus across the superior portion of the broad ligament and the base of the fallopian tube and across the tubal uterine juncture, the tube is then removed through a 10mm endoscopic port. Occasionally morcelation is necessary.

Certainly in regards to follow up, patients with salpingectomy are less likely to have persistent ectopic pregnancy syndrome although there have been a few reports of peritoneal implants that confirm to produce bHCG. Patients with both procedures (laparoscopy and laparotomy) should be followed with serum bHCG testing after two weeks and if it remains positive, a single dose of methotrexate should be given because the bHCG hormone should be clear by that time.

The primary decision is based on future child bearing, desires of the patient, and anatomical destruction both prior to and incurred by the presence of the ectopic pregnancy. Most of these cases can be handled through a laparoscopic approach. On balance, a salpingostomy on the patient has function in that fallopian tube where as if you do a salpingectomy, the chances are persistent in an ectopic pregnancy syndrome is diminished. As far as future child bearing, a salpingosotmy carries a good chance of success for functionality of the tube that was operated on. (Seifer, D.B et. al, 1990)

V. What makes Ectopic Pregnancy different from other pregnancy problems?

During the follow-up time in the hospital inpatient register, fewer exposed women had a completed pregnancy. Ectopic pregnancy was more common among the exposed women than among the controls. Placenta previa was more common among primiparous exposed women than among control women. Preeclampsia affects vigorously the placenta, and it can affect the mother's kidney, liver, and brain and is potentially life-threatening of women during pregnancy.

Placenta Previa

One of the pregnancy problems is the placenta previa, a condition in which the placenta is attached close to or covering the cervix (opening of the uterus). Bleeding may occur at various times in pregnancy. The initial bleeding may be very slight, but, as further stretching of the lower segment proceeds, the bleeding recurs at intervals of hours or days. Placenta previa is the bleeding in late pregnancy or after 20 weeks.

Ectopic Pregnancy differs in Placenta previa were ectopic pregnancy is the bleeding in first trimesters of pregnancy that occur in the fallopian tube instead of continuing its journey to the uterus, where it is supposed to implant.

Base on the Childrens Hospital of Wisconsin, Placenta previa occurs in about one in every 200 live births. There are three types of placenta previa:

Total placenta previa - the placenta completely covers the cervix.

Partial placenta previa - the placenta is partially over the cervix.

Marginal placenta previa - the placenta is near the edge of the cervix.

Common causes of Placenta Previa

The cause of placenta previa is unknown, but it is associated with certain conditions including the following:

Women who have scarring of the uterine wall from previous pregnancies. Women who have fibroids or other abnormalities of the uterus. Women who have had previous uterine surgeries or cesarean deliveries. Older mothers (over age 35). African-American or other minority race mothers. Cigarette smoking. Placenta previa in a previous pregnancy.

Placenta Previa concerns

The greatest risk of placenta previa is bleeding (or hemorrhage). Bleeding often occurs as the lower part of the uterus thins during the third trimester of pregnancy in preparation for labor. This causes the area of the placenta over the cervix to bleed. The more of the placenta that covers the cervical os (operating system), the greater the risk for bleeding. Other risks include the following:

Abnormal implantation of the placenta. Slowed fetal growth. Preterm birth.

Birth defects. Infection after delivery.

Symptoms of Placenta Previa

The most common symptom of placenta previa is vaginal bleeding that is bright red and not associated with abdominal tenderness or pain, especially in the third trimester of pregnancy. However, each woman may exhibit different symptoms of the condition or symptoms may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

Placenta Previa Diagnosed

In addition to a complete medical history and physical examination, an ultrasound (a test using sound waves to create a picture of internal structures) may be used to diagnose placenta previa. An ultrasound can show the location of the placenta and how much is covering the cervix. A vaginal ultrasound may be more accurate in diagnosis.

Although ultrasound may show a low-lying placenta in early pregnancy, only a few women will develop true placenta previa. It is common for the placenta to move upwards and away from the cervix as the uterus grows, called placental migration.

Treatment for Placenta Previa

Your physician based on will determine specific treatment for placenta previa:

Your pregnancy, overall health and medical history. Extent of the condition. Your tolerance for specific medications, procedures or therapies. Expectations for the course of the condition. Your opinion or preference.

There is no treatment to change the position of the placenta. Once placenta previa is diagnosed, additional ultrasound examinations are often performed to track its location. It may be necessary to deliver the baby, depending on the amount of bleeding, the gestational age, and condition of the fetus. Cesarean delivery is necessary for most cases of placenta previa. Severe blood loss may require a blood transfusion.

Another pregnancy problem that is related to ectopic pregnancy is the preeclampsia.

Preeclampsia

According to the Myles textbook for midwives with modern concept of obstetric and neonatal care 9th edition, preeclampsia is peculiar to pregnancy, usually becoming manifest after the 30th week, and rarely prior to the 24th week. It occurs more commonly in primigravidae, and the incidence is increased in cases of multiple pregnancy, essential hypertension, diabetes and hydatidiform mole. Preeclampsia is associated with placental

dysfunction and if so, intra-uterine growth retardation is likely to occur. Reduced uterine blood flow is a feature of preeclampsia.

Preeclampsia and ectopic pregnancy are both problems in pregnancy that can resolve by attempting to deliver the baby when it is discovered. They are both totally different that in the case of preeclampsia is characterized by high blood pressure, swelling of the face and hands and protein in the urine after the 20th week of pregnancy. It is a potentially serious condition that, if it is left untreated, it can lead to complications or death in the mother or the baby while in ectopic pregnancy, the fertilized egg attaches itself in a place other than inside the uterus in short, it is pregnancy outside the uterus. Causes of preeclampsia In the initial stages of pregnancy, the fertilised egg implants itself into the wall of the womb (uterus). The womb is a hollow, pear-shaped organ in which a baby grows during pregnancy. The egg produces root-like growths called villi, which help to anchor it to the lining of the womb.

The villi are fed nutrients through blood vessels in the womb and will eventually grow into the placenta. During the early stages of pregnancy, these arteries change shape and become wider. If the arteries do not fully transform, it is likely that the placenta will not develop properly because it will not get enough nutrients. This may then lead to pre-eclampsia.

It is still unclear why the blood vessels do not transform as they should. Some research has suggested a possible link between pre-eclampsia, miscarriage and infertility. It is possible

that the same medical reasons that cause infertility and miscarriage are responsible for the problems that lead to pre-eclampsia. However, the exact nature of pre-eclampsia and why it affects certain people is still being researched.

Risk of preeclampsia Although it's hard to predict which women will develop preeclampsia, they're at greater risk if:

They've had it before Their mother or sister(s) have had it It's a first pregnancy, or first by a new partner They're over 35 They're expecting more than one baby They have a chronic illness, including pressure, diabetes, kidney problems and migraine

Symptoms of preeclampsia There are no symptoms in the early stages of the disease. At this point it can only be detected by checking blood pressure (which may be raised) and testing the urine for protein (known as proteinuria). These checks are a routine part of all antenatal appointments, and it's important all pregnant women attend these.

Another early sign of preeclampsia is swelling of the ankles, or edema. The hands and face may swell too. Pregnant women should report any swelling, although it's common in pregnancy and may be due to less worrying causes. Pregnant women should be aware of the early signs of preeclampsia because the condition can rapidly become life-threatening. Symptoms of more serious problems may develop as preeclampsia progresses. These include:

Headaches Blurred or altered vision Abdominal or shoulder pain Nausea and vomiting Confusion Shortness of breath

If you're worried about any symptoms, see your midwife or doctor as soon as possible.

Complications of preeclampsia The main risk is that pre-eclampsia will progress to one of several potentially deadly complications. These include eclampsia, where the main problem is convulsions, which may occur before the typical high blood pressure and oedema of pre-eclampsia have developed, or after the baby has been born.

Other complications include kidney failure and HELLP syndrome, which affects as many as one in 150 advanced pregnancies. In HELLP there's disruption of the liver, a breakdown of red blood cells and a low blood platelet count. Preeclampsia accounts for about 15 per cent of premature births. The babies are not only premature but also often 'small for dates' because of growth problems. Treatment of preeclampsia Until recently, there was little that could be done to treat pre-eclampsia other than stop the pregnancy by delivering the baby early, usually by caesarean section. Now treatment aims to lower blood pressure and includes strict bed rest and drugs. However, this doesn't cure preeclampsia - it merely holds it in check. This may be sufficient to allow time to ensure the baby is sufficiently developed to survive premature birth. An injection of magnesium sulphate (the same chemical as in Epsom salts) can halve the risk of preeclampsia progressing to eclampsia. Preeclampsia is known to involve a problem with the blood vessels in the placenta. For this reason, researchers are trying to establish whether anti-platelet drugs (such as aspirin, which make platelets in the blood less sticky) or calcium supplements may reduce the risk of preeclampsia. Ectopic Pregnancy and Placenta Previa are both a condition of pregnancy wherein Placenta previa has serious implications to the health of the woman and her child in later pregnancies that occurs when the placenta implants in the lower part of the uterus in which the placenta covers the birth canal. Ectopic pregnancies which, if undiagnosed and not treated, can

lead to a womans death. On the other hand, preeclampsia is a complication or illness occurs only during pregnancy which, if left not treated it may lead either the child or the mothers death.