ECTOPIC PREGNANCY

An ectopic pregnancy or eccyesis is an abnormal pregnancy that occurs outside the uterine cavity.
The most common site for an ectopic pregnancy is in the Fallopian tube or so-called tubal pregnancies, but implantation can also occurin the cervix, ovaries, and abdomen. Ectopic pregnancies are poses serious threat to the general and reproductive health of the mother , also dangerous for the mother as a effect of internal bleeding being a common complication and if not get treated medical emergency properly can lead to death.

An ectopic pregnancy is usually caused by a condition that inhibit or slowing down movement of afertilized egg through the fallopian tube to the uterus, and this matter may becaused by a physical blockage in the tube.

Risk factors of ectopic pregnancy include :

• Pelvic inflammatory disease.
• Infertility.
• Cilia located on the internal surface of the Fallopian tubesis damage.
• Use of an intrauterine device ( IUD ).
• Those who have been exposed to diethylstilbestrol ( DES ).
• Use of the "morning after pill" ( emergencycontraception ).
• Tubal surgery.
• Vaginal douching.
• Smoking.
• Previous ectopic pregnancy.
• Tubal ligation.
• Birth defects of the fallopian tubes.
• Complications of a ruptured appendix.
• Endometriosis.
• Scarring caused by previous pelvic surgery.
• Clinical presentation of ectopic pregnancy occurs at a meanof 7.2 weeks after the last normal menstrual period, with a range of 5 to 8weeks.

1. Early signs of ectopic pregnancy include:

• Inflammation and pain in the lower abdomen or pelvic area ( pain may beconfused with a strong stomach pain, it may also feel like a strong cramp ).
• Pain while urinating.
• Mild cramping on one side of the pelvis.
• Vaginal bleeding is usually mild.
• Pain while having a bowel movement.
• Low back pain.
• Nausea.
• Breast tenderness.
• Amenorrhea.

If the area of the abnormal pregnancy ruptures and bleeds, symptoms may get worse include:

• Feeling faint or actually fainting.
• Pain that is felt in the shoulder area.
• Severe, sharp, and sudden pain in the lower abdomen.

2. Patients with a late ectopic pregnancy typically experience pain and bleeding that has two pathophysiologic mechanisms :
a. External bleeding is due to the falling progesterone levels.
b. Internal bleeding ( hematoperitoneum ) is due to hemorrhage from the affected tube.

More severe internal bleeding may cause:

• Lower back, abdominal, or pelvic pain.
• Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign.
• There may be cramping or even tenderness on one side of thepelvis.
• The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Classification of ectopic pregnancy :

1. Tubal pregnancy.
The majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end, the ampullary section, the isthmus, the cornual and interstitial part of the tube. Mortality of a tubal pregnancy at the isthmus or within the uterus ( interstitial pregnancy ) is higher.

2. Nontubal ectopic pregnancy.
Ectopic pregnancies that occur in the ovary, cervix, or intra abdominal.

3. Heterotopic pregnancy.
Heterotopic pregnancy is rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside.

4. Persistent ectopic pregnancy.
A persistent ectopic pregnancy that refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopicpregnancy.

Firmness diagnose at case of an ectopic pregnancy should be considered in any woman that experience of abdominal pain or vaginal bleeding that has a positivepregnancy test.

If there are tenderness in the pelvic area as a one of early signs of ectopicpregnancy can be done a pelvic exam, include :

• Culdocentesis.
• Hematocrit.
• Pregnancy test.
• Transvaginal ultrasound or pregnancy ultrasound.
• Quantitative HCG blood test. The thres hold of discriminationfor Beta-human chorionic gonadotropin ( Beta-hCG ) at intrauterine pregnancy isaround 1500 IU/ml, so that if trans vaginal ultrasound showing an empty uteruswith levels of hCG higher than 1500 IU/ml may be indicate an ectopic pregnancy.
• White blood count.

Other tests may be used to confirm the diagnosis ofectopic pregnancy, such as:

• Laparoscopy or laparotomy can be performed e uterus and infront of the rectum.
• Cullen's sign can indicate a ruptured ectopic pregnancy.
• Culdocentesis is test to look for internal bleeding using aneedle that be inserted into the space at the very top of the vagina, behindthe uterus and in front of the rectum, and if there are blood or fluid found may be derived from a ruptured ectopic pregnancy.
• Treatment of ectopic pregnancy :

1. Medical.
Early treatment of an ectopic pregnancy with methotrexate, a viablealternative to surgical treatment which if administered early in the pregnancycan terminates the growth of the developing embryo and may cause an abortion.  Emergency medical may be recommended if the area of the ectopic pregnancybreaks open ( ruptures ) because rupture can lead to shock, so that treatmentfor shock may include :
a. Blood transfusion.
b. Fluids given through a vein.
c. Keeping warm.
d. Oxygen.
e. Raising the legs.

2. Surgical.
Surgery ( laparotomy ) is done to stop blood loss if there is a rupture. Aminilaparotomy and laparoscopy are the most common surgical treatments for anectopic pregnancy that has not ruptured. Surgery is also done to confirm anectopic pregnancy, remove the abnormal pregnancy, repair any tissue damage.

Prevention that can reduce risk of ectopic pregnancy :

• Avoiding risk factors for pelvic inflammatory disease ( PID) such as having many sexual partners, having sex without a condom, and getting sexually transmitted diseases ( STDs ).
• Early diagnosis and treatment of STDs.
• Early diagnosis and treatment of salpingitis and PID.

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