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DISPONIBILI
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ARTICLES IN THE BOOK

  1. Acute abdomen
  2. Acute coronary syndrome
  3. Acute pancreatitis
  4. Acute renal failure
  5. Agonal respiration
  6. Air embolism
  7. Ambulance
  8. Amnesic shellfish poisoning
  9. Anaphylaxis
  10. Angioedema
  11. Aortic dissection
  12. Appendicitis
  13. Artificial respiration
  14. Asphyxia
  15. Asystole
  16. Autonomic dysreflexia
  17. Bacterial meningitis
  18. Barotrauma
  19. Blast injury
  20. Bleeding
  21. Bowel obstruction
  22. Burn
  23. Carbon monoxide poisoning
  24. Cardiac arrest
  25. Cardiac arrhythmia
  26. Cardiac tamponade
  27. Cardiogenic shock
  28. Cardiopulmonary arrest
  29. Cardiopulmonary resuscitation
  30. Catamenial pneumothorax
  31. Cerebral hemorrhage
  32. Chemical burn
  33. Choking
  34. Chronic pancreatitis
  35. Cincinnati Stroke Scale
  36. Clinical depression
  37. Cord prolapse
  38. Decompression sickness
  39. Dental emergency
  40. Diabetic coma
  41. Diabetic ketoacidosis
  42. Distributive shock
  43. Drowning
  44. Drug overdose
  45. Eclampsia
  46. Ectopic pregnancy
  47. Electric shock
  48. Emergency medical services
  49. Emergency medical technician
  50. Emergency medicine
  51. Emergency room
  52. Emergency telephone number
  53. Epiglottitis
  54. Epilepsia partialis continua
  55. Frostbite
  56. Gastrointestinal perforation
  57. Gynecologic hemorrhage
  58. Heat syncope
  59. HELLP syndrome
  60. Hereditary pancreatitis
  61. Hospital
  62. Hydrocephalus
  63. Hypercapnia
  64. Hyperemesis gravidarum
  65. Hyperkalemia
  66. Hypertensive emergency
  67. Hyperthermia
  68. Hypoglycemia
  69. Hypothermia
  70. Hypovolemia
  71. Internal bleeding
  72. Ketoacidosis
  73. Lactic acidosis
  74. Lethal dose
  75. List of medical emergencies
  76. Malaria
  77. Malignant hypertension
  78. Medical emergency
  79. Meningitis
  80. Neuroglycopenia
  81. Neuroleptic malignant syndrome
  82. Nonketotic hyperosmolar coma
  83. Obstetrical hemorrhage
  84. Outdoor Emergency Care
  85. Overwhelming post-splenectomy infection
  86. Paralytic shellfish poisoning
  87. Paramedic
  88. Paraphimosis
  89. Peritonitis
  90. Physical trauma
  91. Placenta accreta
  92. Pneumothorax
  93. Positional asphyxia
  94. Pre-eclampsia
  95. Priapism
  96. Psychotic depression
  97. Respiratory arrest
  98. Respiratory failure
  99. Retinal detachment
  100. Revised Trauma Score
  101. Sepsis
  102. Septic arthritis
  103. Septic shock
  104. Sexual assault
  105. Shock
  106. Simple triage and rapid treatment
  107. Soy allergy
  108. Spinal cord compression
  109. Status epilepticus
  110. Stroke
  111. Temporal arteritis
  112. Testicular torsion
  113. Toxic epidermal necrolysis
  114. Toxidrome
  115. Triage
  116. Triage tag
  117. Upper gastrointestinal bleeding
  118. Uterine rupture
  119. Ventricular fibrillation
  120. Walking wounded
  121. Watershed stroke
  122. Wilderness first aid
  123. Wound

 

 
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THE BOOK OF MEDICAL EMERGENCIES
This article is from:
http://en.wikipedia.org/wiki/Ectopic_pregnancy

All text is available under the terms of the GNU Free Documentation License: http://en.wikipedia.org/wiki/Wikipedia:Text_of_the_GNU_Free_Documentation_License 

Ectopic pregnancy

From Wikipedia, the free encyclopedia

 

An ectopic pregnancy is one in which the fertilized ovum is implanted in any tissue other than the uterine wall. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen.

Overview

Oviduct with an ectopic pregnancy
Oviduct with an ectopic pregnancy

In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these all but 2% occur in the fallopian tubes.[1]

In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This bleeding expels the implantation out of the tubal end as a tubal abortion. Some women thinking they are having a miscarriage are actually having a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostagladins released at the implantation site, and by free blood in the peritoneal cavity, which is locally irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into Sampson's artery, causing heavy bleeding earlier than usual.

If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery, however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparascopic or through a larger incision, known as a laparotomy.

Causes

The causes of ectopic pregnancy are unknown. After fertilzation of the oocyte in the peritoneal cavity, the egg takes about nine days to migrate down the tube to the uterine cavity at which time it implants. Wherever the embryo finds itself at that time, it will begin to implant.

There are some speculative specific causes or associations. Smoking, advanced maternal age and prior tubal damage of any origin are well shown risk factors for ectopic pregnancy.

Cilial damage and tube occlusion

Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Damage to the cilia or blockage of the Fallopian tubes is likely to lead to an ectopic pregnancy. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia. If however both tubes were occluded by PID, pregnancy would not occur and this would be protective against ectopic pregnancy. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy. Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine. Reversal of tubal sterilization carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of ectopic pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube, even if the other tube appears normal.

Excessive estrogen and progesterone

There has been speculation about the role of hormones in the genesis of ectopic pregnancy. No proven association has been established. High levels of estrogen and progesterone are thought possibly to increase the risk of ectopic pregnancy because these hormones slow the movement of the fertilized egg through the Fallopian tube. However advancing age is a risk factor for ectopic pregnancy, although this a period of declining hormone levels.

Role of intrauterine devices (IUD)

The use of intrauterine devices (IUDs) was thought at one time to increase the risk of ectopic pregnancy. However the older model copper based IUDs were only effective in preventing intrauterine pregnancies, not tubal pregnancies. As the IUD is effective in reducing pregnacy overall, the relative risk only of ectopic is increased. The old copper-based IUDs reduced the overall pregnancy rate so effectively that even the gross ectopic rates were reduced. Nonetheless any pregnancy conceived with an IUD in situ must be investigated to exclude possible ectopic pregnancy.

The newer hormone-based (levonorgestrel) IUS creates such a profound suppression of the endometrium that overall pregnancy rate is lower even than that of male or female sterilization. There are no data available for ectopic pregnancy with the IUS, but even if there were an increased relative pregnancy rate, the chance of ectopic pregnany with this device is remote indeed.

Association with infertility

Infertility treatments are highly variable and specific to individual patients. IVF is used for patients with damaged tubes which are an inherent risk factor for ectopic. Ectopic pregnacies have been seen with In Vitro Fertilization, but is uncommmon and quickly diagnosed by the early ultrasounds that these intensively surveyed patients undergo.

Other

Patients are at higher risk for ectopic pregnancy with advancing age. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies. Women exposed to diethylstilbestrol (DES) in utero (aka "DES Daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women.

Symptoms

Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability.

The early signs are:

  • Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms.
  • Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarraige or the 'implantation bleed' of a normal early pregnancy.

Patients with an late ectopic pregnancy typically have pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms. - External bleeding is due to the falling progesterone levels. - Internal bleeding is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID.

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 is an ominous sign.
  • There may be cramping or even tenderness on one side of the pelvis.
  • The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.
  • Ectopic pregnancy is noted that it can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.

Diagnosis

An ectopic pregnancy has to be suspected in any woman with lower abdominal pain and/or unusual bleeding who is or might be sexually active and whose pregnancy test is positive. And abnormal rise in blood hCG levels may also indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy today is around 3000 IU/ml of Human Chorionic Gonadotropin (HCG). A high resolution, vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for HCG has been reached. An empty uterus with levels lower than 3000IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If there is uncertainty it might be necessary to wait a few days and repeat the bloodwork and ultrasound.

An ultrasound showing a gestational sac with fetal heart is clear evidence of ectopic pregancy.

Free fluid which is non echogenic is a normal finding in the late menstrual cycle and early normal pregnacy. This is a transudate and is not presumptive evidence of bleeding. Echogenic free fluid suggests the presence of bloood clot and is suggestive of free blood in the peritoneum.

A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion has occurred, or a tubal rupture has occurred, it is hard actually to find the pregnancy tissue. Laparoscopy in very early ectopic pregancy may rarely show a normal looking Fallopian tube!

Nontubal ectopic pregnancy

2% of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria.[2]

While a fetus of ectopic pregnancy is typically not viable, very rarely, an abdominal pregnancy has been salvaged. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. In this author's experience this is invariably bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports.[3] [4] However, the vast majority of abdominal pregnancies require intervention well before fetal viability because the risk of hemorrhage.

Treatment

Nonsurgical treatment

Early treatment of an ectopic pregnancy with the drug methotrexate has proven to be a viable alternative to surgical treatment since 1993. If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy.

Surgical treatment

If hemorrhaging has already occurred, surgical intervention may be necessary if there is evidence of ongoing blood loss. However, as already stated, about half of ectopics result in tubal abortion and are self limiting. The option to go to surgery is thus often a difficult decision to make in an obviously stable patient with minimal evidence of blood clot on ultrasound.

Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.

Chances of future pregnancy

The chance of future pregnancy depends on the status of the tube(s) that are left behind, but is decreased. The chance of recurrent ectopic pregnancy is about 10% and is independent of whether the affected tube was repaired (salpingostomy) or removed (salpingectomy). Successful pregancy rates vary widely between different centres, and appear to be operator dependent. Pregnancy rates with successful methotrexate treatment compare favourably with the highest reported pregnancy rates. Often, patients may have to resort to IVF to achieve a successful pregnancy. The use of IVF does not preclude further ectopic pregnancies, but the likelihood is reduced.

Complications

The most common complication is rupture with internal bleeding that leads to shock. Death from rupture is rare. Infertility occurs in 10 - 15% of women who have had an ectopic pregnancy.

Footnotes

  1. ^ Serdar Ural (May 2004). Ectopic preganancy. KidsHealth. Retrieved on 2006-11-26.
  2. ^ Spiegelberg's criteria synd/2274 at Who Named It
  3. ^ "'Special' baby grew outside womb", BBC news, 2005-08-30. Retrieved on 2006-07-14.
  4. ^ ""Bowel baby born safely", BBC news, 2005-03-09. Retrieved on 2006-11-10.
Retrieved from "http://en.wikipedia.org/wiki/Ectopic_pregnancy"