Ectopic Pregnancy: Etiology, Modern Diagnosis Thesis
Excerpt from Thesis :
Initial tests may be culdocentesis, hematocrit, a pregnancy test, a qualitative HCG blood test, a transvaginal ultrasound or pregnancy ultrasound and a white blood count test. An ectopic pregnancy can be distinguished from a normal intrauterine pregnancy through a rise in quantitative HCG levels. Declining B-hCG levels is indicative of an ectopic pregnancy (Kulp & Barnhart 2008). AD & C, laparoscopy and laparotomy tests will confirm the diagnosis (Chen).
An early diagnosis of ectopic pregnancy with transvaginal ultrasound scan or TVS provides the clinician with conservative options (Madani 2008). Methotrexate may be prescribed if the ectopic pregnancy is small. TVS also reduces chances of mortality. Laparoscopy can be reserved for use as treatment rather than for diagnosis (Madani).
Differential diagnosis includes appendicitis, salpingitis, ruptured corpus luteum cyst, or ovarian follicle, spontaneous or threatened abortion, ovarian torsion, and urinary tract disease (Sepilian & Wood 2009).
An ectopic pregnancy can neither be treated nor saved to continue to full term
(Chen 2008). It must be eliminated to save the mother's life. Emergency medical help for the mother is needed in case of rupture, which can lead to shock. Treatment for shock includes blood transfusion, fluids given intravenously, oxygen, keeping the woman warm and raising her legs. In case of rupture, laparotomy is performed to stop blood loss. At the same time, it confirms an ectopic pregnancy, removes it and repairs any damage tissue. The fallopian tube may need to be removed. If there is no rupture, a minilaparatomy and laparoscopy are often performed. If the doctor does not think a rupture will occur, he may prescribe methotrexate and monitor the patient's condition. He may also direct the patient to undergo blood and liver function tests (Chen).
Medical therapy has become the preferred approach for ectopic pregnancy in place of surgical removal in many instances (Lipscomb 2007). It has a high success rate of 88-92% and even higher on patients with relatively low hCG levels. Methotrexate is a folic acid analog, which works to interfere with DNA synthesis. It is currently used in multiple doses, alternately with citrovorm or as a single planned dose. Which of these is the superior protocol is still unclear (Lipscomb). Certain factors must be considered in prescribing methotrexate (Sepilian & Wood 2009). The patient must be hemodynamically stable, without signs or symptoms of active bleeding or hemoperitoneum. She must be dependable, compliant and capable of following up. The gestation should not be more than 3.5 cm by ultrasound measurement. And there should be no contraindications to the use of methotrexate (Sepilian & Wood).
Minimally invasive surgery has been the more conservative surgical approach to un-ruptured ectopic pregnancy (Sepilian & Wood 2009). This is to preserve tubal function. Laparoscopy is the choice in most cases. On the other hand, laparotomy is usually performed in hemodynamically unstable patients or those with corneal ectopic pregnancies. It is also used when the surgeon is inexperienced with the procedure and when the use of laparoscopy presents difficulty in a particular patient. And salpingectomy is the choice for a patient who no longer desires fertility, has previous ectopic pregnancy in the same tube or has severely damaged tubes (Sepilian & Wood).
The more popular therapy today is the single-dose injection of methotrexate 50 mg/m2 IM or as a divided dose into each buttock (Sepilian & Wood 2009). Its effectiveness is comparable to that of multiple doses. Smaller doses and fewer injections can result in fewer adverse effects. The patient must be extensively informed about the risks, benefits, adverse effects, and the possibility of failure with the use of injectible methotrexate. Failure of use can lead to tubal rupture, which requires surgery. The patient should be informed about the signs and symptoms of tubal rupture. She should be instructed to contact the physician in case of severe abdominal pain or tenderness, heavy vaginal bleeding, dizziness, tachycardia, palpitations or syncope (Sepilian & Wood).
Most women who suffer a single ectopic pregnancy are able to have normal pregnancies afterwards (Chen 2008). A repeat occurs in 10-20% of cases. Some do not become pregnant again. Deaths from ectopic pregnancy in the United States have declined to less than .1% in the last three decades (Chen).
Internal bleeding, which leads to shock, is the most common (Chen 2008). Death from rupture is rare and infertility is placed at 10-15% (Chen).
A b hCG level of higher than 15,000 IU/L, fetal heart activity and free fluid in the cul-de-sac are the major contraindications to the use of methotrexate (Sepilian & Wood 2009).
Documented hypersensitivity to methotrexate, breastfeeding, immunodeficiency, alcoholism, alcohol liver disease or any liver disease, blood dyscrasias, leucopenia, thrombocytopenia, anemia, active pulmonary disease, peptic ulcer and renal, hepatic or hematologic dysfunction are other contraindications to methotrexate (Sepilian & Wood).
Ectopic pregnancy in the cervix, ovary or interstitial or corneal part of the tube is a contraindication to surgical therapy (Sepilian & Wood 2009). Medical treatment with methotrexate becomes the alternative therapy in any of these cases. In case of uncontrolled bleeding and hemodynamic instability, radical surgery is resorted to (Sepilian & Wood).
Smoking as Risk Factor
The Perils of Smoking
Tobacco smoke consists of more than 4,000 chemicals, most of them toxins and carcinogens (Copper and Moley 2008). Some of these are nicotine, tar, polycyclic aromatic hydrocarbons, metals, carbon monoxide, arsenic and hydrogen cyanide. These are related to many diseases and disease states. Other contents still have to be identified. Health care professionals have called massive attention to the danger of active smoking. Yet second-hand or passive smoke is just as dangerous. Second-hand or passive smoke is emitted from the burning end of a cigarette stick, while a smoker emits mainstream smoke. Some experts have called attention and caution to the toxins emitted by side-stream smoke because they dilute quickly through the air. The Environmental Protection Agency or EPA classified second-hand smoke as a carcinogen and deleterious to the health of a smoker's family. Both active and passive smoke can and does harm almost every body organ. Both types have been linked to leading causes of death, such as cardiovascular disease, cancer, stroke and chronic lung disease. Present data offer enough evidence on the huge impact of smoking on public health. It not only poses great threat on life and health but also a great economic drain from medical expenses and indirect costs on all resources. And smoking affects fertility rates as well. A 2004 Centers for Disease Control and Prevention report said that 44.5 million adults, both men and women, are smokers. This translates to more than 1 out of every 5 adults (Cooper & Moley).
Women and men smokers face the same health concerns but there are less known health risks women smokers contend with (Cooper & Moley 2008). A recent survey conducted with women health care workers on their awareness of the negative impact of smoking revealed that 95-99% of them were aware about its connection with certain diseases. But only 39% of them connected smoking with miscarriage, osteoporosis at 30%, ectopic pregnancy at 27%, infertility at 22%, and early menopause at 17%. A secondary analysis of the 1995 National Survey of Family Growth identified factors indirectly relating to infertility among 824 women-respondents as increasing age, previous ectopic pregnancy, current smoking, obesity and health status. Other studies pointed to active smoking by either partner as a factor, which delays conception. If the woman is the smoker, the delay tends to be greater than 12 months at 54%. Every cigarette box carries the surgeon general's warning about smoking and adverse pregnancy, yet pregnant women continue to ignore it. There is present evidence linking smoking with increased miscarriage, low birth weight for infants, premature rupture of membranes, placental abruption, perinatal mortality, sudden infant death syndrome and behavioral disorders. Solid evidence of the connection between smoking and untoward pregnancy is still evolving. But the incidence of couples who smoke and cannot "get pregnant" has been rising. Of the available data linking cigarette smoking with reduced fecundity, two reviews make similar conclusions. The first consisted of 13 observational studies of natural conception, which related smoking negatively with live birth rates. The second was a meta-analysis of similar studies, which compared infertile women who smoked with those who did not smoke (Cooper & Moley).
Some other studies sought to establish the toxicity of the long-acting metabolite of nicotine and its effect on the complex process of conception (Cooper & Moley 2008). With rapid achievements in the field of in vitro fertilization, the process could be observed in every stage. And every stage is a potential stage for assault by toxic and mutagenic compounds from tobacco smoke. A group of researchers discovered that exposure to passive smoke is just as deleterious as active smoke. Some toxic compounds can affect, change or distort gene expression as the embryo develops. And the rest of the data suggest that a female…
Sources Used in Documents:
Aronsen, Lena. Smoking is Associated with Increased Risk of Ectopic Pregnancy.
Medical Masteral dissertation. University of Tromso, 1999
Bernstein, S.L. et al. Statement of Emergency Medicine Operations. 32: 370-381 Journal
of Nurse Practitioners: Elsevier, Inc., 2006.
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