**7. Clinical findings**

**Evidence of blood loss**: There will be evidence of blood loss. Rapid pulse rate, pallor, and reduced blood level. In severe haemorrhage, there is be hypotension.

**Shock / syncope:** This is a clinical manifestation of ruptured ectopic pregnancy. Any female in the reproductive age group with a history of collapse without any trauma should be considered to have ectopic pregnancy until proven otherwise. The collapse is due to massive haemorrhage from the rupture with massive haemoperitoneum. The fainting attack is due to blood loss and weakness. The syncope can sometimes coincide with the rupture. The shock is due to hypovolaemic shock due to heamoperitoneum. It is due to circulating failure from reduction in effective circulating blood volume. There will be clinical features of shock such as tachycardia, hypotension, oliguria and occasionally bradycardia, pallor, sweating, confusion, cold, and clammy peripheries. There is inadequate left ventricular preload, significant fall in cardiac output, low central venous pressure and decreased urine output. Further haemorrhage results in decreased cardiac out, sympathetic over activity, further reduction in tissue perfusion, worsening hypoxia, cellular damage, and release of inflammatory cytokines. Decrease in the intravascular blood volume leads to decrease in cardiac output and tissue perfusion. Also, the decrease in intravascular blood volume causes diversion of blood from the skin to maintain organ perfusion giving rise to pale cool skin, hypotension, and tachycardia. Blood is diverted preferentially to the heart and brain. Therefore, thirst, oliguria, tachycardia, and labile blood pressure occurs. Reduced blood flow to the brain and heart results in restlessness, agitated, confusion, hypotension, tachycardia, and tachypnea.

**Pelvic examination:** It may be difficult to define the uterus because of pain. There is severe cervical tenderness in the presence of pelvic inflammatory disease. The pouch of Douglas is full. There may be identification of a pelvic mass separate from the uterus.

**Haematosalpinx**: This is due to accumulation of blood in the fallopian tube.

**Haematocele**: This is due to progressive bleeding with haematoma formation in the pouch of Douglas (Coutrin et al, 2007).

**Haematoperitoneum**: Bloody perfusion into the peritoneal cavity secondary to rupture of the fallopian tube and its blood vessels (Coutrin et al, 2007). This is the clinical picture seen most commonly in rural areas.

## **8. Management of ectopic pregnancy**

In managing ectopic pregnancy, there is the need for a high index of suspicion (Ibekwe, 2004). Investigations must not delay resuscitation. The initial management of the acute patient involves correction of shock with rapid fluid replacement, cross matching of blood, check on the haemoglobin and immediate recourse to laparatomy to stern the source of the haemorrhage (Pitkin et al, 2003).

#### **8.1 Investigations**

118 Ectopic Pregnancy – Modern Diagnosis and Management

**Shoulder tip pain**: Some patients present with shoulder tip pain. There is extensive intraperitoneal bleeding with irritation of the diaphragm by the haemoperitoneum causing

**Nausea and vomiting**: This is not specific to ectopic pregnancy. It is due to irritation of the

**Fever:** It is not common and is due to irritation of the peritoneum by blood. There may be other concurrent infections and infestations such as malaria in malaria endemic areas. The classic triad of amenorrhea, irregular vaginal bleeding and abdominal pain is not always present and occurs usually at more advanced gestational age and in patients in whom ectopic pregnancy has ruptured. In unruptured or slowly leaking ectopic pregnancy, the patient may be haemodynamically stable. A stable patient may have ill-defined abdominal pain and amenorrhea. A stable patient with ectopic may suddenly rupture and decompensate. It is because as the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate foetal development. The clinical manifestations in slowly leaking ectopic pregnancy are on and off lower abdominal pain, amenorrhea, irregular scanty vaginal bleeding, and with or without spells of dizziness. In unruptered ectopic pregnancy, the clinical manifestations are stable haemodynamic state, lower abdominal pain, amenorrhoea, may be symptomless and

**Evidence of blood loss**: There will be evidence of blood loss. Rapid pulse rate, pallor, and

**Shock / syncope:** This is a clinical manifestation of ruptured ectopic pregnancy. Any female in the reproductive age group with a history of collapse without any trauma should be considered to have ectopic pregnancy until proven otherwise. The collapse is due to massive haemorrhage from the rupture with massive haemoperitoneum. The fainting attack is due to blood loss and weakness. The syncope can sometimes coincide with the rupture. The shock is due to hypovolaemic shock due to heamoperitoneum. It is due to circulating failure from reduction in effective circulating blood volume. There will be clinical features of shock such as tachycardia, hypotension, oliguria and occasionally bradycardia, pallor, sweating, confusion, cold, and clammy peripheries. There is inadequate left ventricular preload, significant fall in cardiac output, low central venous pressure and decreased urine output. Further haemorrhage results in decreased cardiac out, sympathetic over activity, further reduction in tissue perfusion, worsening hypoxia, cellular damage, and release of inflammatory cytokines. Decrease in the intravascular blood volume leads to decrease in cardiac output and tissue perfusion. Also, the decrease in intravascular blood volume causes diversion of blood from the skin to maintain organ perfusion giving rise to pale cool skin, hypotension, and tachycardia. Blood is diverted preferentially to the heart and brain. Therefore, thirst, oliguria, tachycardia, and labile blood pressure occurs. Reduced blood flow to the brain and heart results in restlessness, agitated, confusion, hypotension,

reduced blood level. In severe haemorrhage, there is be hypotension.

**Vagina bleeding**: There may be vagina bleeding with passage of decidua cast.

**Dizziness and weakness**: This is due to the ongoing peritoneal haemorrhage.

**Amenorrhea**: This is evidence that the woman is pregnant

irritation of the phrenic nerve.

bowel causing negative peristalsis.

diagnosis aided by ancillary diagnostic tests.

**7. Clinical findings** 

tachycardia, and tachypnea.

**Haemoglobin estimation**: There is a drop in the haemoglobin level. Also, there is a gradual drop if serial haemoglobin estimation is done in ruptured or slowly leaking ectopic pregnancy. The haemoglobin level in an unruptured ectopic pregnancy may not give a clue to the condition.

**Pregnancy test:** This measures the human chorionic gonadotrophin level. A negative test does not exclude an ectopic pregnancy. Ectopic pregnancy does not produce as much human chorionic gonadotropihn as much as intrauterine pregnancy. A pregnancy test is only valuable if it is positive (Coutin et al, 2007).

**Ultrasonography:** Diagnostic ultrasound also referred to as sonography is the method of imaging structures inside the body by using high frequency sound waves with no ionizing radiation involved. Ultrasound is safe and non-invasive. In ectopic pregnancy, pelvic ultrasound shows an empty uterus and an ectopic gestation sac with a living embryo if the ectopic pregnancy has not ruptured. There is fluid in the cul-de-sac of the perineum. Real time ultrasound shows foetal heart motion. Real time ultrasonography is of great help in establishing the diagnosis of unruptured ectopic pregnancy. Its primary role lies in documenting a normal intrauterine pregnancy about five to six weeks of gestation. Such a finding essentially excludes the possibility of ectopic pregnancy because the incidence of coexisting ectopic pregnancy and intrauterine pregnancy is about 1 in 30,000 pregnancies. Ultrasound examination may be of secondary importance in supporting a diagnosis of possible ectopic pregnancy by showing an adnexa mass or fluid within the cul-de-sac or both. The ability to identify an adnexa mass as an ectopic pregnancy rather than a large ovarian cyst, hydrosalpinx, tubo-ovarian abscess or other causes of adnexa enlargement varies from centre to centre. Ultrasonography has been found to be promising in the confirmatory diagnosis of ectopic pregnancy (Ikpeze, 1991). Use of ultrasonographic imaging should never preclude adequate resuscitation or definitive surgical therapy in a patient who is haemodynamically unstable and in whom ectopic pregnancy is a highly suspected. The goal of bedside ultrasonography is to diagnose an intrauterine pregnancy as heterotopic pregnancy although rarely still occurs. Bedside ultrasonography should not be

Management and Outcome of Ectopic Pregnancy in Developing Countries 121

disadvantages of using non-cross matched blood include possible transfusion of incompatible blood owing to clinically significant antibodies to blood groups other than

Ectopic pregnancy can be treated surgically or non-surgically depending if it is ruptured or not and the equipments available at the centre. Due to advances in the diagnostic techniques, it has become possible to identify and manage ectopic pregnancy before they cause clinical symptoms in many developed countries. (Amok & Buga, 1995). This is not so in most developing countries. Subsequent fertility is substantially improved when conservative surgery is utilised instead of salpingectomy. Subsequent intrauterine pregnancy rates have been found to be 76% when conservative surgery is performed and 44% when salpingectomy is performed (Sherman et al, 1982). In patients with adhesive disease in the contra-lateral adnexa and a history of infertility, conservative management of ectopic pregnancy has produced good results with restoration of tubal potency in over 80 % in some cases if the ectopic pregnancy has not ruptured (Rajkhowa et al, 2000, Ekele, 2001, Lipscomb et al, 2000). The management of ectopic pregnancy has been improved upon by the use of ultrasound, laparoscopy, and monitoring of the beta subunit of the Human Chorionic Gonadotrophin (Gracia & Barnhan, 2001). Early diagnosis before tubal rupture is important in reducing mortality as well as preserving the potential for future fertility through conservative management (Gazvani, 1996). If not treated vigorously and early enough, ectopic pregnancy may be fatal. Women with ectopic pregnancy continue to present late precluding early diagnosis and use of conservative modalities of management. Morbidity remains high but mortality has declined. Blood bank services and availability of antibiotics are necessary in the management of most gynaecological emergencies. This is a problem in some developing countries and sometimes absent in some hospitals in rural areas. Transportation to an appropriate health facility can be a cause of late presentation.

Surgical treatment of ectopic pregnancy can be by laparatomy or minimally invasive surgery that is laparoscopy. Laparatomy involves removing the affected fallopian tube (salpingectomy) or dissecting the ectopic pregnancy with conservation of the fallopian known as salpingostomy. Laparatomy is reserved for patients with extensive intraperitoneal bleeding, intravascular collapse, or poor visualisation of the pelvis at the time of laparoscopy. The decision to perform a salpingostomy or salpingectomy is often made intraoperatively based on the extent of damage to the affected and contra-lateral tubes but it is also dependent on the patient's history of previous ectopic pregnancy and wish for future fertility, availability of assisted reproductive technology and the skill of the surgeon (Barnhart, 2009). Most gynaecological emergencies that are managed by laparatomy can be treated by laparoscopy and benefit both patient and the health facility (Baumann et al, 1989). Not all cases of ectopic pregnancy can be treated with laparoscopy especially ruptured ectopic pregnancy. The treatment of ectopic pregnancy is influenced by the clinical state of the patient, the site of the ectopic gestation, the reproductive wish of the patient and available facilities and technology. Surgical treatment for ectopic pregnancy is still the norm and gold standard. The surgical procedure may also be radical (salpingectomy) or conservative (linear salpingostomy). In the surgical management of ectopic pregnancy, the

ABO.

**8.3 Treatment** 

**8.3.1 Surgical therapy** 

performed if it delays resuscitation or definitive surgical care in an unstable patient. Transvaginal sonography facilities diagnose the location of the gestational sac, age, size, and viability of an ectopic pregnancy even within a uterine scar (Herman et al, 1995). Bedside ultrasonography is the test of choice in unstable patients. Ectopic pregnancy within a previous caesarean section scar is best diagnosed by transvaginal ultrasound. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal mortality. As soon as the diagnosis is confined, proper surgical treatment by laparatomy should be arranged. Ultrasound evaluation especially transvaginal scan is invaluable but where there result is equivocal, ancillary tests should be done (Tenore, 2000). The ultrasonographic findings of a ruptured ectopic pregnancy are absence of an intrauterine gestational sac, fluid particularly haemorrhagic in the pelvis or perineum, adnexal masses or haematosalpinx. Transvaginal ultrasound provides improved resolution allowing descriptions of early embryonic development characteristics. Improvement in the identification of the sonographic landmark of normal embryonic development and awareness of the sonographic risk factors of pregnancy failure may lead to more successful management strategies. Diagnosis of suspected ectopic pregnancy often involves an assessment of both hormonal markers and sonographic features (Lucie et al, 2005). Ultrasound that demonstrates an intrauterine pregnancy is reassuring because heterotopic pregnancy occurs in only 1: 7000 to 1: 30,000 of spontaneously conceived pregnancies (DeVoe & Pratt, 1948). The sonographic appearance of an ectopic pregnancy is varied. There may be simple adnexal cyst, complex adnexal mass, tubal ring, free fluid in the adnexal culde-sac, a live extra uterine foetus or an empty uterus with no other sonographic findings (Lucie et al, 2005). A live extra uterine embryo is diagnostic of an ectopic pregnancy. Isolated free fluid in the pelvis is rarely the only sonographic findings. Presence of an adnexal mass and / or free pelvic fluid is strong predictor of an ectopic pregnancy (diagnostic imaging). Where ultrasound is not available and there is still some doubt, two other diagnostic procedures can be used. They are culdocentesis, which is puncture of the pouch of Douglas and abdominis parencentesis.

**Culdocentesis**: This involves aspiration of fluid from the pouch of Douglas through the posterior fornix of the vagina.

**Parencentesis abdominis**: This involves aspiration of non-clotting blood from the abdomen. It is not diagnostic because the needle used for aspiration can go into the inferior vena cava, or rectum. It is technically difficult in the obese patient. The pouch of Douglas may be full. There can be adhesions therefore the needle may not get to the abdomen.

#### **8.2 Resuscitation**

Volume replacement is done with plasma expanders and preparations for the definitive therapy. In developing countries and low resource settings, colloids are not readily available. In severe anaemia, blood transfusion is commenced before surgery. In ruptured ectopic pregnancy, intravenous access is established with a wide bore cannula and rapid infusion of a plasma expander done if the patient is in shock or in the presence of hypotension. If there is evidence of haemoperitoneum with clinical shock following rupture, there is little room for delay. Blood sample is collected for haemoglobin estimation, grouping, and crossmatching of at least two units of blood. Occasionally a delay in red blood cell transfusion poses a substantial risk to the patient. In these circumstances, transfusion with non-crossmatched type O rhesus negative blood may be necessary. The

disadvantages of using non-cross matched blood include possible transfusion of incompatible blood owing to clinically significant antibodies to blood groups other than ABO.

#### **8.3 Treatment**

120 Ectopic Pregnancy – Modern Diagnosis and Management

performed if it delays resuscitation or definitive surgical care in an unstable patient. Transvaginal sonography facilities diagnose the location of the gestational sac, age, size, and viability of an ectopic pregnancy even within a uterine scar (Herman et al, 1995). Bedside ultrasonography is the test of choice in unstable patients. Ectopic pregnancy within a previous caesarean section scar is best diagnosed by transvaginal ultrasound. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal mortality. As soon as the diagnosis is confined, proper surgical treatment by laparatomy should be arranged. Ultrasound evaluation especially transvaginal scan is invaluable but where there result is equivocal, ancillary tests should be done (Tenore, 2000). The ultrasonographic findings of a ruptured ectopic pregnancy are absence of an intrauterine gestational sac, fluid particularly haemorrhagic in the pelvis or perineum, adnexal masses or haematosalpinx. Transvaginal ultrasound provides improved resolution allowing descriptions of early embryonic development characteristics. Improvement in the identification of the sonographic landmark of normal embryonic development and awareness of the sonographic risk factors of pregnancy failure may lead to more successful management strategies. Diagnosis of suspected ectopic pregnancy often involves an assessment of both hormonal markers and sonographic features (Lucie et al, 2005). Ultrasound that demonstrates an intrauterine pregnancy is reassuring because heterotopic pregnancy occurs in only 1: 7000 to 1: 30,000 of spontaneously conceived pregnancies (DeVoe & Pratt, 1948). The sonographic appearance of an ectopic pregnancy is varied. There may be simple adnexal cyst, complex adnexal mass, tubal ring, free fluid in the adnexal culde-sac, a live extra uterine foetus or an empty uterus with no other sonographic findings (Lucie et al, 2005). A live extra uterine embryo is diagnostic of an ectopic pregnancy. Isolated free fluid in the pelvis is rarely the only sonographic findings. Presence of an adnexal mass and / or free pelvic fluid is strong predictor of an ectopic pregnancy (diagnostic imaging). Where ultrasound is not available and there is still some doubt, two other diagnostic procedures can be used. They are culdocentesis, which is puncture of the

**Culdocentesis**: This involves aspiration of fluid from the pouch of Douglas through the

**Parencentesis abdominis**: This involves aspiration of non-clotting blood from the abdomen. It is not diagnostic because the needle used for aspiration can go into the inferior vena cava, or rectum. It is technically difficult in the obese patient. The pouch of Douglas may be full.

Volume replacement is done with plasma expanders and preparations for the definitive therapy. In developing countries and low resource settings, colloids are not readily available. In severe anaemia, blood transfusion is commenced before surgery. In ruptured ectopic pregnancy, intravenous access is established with a wide bore cannula and rapid infusion of a plasma expander done if the patient is in shock or in the presence of hypotension. If there is evidence of haemoperitoneum with clinical shock following rupture, there is little room for delay. Blood sample is collected for haemoglobin estimation, grouping, and crossmatching of at least two units of blood. Occasionally a delay in red blood cell transfusion poses a substantial risk to the patient. In these circumstances, transfusion with non-crossmatched type O rhesus negative blood may be necessary. The

There can be adhesions therefore the needle may not get to the abdomen.

pouch of Douglas and abdominis parencentesis.

posterior fornix of the vagina.

**8.2 Resuscitation** 

Ectopic pregnancy can be treated surgically or non-surgically depending if it is ruptured or not and the equipments available at the centre. Due to advances in the diagnostic techniques, it has become possible to identify and manage ectopic pregnancy before they cause clinical symptoms in many developed countries. (Amok & Buga, 1995). This is not so in most developing countries. Subsequent fertility is substantially improved when conservative surgery is utilised instead of salpingectomy. Subsequent intrauterine pregnancy rates have been found to be 76% when conservative surgery is performed and 44% when salpingectomy is performed (Sherman et al, 1982). In patients with adhesive disease in the contra-lateral adnexa and a history of infertility, conservative management of ectopic pregnancy has produced good results with restoration of tubal potency in over 80 % in some cases if the ectopic pregnancy has not ruptured (Rajkhowa et al, 2000, Ekele, 2001, Lipscomb et al, 2000). The management of ectopic pregnancy has been improved upon by the use of ultrasound, laparoscopy, and monitoring of the beta subunit of the Human Chorionic Gonadotrophin (Gracia & Barnhan, 2001). Early diagnosis before tubal rupture is important in reducing mortality as well as preserving the potential for future fertility through conservative management (Gazvani, 1996). If not treated vigorously and early enough, ectopic pregnancy may be fatal. Women with ectopic pregnancy continue to present late precluding early diagnosis and use of conservative modalities of management. Morbidity remains high but mortality has declined. Blood bank services and availability of antibiotics are necessary in the management of most gynaecological emergencies. This is a problem in some developing countries and sometimes absent in some hospitals in rural areas. Transportation to an appropriate health facility can be a cause of late presentation.

#### **8.3.1 Surgical therapy**

Surgical treatment of ectopic pregnancy can be by laparatomy or minimally invasive surgery that is laparoscopy. Laparatomy involves removing the affected fallopian tube (salpingectomy) or dissecting the ectopic pregnancy with conservation of the fallopian known as salpingostomy. Laparatomy is reserved for patients with extensive intraperitoneal bleeding, intravascular collapse, or poor visualisation of the pelvis at the time of laparoscopy. The decision to perform a salpingostomy or salpingectomy is often made intraoperatively based on the extent of damage to the affected and contra-lateral tubes but it is also dependent on the patient's history of previous ectopic pregnancy and wish for future fertility, availability of assisted reproductive technology and the skill of the surgeon (Barnhart, 2009). Most gynaecological emergencies that are managed by laparatomy can be treated by laparoscopy and benefit both patient and the health facility (Baumann et al, 1989). Not all cases of ectopic pregnancy can be treated with laparoscopy especially ruptured ectopic pregnancy. The treatment of ectopic pregnancy is influenced by the clinical state of the patient, the site of the ectopic gestation, the reproductive wish of the patient and available facilities and technology. Surgical treatment for ectopic pregnancy is still the norm and gold standard. The surgical procedure may also be radical (salpingectomy) or conservative (linear salpingostomy). In the surgical management of ectopic pregnancy, the

Management and Outcome of Ectopic Pregnancy in Developing Countries 123

depends on the clinical experience of the surgeon, equipment availability, and patients' physical status (Ling & Stovall, 1994). In women desiring fertility, conservative tube sparing surgery has been recommended, as it does not increase the subsequent recurrence of ectopic pregnancy (Arora et al, 2005). Salpingectomy is the procedure of choice if the woman has no desire for future pregnancy. Laparoscopic management of ectopic pregnancy has been demonstrated to be safe and an effective alternative to conventional management by laparatomy. Laparoscopic procedures are associated with less intra-operative blood loss, lower analgesic requirements, shorter hospital stay and a quicker return to normal activities (Qureshi et al, 2006). Experienced operators may be able to manage laparoscopically women with even large haemoperitoneum safely but the surgical procedure, which prevents further loss quickly should be used (Guideline: 2004). In most centres, this will be by laparatomy. A pregnancy ectopically implanted into the fallopian tube, ovary or other distant sites may also be associated with the accumulation of fluid in the uterine lumen at five weeks gestation. This absence of a chorionic sac however leads to the appearance of only a single ring or pseudo sac in the uterus, in contrast to the double ring of an intrauterine pregnancy. The identification of a cystic mass with complex shadows in the adnexa may give a further clue to the presence of an ectopic pregnancy although it is often impossible to determine the exact site of origin of such a mass on ultrasound. Finally, bleeding associated with ectopic pregnancy may manifest itself as free fluid in the pouch of Douglas (Loughney & Stirges, 2004). Ectopic pregnancy can occur in the absence of either a single uterine ring, an adnexa

Medical therapy has an established place in the treatment of ectopic pregnancy and in carefully selected patients; it appears to be effective as surgery (Sowter & Farquhar, 2004). For medical therapy of ectopic pregnancy, systemic methotraxate is usually employed. However, ultrasonographic or laparoscopic guide injection into the gestational sac can lead to resolution in asymptomatic patients. There are numerous reports describing successful treatment of all varieties of ectopic pregnancies using a number of methotrexate (MTX) regimens. It is clear that many women with an ectopic pregnancy are not suitable for medical therapy. Active intra-abdominal haemorrhage is a contraindication. The size of the mass is important. Medical therapy for ectopic pregnancy involves also monitoring the patients' quantitative beta human chorionic gonadotropihn concentrations and this is not available in low resource areas. Single dose methotrexate is associated with a higher risk of rupture than multiple doses (Buster & Barnhart, 2004). Medical management is indicated with no viable intrauterine pregnancy, absence of rupture, adnexal mass of 4 cm or less and beta Human Chorionic Gonadotrophin levels are below 10,000 iu/ml (Buster & Barnhart, 2004). Some of the side effects of methotrexate are abdominal discomfort, chills and fever, dizziness, immunosuppression, leucopoenia, malaise, nausea, ulcerative stomatitis, photosensitivity and undue fatigue. Breastfeeding is an absolute contraindication to methotrexate therapy. Relative contraindications to methotrexate therapy are abnormal liver function test, blood dyscrasias, ongoing radiotherapy, excessive alcohol consumption, HIV / AIDS, psoriasis, rheumatoid arthritis and significant pulmonary disease. There is no role for medical management in the treatment of ruptured tubal pregnancy or suspected tubal

pregnancy when a patient shows signs of hypovolaemic shock (Guideline, 2004).

mass or free peritoneal fluid.

**8.3.3 Medical treatment** 

benefits of salpingectomy over salpingostomy are uncertain (Farquhar, 2005). In developed countries, most ectopic pregnancies are diagnosed before rupture and there is room for conservative surgical procedures (Ibekwe, 2004). The emphasis in the management of ectopic pregnancy is on early diagnosis before rupture and conservative surgery. However, in most developing countries especially Nigeria where patients still present late after rupture, salpingectomy remains the operative procedure (Ibekwe, 2004). Salpingectomy is the commonest surgical management for tubal pregnancy in Nigeria because most of the women present late (Egwuatu & Ozumba, 1987, Gharoro & Igbafe, 2002). Salpingectomy, which leads to tubal loss and reduced reproductive potentials is the commonest management option in low resource settings (Eze, 2008). Intrauterine pregnancy rate after salpingectomy is about 45 % with a 9 % repeat ectopic pregnancy (Eze, 2008). In salpingostomy, tissue handling is minimized to reduce tissue trauma and prevent tubal occlusion or peritubal adhesions. The success of reconstructive tubal surgery for ectopic pregnancy can be only measured in terms of subsequent live births the individual achieves. During the surgical treatment of ectopic pregnancy by both laparatomy and laparoscopy, the state of the contra-lateral tube is noted. The condition of the contra-lateral tube has been reported to play a crucial role in subsequent fertility of patients with ectopic pregnancy (Kjellberg & Lalos, 2000, Tuomivaara & Kauppila, 1988). An ectopic pregnancy with a ruptured or severely damaged tube renders little choice but salpingectomy (Nannie et al, 2003). Salpingostomy is where the ectopic conceptus is removed from the affected tube through a linear incision of the tube overlying the ectopic pregnancy. This incision is not surgically closed and is allowed to heal through secondary intention. This surgical treatment conserves the affected tube (Varma & Gupta, 2008).

8.3.1.1 Ectopic pregnancy in caesarean section scar

Although the expedient and medical management have been reported, termination of a caesarean section scar pregnancy by laparatomy and hysterectomy with repair of the accompanying uterine scar dehiscence may be the best option (Fylstra, 2002).

#### **8.3.2 Laparoscopy**

This service is not readily available in developing countries especially those in low resource areas and in underequipped hospitals. Elsewhere in the developed world, minimal access laparoscopic surgery has become the preferred technique unless the woman is haemodynamically unstable (Tulandi & Saleh, 1997). Laparoscopic surgery has brought a lot of revolution in the field of medicine. Its evolution and spread was rapid in developed countries. In the industrialized countries, it is often the first choice intervention when surgery is needed. However, there is still a major gap in the implementation of laparoscopic surgery in under resourced settings often due to restricted availability to access to the equipment and lack of training. Laparoscopic surgery compared to open surgery may offer advantages such as less infections, complications, minimal tissue trauma, faster recovery, and shorter stay in hospital. Its implementation is associated with some constraints such as the surgeons' skills, the cost of acquisition and maintenance of the laparoscope, need for a trained anaesthetist, the availability of electricity and medical carbon dioxide.

Diagnostic and therapeutic laparoscopy has increased over the last decade without increase in maternal and foetal complications. Laparoscopic approach is useful for haemodynamically stable patients. The choice of laparoscopic surgery versus laparatomy depends on the clinical experience of the surgeon, equipment availability, and patients' physical status (Ling & Stovall, 1994). In women desiring fertility, conservative tube sparing surgery has been recommended, as it does not increase the subsequent recurrence of ectopic pregnancy (Arora et al, 2005). Salpingectomy is the procedure of choice if the woman has no desire for future pregnancy. Laparoscopic management of ectopic pregnancy has been demonstrated to be safe and an effective alternative to conventional management by laparatomy. Laparoscopic procedures are associated with less intra-operative blood loss, lower analgesic requirements, shorter hospital stay and a quicker return to normal activities (Qureshi et al, 2006). Experienced operators may be able to manage laparoscopically women with even large haemoperitoneum safely but the surgical procedure, which prevents further loss quickly should be used (Guideline: 2004). In most centres, this will be by laparatomy. A pregnancy ectopically implanted into the fallopian tube, ovary or other distant sites may also be associated with the accumulation of fluid in the uterine lumen at five weeks gestation. This absence of a chorionic sac however leads to the appearance of only a single ring or pseudo sac in the uterus, in contrast to the double ring of an intrauterine pregnancy. The identification of a cystic mass with complex shadows in the adnexa may give a further clue to the presence of an ectopic pregnancy although it is often impossible to determine the exact site of origin of such a mass on ultrasound. Finally, bleeding associated with ectopic pregnancy may manifest itself as free fluid in the pouch of Douglas (Loughney & Stirges, 2004). Ectopic pregnancy can occur in the absence of either a single uterine ring, an adnexa mass or free peritoneal fluid.

#### **8.3.3 Medical treatment**

122 Ectopic Pregnancy – Modern Diagnosis and Management

benefits of salpingectomy over salpingostomy are uncertain (Farquhar, 2005). In developed countries, most ectopic pregnancies are diagnosed before rupture and there is room for conservative surgical procedures (Ibekwe, 2004). The emphasis in the management of ectopic pregnancy is on early diagnosis before rupture and conservative surgery. However, in most developing countries especially Nigeria where patients still present late after rupture, salpingectomy remains the operative procedure (Ibekwe, 2004). Salpingectomy is the commonest surgical management for tubal pregnancy in Nigeria because most of the women present late (Egwuatu & Ozumba, 1987, Gharoro & Igbafe, 2002). Salpingectomy, which leads to tubal loss and reduced reproductive potentials is the commonest management option in low resource settings (Eze, 2008). Intrauterine pregnancy rate after salpingectomy is about 45 % with a 9 % repeat ectopic pregnancy (Eze, 2008). In salpingostomy, tissue handling is minimized to reduce tissue trauma and prevent tubal occlusion or peritubal adhesions. The success of reconstructive tubal surgery for ectopic pregnancy can be only measured in terms of subsequent live births the individual achieves. During the surgical treatment of ectopic pregnancy by both laparatomy and laparoscopy, the state of the contra-lateral tube is noted. The condition of the contra-lateral tube has been reported to play a crucial role in subsequent fertility of patients with ectopic pregnancy (Kjellberg & Lalos, 2000, Tuomivaara & Kauppila, 1988). An ectopic pregnancy with a ruptured or severely damaged tube renders little choice but salpingectomy (Nannie et al, 2003). Salpingostomy is where the ectopic conceptus is removed from the affected tube through a linear incision of the tube overlying the ectopic pregnancy. This incision is not surgically closed and is allowed to heal through secondary intention. This surgical treatment

Although the expedient and medical management have been reported, termination of a caesarean section scar pregnancy by laparatomy and hysterectomy with repair of the

This service is not readily available in developing countries especially those in low resource areas and in underequipped hospitals. Elsewhere in the developed world, minimal access laparoscopic surgery has become the preferred technique unless the woman is haemodynamically unstable (Tulandi & Saleh, 1997). Laparoscopic surgery has brought a lot of revolution in the field of medicine. Its evolution and spread was rapid in developed countries. In the industrialized countries, it is often the first choice intervention when surgery is needed. However, there is still a major gap in the implementation of laparoscopic surgery in under resourced settings often due to restricted availability to access to the equipment and lack of training. Laparoscopic surgery compared to open surgery may offer advantages such as less infections, complications, minimal tissue trauma, faster recovery, and shorter stay in hospital. Its implementation is associated with some constraints such as the surgeons' skills, the cost of acquisition and maintenance of the laparoscope, need for a

Diagnostic and therapeutic laparoscopy has increased over the last decade without increase in maternal and foetal complications. Laparoscopic approach is useful for haemodynamically stable patients. The choice of laparoscopic surgery versus laparatomy

accompanying uterine scar dehiscence may be the best option (Fylstra, 2002).

trained anaesthetist, the availability of electricity and medical carbon dioxide.

conserves the affected tube (Varma & Gupta, 2008). 8.3.1.1 Ectopic pregnancy in caesarean section scar

**8.3.2 Laparoscopy** 

Medical therapy has an established place in the treatment of ectopic pregnancy and in carefully selected patients; it appears to be effective as surgery (Sowter & Farquhar, 2004). For medical therapy of ectopic pregnancy, systemic methotraxate is usually employed. However, ultrasonographic or laparoscopic guide injection into the gestational sac can lead to resolution in asymptomatic patients. There are numerous reports describing successful treatment of all varieties of ectopic pregnancies using a number of methotrexate (MTX) regimens. It is clear that many women with an ectopic pregnancy are not suitable for medical therapy. Active intra-abdominal haemorrhage is a contraindication. The size of the mass is important. Medical therapy for ectopic pregnancy involves also monitoring the patients' quantitative beta human chorionic gonadotropihn concentrations and this is not available in low resource areas. Single dose methotrexate is associated with a higher risk of rupture than multiple doses (Buster & Barnhart, 2004). Medical management is indicated with no viable intrauterine pregnancy, absence of rupture, adnexal mass of 4 cm or less and beta Human Chorionic Gonadotrophin levels are below 10,000 iu/ml (Buster & Barnhart, 2004). Some of the side effects of methotrexate are abdominal discomfort, chills and fever, dizziness, immunosuppression, leucopoenia, malaise, nausea, ulcerative stomatitis, photosensitivity and undue fatigue. Breastfeeding is an absolute contraindication to methotrexate therapy. Relative contraindications to methotrexate therapy are abnormal liver function test, blood dyscrasias, ongoing radiotherapy, excessive alcohol consumption, HIV / AIDS, psoriasis, rheumatoid arthritis and significant pulmonary disease. There is no role for medical management in the treatment of ruptured tubal pregnancy or suspected tubal pregnancy when a patient shows signs of hypovolaemic shock (Guideline, 2004).

Management and Outcome of Ectopic Pregnancy in Developing Countries 125

all patients diagnosed with ectopic pregnancy. Referral of a patient with ectopic pregnancy to a centre with laparoscopic service may lead to death during transportation and transfer because there is continuous intraperitoneal bleeding which can lead to exsanguination. Blood transfusion services are necessary in the management of ectopic pregnancy. Mortality and morbidity are low when diagnosis is made before rupture occurs. The most common cause of these deaths is massive bleeding after rupture of the ectopic pregnancy. Absence of cross-matched blood should not be a deferment to exploratory laparatomy because intraperitoneal haemorrhage is on going. In developed countries, diagnosis is made before rupture occurs however most cases in our environment still present late with severe

Early presentation, high index of suspicion and use of modern diagnostic techniques will improve overall clinical outcome in patients. Promotion of family planning, early treatment of pelvic inflammatory disease and good quality obstetric care could be important

Abdominal pain and tenderness are the most frequent sign and symptom of ectopic pregnancy (Airede & Ekele, 2005). Diagnosis was usually based on clinical findings augmented by procedures such as parencentesis abdominis, abdominal and pelvic examination, and urine pregnancy test. Blood products are not available at the centre hence

A 24-year-old nullipara presented with complaints of abdominal pain and vaginal bleeding of one-week duration. The pain was cramp-like and sharp at the umbilicus. She had amenorrhea for six weeks. Physical examination revealed a young woman in painful distress that was very pale. Pulse rate was 120 beats per minute and blood pressure 90/60 mmhg. The abdomen was distended and tender. It was difficult to palpate abdominal organs because of guarding. Pelvic examination showed an uneffaced cervix, which was firm, tender, and central. Cervical Os was closed. The uterus was empty with free adnexa, full, tender, and cystic pouch of Douglas on pelvic examination. There was cervical excitation tenderness and the examining gloved finger was stained with altered blood. The packed cell volume was 22%. A diagnosis of ruptured ectopic pregnancy was made. Abdominal ultrasound showed a bulky uterus, which was anteverted. The endometrial cavity was empty and intact. There was significant decidual reaction suggestive of ruptured ectopic gestation. The entire pelvic organs was floating on fluid suggestive to be internal haemorrhage. Differential diagnosis of massive peritoneum, ascitis, very bulky uterus with decidual reaction and ruptured ectopic pregnancy was made. At laparatomy, there was seropurulent peritoneal fluid with a gangrenous 80 cm of the terminal ileum, gangrene of 10 cm of the sigmoid colon trapped in a sigmoid volvolus. The gangrenous segment of bowel

was excised and resected with an ileo-ileal and colo-colic anastomosis done.

A 30-year-old woman presented with complaints of six hours severe abdominal pain and eight weeks of amenorrhoea. Clinical findings showed tender right iliac fossa and lumber region. She was in painful distress and pale. Cervical excitation tenderness was tender on

intraperitoneal haemorrhage (Nwagha et al, 2007).

all the patients received transfusion of whole blood.

preventive intervention.

**10. Case series** 

**10.1 Case 1** 

**10.2 Case 2** 

#### **8.4 Postoperative management**

The patient may still require blood transfusion if anaemia is still present. Intravenous fluids are administered until bowel sounds return and the patient is able to take orally. Antibiotics and analgesics are administered. Haematinics is commenced once the patient has commenced oral feeding. The patient is encouraged to ambulate especially if obese. On discharge, the patient is counselled for family planning and follow-up. Follow-up visit is necessary. Broad-spectrum antibiotics are administered.

## **8.5 Blood transfusion**

Blood transfusion involves the infusion of whole blood or blood component from one individual to another. In an emergency with massive blood loss that threatens life, it is permissible to transfuse group O negative packed cells but blood sample must be taken for grouping and crossmatching prior to transfusions (Simmons, 2008). Blood transfusion is associated with significant risk hence it calls for great caution. Transfusion safety lies on the avoidance of transfusion reaction. Blood transfusion services are necessary in the management of ectopic pregnancy because of the intraperitoneal haemorrhage. Some patients may present in haemorrhagic shock. Blood transfusion could be life saving in cases of ruptured ectopic pregnancy. Blood products are scarce resources in developing countries especially in low resource centres although blood transfusion carries its own risks. Transfusion of safe blood when life-threatening conditions cannot be prevented or managed by other means. Blood transfusion is just a part of clinical management. Blood loss can be massive requiring blood transfusion. Autologous blood transfusion is done in most rural centres. Blood from the intraperitoneal haemorrhage is scooped out and filtered through five to eight layers of sterile gauze to remove large blood clots. This filtered blood is introduced into a blood bag, which contains an anticoagulant to prevent clotting of the filtered blood, and transfused to the patient via blood giving set.

#### **8.6 Patients who refuse blood transfusion**

Even after extensive counselling regarding the risks and benefits of blood transfusion, some patients still refuse blood transfusion even under life threatening conditions. These are due to religious and traditional beliefs. Written informed consent concerning this issue should be obtained in the presence of a witness because if death of the patient occurs, the patient will no longer be there to attest herself. Initial management with intravenous fluids sufficient to maintain perfusion and haemodynamic stability should be commenced.

## **9. Discussion**

Ectopic pregnancy is a cause of maternal morbidity and mortality and is reduced where there are emergency surgical facilities and blood transfusion services. All the patients in this study had laparatomy as in most studies conducted in Nigeria. This is because laparoscopic services are not available at the centre. Laparatomy for now remains the most common surgical intervention method at our disposal for the management of ectopic pregnancy. This is due in part to non-availability of operating laparoscopes, which have been shown to be very useful (Barnhart et al, 1980). Moreover, significant haemoperitoneum from ruptured tubal pregnancy makes laparoscopic surgery less than ideal. The doctors at the study centre do not have specialist training in obstetrics and gynaecology hence salpingectomy is done in all patients diagnosed with ectopic pregnancy. Referral of a patient with ectopic pregnancy to a centre with laparoscopic service may lead to death during transportation and transfer because there is continuous intraperitoneal bleeding which can lead to exsanguination. Blood transfusion services are necessary in the management of ectopic pregnancy. Mortality and morbidity are low when diagnosis is made before rupture occurs. The most common cause of these deaths is massive bleeding after rupture of the ectopic pregnancy. Absence of cross-matched blood should not be a deferment to exploratory laparatomy because intraperitoneal haemorrhage is on going. In developed countries, diagnosis is made before rupture occurs however most cases in our environment still present late with severe intraperitoneal haemorrhage (Nwagha et al, 2007).

Early presentation, high index of suspicion and use of modern diagnostic techniques will improve overall clinical outcome in patients. Promotion of family planning, early treatment of pelvic inflammatory disease and good quality obstetric care could be important preventive intervention.

Abdominal pain and tenderness are the most frequent sign and symptom of ectopic pregnancy (Airede & Ekele, 2005). Diagnosis was usually based on clinical findings augmented by procedures such as parencentesis abdominis, abdominal and pelvic examination, and urine pregnancy test. Blood products are not available at the centre hence all the patients received transfusion of whole blood.
