**5. Results**

During the period of study, 13 patients were managed for ectopic pregnancy making 8.23 % of gynaecological emergencies at the hospital. One hundred and fifty eight patients were managed for various gynaecological emergencies during the study period. The other gynaecological emergencies are spontaneous abortion, ovarian cyst, hydantidiform mole, and uterine fibroid. All the patients had a history of collapse at home before presenting in hospital. The age of patients ranged from 20 to 42 years with a mean of 25.12 years. All the patients were married and were accompanied by there spouses and family members to the hospital. Ten of the patients were nullipara, one primipara, and two Para three. All patients in the study have never been treated for pelvic inflammatory disease and none of them have used any form of contraception. Most of the women in the community prefer to have their babies at home with the assistance of a traditional birth attendant also known as traditional midwife. Some of these traditional birth attendants and traditional midwives have received some form of training. Therefore, it is difficult to calculate the incidence as per the number of deliveries. Twelve patients presented with ruptured ectopic pregnancy. Only one patient had an

unruptured ectopic pregnancy. All the patients had emergency exploratory laparatomy, as laparoscopic services are not available at the centre at the time of the study. Also, methotrexate was not available at the centre at the time of the study. The patients had an uneventful postoperative period and were discharged home with an advise to complete there course of antibiotics, analgesics, and haematinics. The twelve patients that presented with ruptured ectopic pregnancy received whole blood intra-operatively as blood products are not available at the centre. Findings at laparatomy were right fallopian tube ectopic pregnancy in eleven patients and two patients had left ampullary ectopic pregnancy. Salpingectomy was done for all the patients. There was no history of previous ectopic pregnancy in the patients. The patients' were followed up until after discharge from hospital.

### **6. Clinical manifestations**

116 Ectopic Pregnancy – Modern Diagnosis and Management

is bordered by Sokoto State, Niger State, Dosso region in the Republic of Niger and the Nation of Benin. Kebbi state is traditionally considered to belong to the Banza Bakwai States of Hausa land. Kebbi State has the slogan 'Land of Equity'. At the time of the study, General Hospital Aliero is located in Aliero, which is the capital of Aliero Local Government Area. The study was conducted during the author's National Youth Service Corps at Kebbi State, Nigeria. National Youth Service Corps is a one-year compulsory posting of Nigerian graduates outside the area of there abode within the country to serve their fatherland for

All patients managed for ectopic pregnancy during the study period were included in this study. The patients were admitted through the casualty department as they all presented as emergencies. Once a patient is diagnosed with ectopic pregnancy, blood sample was sent to the laboratory for haemoglobin estimation and whole blood is grouped and cross-matched against the patients' serum as blood products are not available at the centre. The patient is counselled for surgery and informed consent obtained. At presentation, a brief history was obtained and physical examination carried out for pallor, jaundice, cyanosis and any form of bleeding and pain. History of any previous ectopic pregnancy and tubal and pelvic infections are obtained. Including any previous treatment for pelvic inflammatory disease.

During the period of study, 13 patients were managed for ectopic pregnancy making 8.23 % of gynaecological emergencies at the hospital. One hundred and fifty eight patients were managed for various gynaecological emergencies during the study period. The other gynaecological emergencies are spontaneous abortion, ovarian cyst, hydantidiform mole, and uterine fibroid. All the patients had a history of collapse at home before presenting in hospital. The age of patients ranged from 20 to 42 years with a mean of 25.12 years. All the patients were married and were accompanied by there spouses and family members to the hospital. Ten of the patients were nullipara, one primipara, and two Para three. All patients in the study have never been treated for pelvic inflammatory disease and none of them have used any form of contraception. Most of the women in the community prefer to have their babies at home with the assistance of a traditional birth attendant also known as traditional midwife. Some of these traditional birth attendants and traditional midwives have received some form of training. Therefore, it is difficult to calculate the incidence as per the number of deliveries. Twelve patients presented with ruptured ectopic pregnancy. Only one patient had an unruptured ectopic pregnancy. All the patients had emergency exploratory laparatomy, as laparoscopic services are not available at the centre at the time of the study. Also, methotrexate was not available at the centre at the time of the study. The patients had an uneventful postoperative period and were discharged home with an advise to complete there course of antibiotics, analgesics, and haematinics. The twelve patients that presented with ruptured ectopic pregnancy received whole blood intra-operatively as blood products are not available at the centre. Findings at laparatomy were right fallopian tube ectopic pregnancy in eleven patients and two patients had left ampullary ectopic pregnancy. Salpingectomy was done for all the patients. There was no history of previous ectopic pregnancy in the patients. The patients' were followed up until after discharge from hospital.

Urinalysis is done and venous intravenous access established.

one year.

**5. Results** 

**4.3 Study population** 

There is no pelvic condition that gives rise to more diagnostic errors than ectopic pregnancy. There are no specific signs and symptoms that are pathnognomonic but a condition of findings may be suggestive of an ectopic pregnancy. Therefore, there should be high index of suspicion all the time when symptoms of early pregnancy are followed by irregular vaginal bleeding, lower abdominal pain, tenderness, fainting attack, shoulder tip pain, signs and symptoms of massive blood loss and diarrhoea and vomiting. The signs and symptoms depend on the amount and pattern of bleeding. In slowly leaking ectopic pregnancy, the bleeding occurs slowly. A delayed period is followed by spotting to continuous bleeding and unilateral pelvic pain with an adnexal mass. Rupture is signalled by hypotension, marked tenderness and severe pain radiating to the shoulder. A ruptured ectopic pregnancy typically presents with abdominal pain and can be in hypovolaemic shock. Some patients may have a paradoxical bradycardia despite a large amount of blood loss. Syncope or collapse is also common. An unruptured ectopic pregnancy presents with abdominal pain with or without vagina bleeding (Wagner & Promes, 2007).

The clinical presentation of ectopic pregnancy depends on whether it has ruptured or not. Ruptured ectopic pregnancy presents usually from 6 to 12 weeks of pregnancy. Ruptured ectopic pregnancy can lead to massive haemorrhage and death. The presentation is variable. The combination of pain, vagina bleeding, and shock is the classical presentation of ruptured ectopic pregnancy. Some patients may have syncope attacks while others may just have a sudden excruciating abdominal pain. This may be associated with severe cardiovascular compromise.

Patients usually present with the ruptured variety with attendant peritoneal flooding and its clinical consequence unlike the situation in the developed countries where up to 75 % are unruptured (Kouam et al, 1996, Morcau et al, 1995). This is because they present early to a health facility. Ectopic pregnancy has a protean manifestation (Ilesanmi & Shobowale, 1992). The delayed diagnosis of ruptured ectopic pregnancy is an important cause of death in women (Fowler, 2006). A dilemma may arise when there is a properly and reliable diagnosis of ectopic pregnancy with a live foetus. Nevertheless, the magnitude of complications of ruptured ectopic gestation is enormous. Delaying the patient of an a reliable diagnosis of ectopic pregnancy to a time of rupture or imminent rupture in other to justify not tampering with life may be considered unethical and illegal (Dickens at al, 2003).

**Abdominal pain**: Patients with ectopic pregnancy may have abdominal pain. This may be sharp or sudden tearing pain in the patient with ruptured ectopic pregnancy. It may start in any of the flanks or iliac fossa depending on the affected fallopian tube if the ectopic pregnancy is implanted in the fallopian tube. This gradually moves towards the umbilical region and becoming generalised. When it is an unruptured ectopic pregnancy, or slowly leaking, the abdominal pain is dull and continuous. Depending on the intensity of the pain, some patients may seek medical attention now. Ectopic pregnancy can lead to massive haemorrhage or death. It mimics virtually every condition that causes acute abdomen in women of the reproductive age group (Kigbu et al, 2006). Abdominal pain is the commonest symptom of ectopic pregnancy. The pain may be present even prior to rupture. When there is a rupture, the pain becomes sudden with each bleeding continuous and extensive intraperitoneal bleeding, the pain becomes generalized because of irritation of the diaphragm by the haemoperitoneum can cause shoulder tip pain. The abdominal pain is caused by distension of the gravid tube, by its efforts to contract and expel the ovum and by irritation of the peritoneum by leakage of blood.

Management and Outcome of Ectopic Pregnancy in Developing Countries 119

**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.

**Haematocele**: This is due to progressive bleeding with haematoma formation in the pouch

**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

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

**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

**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

**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

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

of Douglas (Coutrin et al, 2007).

most commonly in rural areas.

haemorrhage (Pitkin et al, 2003).

**8.1 Investigations** 

to the condition.

**8. Management of ectopic pregnancy** 

only valuable if it is positive (Coutin et al, 2007).

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

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

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

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

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

**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 diagnosis aided by ancillary diagnostic tests.
