**12. Conclusion**

126 Ectopic Pregnancy – Modern Diagnosis and Management

pelvic examination and tenderness of the right adnexa. Abdominal ultrasound suggested right ovarian cyst torsion. Laparatomy findings was a right ruptured ectopic pregnancy.

32-year-old nullipara presented with complaints of bleeding altered blood per vaginum of four weeks duration with associated offensive discharge, abdominal pain of three weeks duration, generalized body weakness, abdominal swelling, two episodes of fainting attacks and vomiting of one-week duration. She never used any form of contraceptives and has had two terminations of pregnancies. On examination, she was pale with an unrecordable blood pressure at presentation. She was resuscitated with intravenous normal saline and the blood pressure became 100/ 60 mmhg. Abdomen was distended with guarding. The abdominal organs were difficult to palpate due to tenderness with the presence of ascitis evidenced by positive shifting dullness, the cervix was firm and uneffaced. Uterus was bulky and the left adnexa were bulky and tender on pelvic examination. The packed cell volume was 10 % with a positive pregnancy test. At laparatomy, there was haemoperitoneum of 3L with a right ruptured ampullary gestation with normal right ovary. Right partial salpingectomy

A 26-year-old nulliparous undergraduate presented with six weeks of amenorrhea, fainting attacks, and severe abdominal pain. On examination, she was in shock with a fast and thready pulse and unrecordable blood pressure. She was resuscitated with 1.5 L of normal saline. Packed cell volume was 20%. Pelvic examination showed a bulky uterus with cervical excitation tenderness and full pouch of Douglas. A diagnosis of ruptured ectopic gestation was made. She was immediately planned for laparatomy. At laparatomy, there was haemoperitoneum of 3L with a ruptured left ovarian ectopic pregnancy. Left partial salpingecyomy with left oophprecytomy was performed. She received two units of blood

A 35-year-old Para two woman with one previous caesarean section was diagnosed to have slowly leaking ectopic pregnancy. She refused surgical intervention. After surfing the internet, she found out that ectopic pregnancy could be treated medically. Without finding out the criteria for medical therapy of ectopic pregnancy, she was able to obtain methotraxate on her own. One week later, she collapsed while at work and was rushed to a nearby hospital where emergency laparatomy and right salpingectomy for ruptured ectopic

Ectopic pregnancy results in significant morbidity for the mother and inevitable loss of the pregnancy. Apart from foetal wastage, maternal morbidity and mortality occurs, ectopic pregnancy is also associated with repeat ectopic gestation and impairment of subsequent fertility (Abdul, 1999). The survival rate of ectopic pregnancy has improved with great improvements in anaesthesia, antibiotics, and blood transfusion. Maternal morbidity and mortality can be reduced with an early diagnosis of ectopic pregnancy. Early diagnosis before tubal rupture is important in reducing mortality as well as preserving the potential

intra-operatively and one unit of whole blood postoperatively.

**10.3 Case 3** 

was performed.

**10.4 Case 4** 

**10.5 Case 5** 

pregnancy was performed.

**11. Prognosis** 

Ectopic means out of place. The egg settles in the fallopian tube in more than 95% of cases. This is why it is commonly called tubal pregnancy. The egg can also implant in the ovary, abdomen, or cervix. None of these areas has as much space for nurturing tissue as a uterus for a pregnancy to develop. As the foetus grows, it will eventually burst the organ that containing it causing severe bleeding and endanger the mothers' life.

Ectopic pregnancy remains the leading cause of maternal morbidity and mortality in the first trimester of pregnancy and is a significant cause of reproductive failure in Nigeria (Igberase et al, 2005). It remains a major public health challenge among women of the reproductive age group in this region. Community based comprehensive health education programme focusing on contraception, sex education, prevention and treatment of post abortal sepsis, pelvic inflammatory disease and puerperal sepsis are urgently needed. It continues to be an important contributor to maternal morbidity and mortality and early wastages in the first trimester of pregnancy in our environment mainly because of the late diagnosis because of seeking for medical help late with attendant risk of tubal rupture and haemorrhage (Igberase, 2005, Kora et al, 1996). A high prevalence of sexually transmitted infections and unsafe abortions results in a high incidence of ectopic pregnancy. Poverty, ignorance, late presentation, non-availability of modern diagnostic tools is the basis of significant improvement in the detection and prompt treatment of ectopic pregnancy in developing nations. Emphasis should be placed on prevention and early detection as to give patients the opportunities for tubal conservative treatment. The incidence of ruptured ectopic pregnancy is decreased in westernised and developed countries because of increased awareness of the disease condition, early referral and better techniques and diagnostic instruments such as quantitative beta human chorionic gonadotrophin and vagina ultrasound probe.

The importance of ectopic pregnancy in our environment is peculiar because rather than join the global trend of early diagnosis and conservative approach in management we are challenged by late presentations with rupture in more than eight percent in most of the cases (Gharoro & Igbafe, 2002).

Promotion of family planning, early and prompt treatment of pelvic inflammatory disease and good quality obstetric care could be important in preventive intervention measures (Adesiyun & Adze, 2001). The high incidence of ectopic pregnancy may be related to a higher incidences of tubal disease notably salpingitis. Technological advances have led to earlier diagnosis of ectopic pregnancy with a decline in morbidity and mortality in developed countries. Early presentation, high index of suspicion and use of modern diagnostic techniques will improve overall clinical outcome of patients. Considerable progresses have been accompanied in the diagnosis and treatment of ectopic pregnancy (Ayoubi & Fanchin, 2003). The combination of abdominal pain, vaginal bleeding, and shock is the classical presentation of ruptured ectopic pregnancy though the presentation can be varied. Although advances in earlier diagnosis have led to reduced case fatality rates and conservative laparoscopic treatments have enabled improved outcomes (Doyle et al, 1990). Ectopic pregnancy accounts for a sizable proportion of infertility and ectopic reoccurrence (Dolye et al, 1990). Health education of women in the reproductive age on safe sex and

Management and Outcome of Ectopic Pregnancy in Developing Countries 129

from ectopic pregnancy in Africa. Transportation to an appropriate health facility can be a cause of late presentation. Ectopic pregnancy should be considered a relevant public health indicator in developing countries providing an overall picture of the capacity of a

Dr Emmanuel Etriem and Dr Aliyu Abdullahi both medical officers at General hospital

Abasiattai AM, Utuk MN, Ugege W. (2010). Spontaneous Heterotropic Pregnancy with

Abedi HO, Okonta PI, Igberase GO. (2010). Heterotropic Gestation: Successful Vaginal Term

Aboyeji AP, Fawole AA, Ijaiya MA. (2002). Trends in Ectopic Pregnancy in Ilorin, Nigeria.

Abudu OO, Egwatu JI, Imosemi OO, Ola ER. (1999). Ectopic Pregnancy: Lagos University

Abudu OO, Olatunji AD. (1996). A Review of Maternal Mortality in Lagos University

Adesiyun GA, Adze J, Onwuhafua A, Onwuhafua PI. (2001). Ectopic pregnancies at

*Journal of Obstetrics and Gynaecology*. Vol 18. No 2. Pp: 82-86. ISSN 0189-5178 Airede LR, Ekele BA. (2005). Ectopic Pregnancy in Sokoto, Northern Nigeria. *Malawi Medical* 

Aliyu JA, Eigbefoh JO, Mabayoje PS. (2008). Heterotropic Pregnancy: A Report of Two

Amoko DH, Buga GA. (1995). Clinical Presentation of Ectopic Pregnancy in Transkei, South

Anorlu RI, Oluwole A, Abudu OO, Adebajo S. (2005). Risk Factors for Ectopic Pregnancy in

*Journal*. Vol 17. No 1. Pp: 14-16. ISSN 1995-7262, online 1995-7270

*of Medicine*. Vol 19. No 2. (April-June 2010). Pp 236-238. ISSN 1115 – 2613 Abdul IF. (1999). Ectopic Pregnancy in Ilorin, Nigeria. *International Journal of gynecology and* 

Tubal Rupture and Delivery of a Live Baby at Term: A Case Report. *Nigerian Journal* 

Delivery after Laparatomy in the First Trimester. *Nigerian Journal of General Practice*.

*Nigerian Journal of Surgical Research*. Vol 4. No 1-2. (March-June 2002). Pp 6-10. ISSN:

Teaching Hospital Experience over a Five-Year Period. *Nigerian Quarterly Journal of* 

Teaching Hospital. *Nigerian Medical Practitioner*. Vol 31. Pp: 12-6. ISSN 0189-

Ahmadu Bello University Teaching Hospital, Kaduna, Northern Nigeria. *Tropical* 

Cases. *Nigerian Journal of Clinical* Practice. (March 2008). Vol 11. No 1. Pp: 85-87.

Africa. *East African Medical Journal.* Vol 72. No 12. (December 1995). Pp: 770-3. ISSN

Lagos, Nigeria. *Acta Obstetricia et Gynecologica Scandinavica*. Vol 84. No 2. (February

Aliero Kebbi State, Nigeria at the time of the study are both acknowledged.

*obstetrics* Vol 66. Pp 179-80. ISSN 0020-7292

*Hospital Medicine*. Vol 9. Pp: 100-3. ISSN 0189-2657

Vol 8. No 5. Pp 8-10. ISSN 1118-4647

health system to deal with the diagnosis.

**13. Acknowledgement** 

1595-1103

0964

ISSN 1119-3077

2005). Pp: 184-8. ISSN 1600-0412

0012-835X

**14. References** 

eradication of unsafe abortion and early treatment of pelvic infections and good quality obstetric care will prove useful as preventive measures.

A high index of suspicion and up to date diagnostic methods, proper sex education, prevention of unwanted pregnancy, prevention and proper treatment of sexually transmitted infections will reduce the incidence of ectopic pregnancy. Ectopic pregnancy presents a major health problem for women of childbearing age. It is the result of a flaw in the human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in death of the foetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well.

Ectopic pregnancy should be considered a relevant public health indicator in developing countries. An overall picture of the capacity of a health system to deal with the diagnosis and treatment of emergencies especially in the field of obstetrics and gynaecology (Goyaux et al, 2003). Ectopic pregnancy remains a major cause of maternal mortality and morbidity as well as early foetal wastage in Nigeria and other developing countries (Okunlola et al, 2006, Makinde et al, 1990, Baffoe & Nkyekyer, 1991, Abdul, 1999, Elhelw, 2003). A classical ectopic pregnancy does not develop into livebirth. Ectopic pregnancy can be difficult to diagnose because symptoms often mimic those of a normal early pregnancy. The first warning signs of an ectopic pregnancy are often pain or vaginal bleeding. Ectopic pregnancies continue to be a significant cause of maternal morbidity, mortality, and reproductive failure in Nigeria (Faleyimu et al, 2008). Ipsilateral ectopic pregnancy occurs rarely and may be difficult to diagnose in low resource settings where there are no diagnostic tools especially vaginal ultrasound probe. When vaginal ultrasound probe is available, there are no trained medical personnel to operate such sophisticated equipments. There are few reported cases of ectopic pregnancy on a previous ectopic pregnancy stump. Ectopic pregnancy may pose a diagnostic dilemma where facilities are not available. In developed nations, treatment options have shifted from laparatomy to conservative surgical and non-surgical techniques. The availability of high-resolution ultrasonography with vaginal transducers in combination with the discriminatory zone of the beta subunit of human chorionic gonadotrophin has increased early diagnosis of the ectopic pregnancy in centres, which have such facilities (Ory, 1992). As the ability to diagnose ectopic pregnancy improves, physicians will be able to intervene sooner, preventing life threatening sequalae and extensive tubal damage, which could preserve future fertility. Already with improving technology, physicians are treating ectopic pregnancies with minimally invasive surgery or no surgery at all. Physicians have been able to reduce the mortality rate secondary to ectopic pregnancy despite its growing incidence.

Efforts to improve early diagnosis prior to tubal rupture however remain a great challenge in the developing countries and under equipped hospitals. The future fertility outcome is improved if the contra-lateral tube is normal. However, it is subjective to assess the normalcy of the tube by gross assessment since the pathology that usually predisposes to the ectopic pregnancy is intraluminal and may be present in the contralateral tube. Nevertheless, the practice of examination and documentation of the status of the contra-lateral tube during laparatomy for ectopic pregnancy is important. Late diagnosis leading to almost all cases of major complications and emergency surgical treatments are key elements accounting for such high fatality rates in women suffering from ectopic pregnancy in Africa. Transportation to an appropriate health facility can be a cause of late presentation. Ectopic pregnancy should be considered a relevant public health indicator in developing countries providing an overall picture of the capacity of a health system to deal with the diagnosis.
