**10. Case series**

#### **10.1 Case 1**

124 Ectopic Pregnancy – Modern Diagnosis and 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

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

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

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

**8.4 Postoperative management** 

**8.5 Blood transfusion** 

necessary. Broad-spectrum antibiotics are administered.

filtered blood, and transfused to the patient via blood giving set.

maintain perfusion and haemodynamic stability should be commenced.

**8.6 Patients who refuse blood transfusion** 

**9. Discussion** 

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.

#### **10.2 Case 2**

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

Management and Outcome of Ectopic Pregnancy in Developing Countries 127

for future fertility through conservative management (Gazvani, 1996). In many cases, early diagnosis allows a conservative approach resulting in a normal macroscopic appearance and

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

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

containing it causing severe bleeding and endanger the mothers' life.

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

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

thereby preserving tubal potency and function.

**12. Conclusion** 

cases (Gharoro & Igbafe, 2002).

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

#### **10.3 Case 3**

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 was performed.

#### **10.4 Case 4**

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 intra-operatively and one unit of whole blood postoperatively.

#### **10.5 Case 5**

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 pregnancy was performed.

## **11. Prognosis**

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 for future fertility through conservative management (Gazvani, 1996). In many cases, early diagnosis allows a conservative approach resulting in a normal macroscopic appearance and thereby preserving tubal potency and function.
