UNIVERSITY OF KABIANGA- KAPKATET CAMPUS

DEPARTMENT OF CLINICAL MEDICINE

COURSE CODE: BCM 424

COURSE NAME: REPRODUCTIVE HEALTH EMERGENCIES

REG NO: BCM/K/0032/2020

NAME: DAVIS MASUGU OMBUI

TASK: CAT 1

Question: discuss ectopic pregnancy in Kenya (20marks)

 1. Discuss ectopic pregnancy in Kenya (20marks)

Introduction

An ectopic or extra uterine pregnancy is one in which the blastocyst/fertilized ovum implants

anywhere other than the endometrial lining of the uterine cavity. 98% implant in the fallopian tube,

with 80% occurring in the ampulla segment. Other locations include, but are not limited to, the

ovary, cervix, and abdomen.

Ectopic pregnancies remain an important cause of morbidity and mortality in Kenya, a life

threatening condition. In Kenya sometimes ectopic pregnancy is referred as “mimba ya mishipa”

or tubal pregnancy

Tubal pregnancy-tubal abortion, tubal rupture, spontaneous resolution.

Epidemiology

Ectopic pregnancies remain an important cause of morbidity and mortality in Kenya and

worldwide. In Kenya, the incidence of ectopic pregnancy is estimated to be between 1.5% and

2.5% of all pregnancies. The incidence is higher in women who have had a previous ectopic

pregnancy, pelvic inflammatory disease, or tubal surgery.

Etiology of ectopic pregnancy in Kenyan women

Risk factors predisposing Kenyan women to ectopic pregnancy

 Pelvic inflammatory disease

 Tubal corrective surgery

 Previous family planning

 In utero DES exposure

  Intrauterine device

 Documented tubal pathology

 Infertility

 Previous genital infection

 Multiple partners

 Previous pelvic or abdominal surgery

 Smoking

 Intercourse before 18years

Mechanical factors associated with ectopic pregnancy in Kenyan women

 Congenital: long narrow tube, diverticula, accessory ostia

 Traumatic: operation on the tube- salpingoplasty, tubal reversal following ligation

 Inflammatory: chronic salpingitis

 Neoplastic: narrowing of the tube by a fibroid or a broad ligament tumor

 Functional as tubal spasms or antiperistalsis contractions

 Endometriosis in the tube, encourages embedding of the fertilized ovum

Pathophysiology of ectopic pregnancy in Kenyan women

Physiology of normal implantation

After ovulation, ovum is picked, swept by ciliary action towards ampulla where fertilization

occurs. Zygote, cleavage division in 3-4days, morula 8-12 cell stage, embryo to uterine cavity for

up to 72hours. It does enters the uterus for implantation in uterine cavity in normal positioned

pregnancy. hCG (trophoblast) mothers serum 1 week after implantation the levels doubles every

36-48hrs
Abnormal implantation

Delay or obstruction of the passage of fertilized egg down the fallopian tube to the uterus causes

implantation in tube or ovary or peritoneal cavity causing ectopic pregnancy. Eventually fails to

develop, hCG fails to raise dramatically.

Pathophysiology

Separation of the gestational sac from the tubal wall leading to degeneration thus fall of hCG level,

regression of the corpus luteum, drop in the estrogen and progesterone level leading to separation

of the uterine decidua with uterine bleeding.

Types of ectopic pregnancy

 Tubal (95%-98%)

 Non tubal (2-5%)

 Heterotrophic( 1/10000

Fate of tubal pregnancy

 Tubal mole:

 Sac is surrounded by blood clot and retained

 Chronic ectopic pregnancy/ involution

 Tubal abortion: ampulla

 Separation of sac- expulsion into peritoneal cavity through ostium

 Rarely, reimplantation of conceptus occurs in another abdominal structure-

secondary abdominal pregnancy

 Tubal rupture: isthmus

  Rupture in anti-mesenteric border- profuse bleeding- intraperitoneal hemorrhage

 Rupture in mesenteric border- broad ligament at hematoma.

Clinical findings

 Classical; symptoms triad

 Abdominal pain

 Amenorrhea

 Abnormal vaginal bleeding

Others

 Breast tenderness

 Nausea

 Urinary frequency

 Acute ectopic

Apart from the classical triad patient may present with;

 Features of shock

 Danforth sign- shoulder pain on inspiration, due to irritation of the diaphragm by a

hem peritoneum in ruptured ectopic pregnancy

 Cullen sign- ecchymosis or bruising around the umbilicus indicating intraperitoneal

or retroperitoneal hemorrhaging

 Per abdominal exam- abdominal tenderness, guarding, bowel sounds decreased or

absent

 Per vaginal exam- uterus bulky, fornix tender full, pod full, adnexal mass, cervical

motion tenderness “jumping sign”

 Chronic ectopic

 History of acute attack of pain from which she has recovered

 On examination- ill looking without signs of shock

 Per abdomen exam- irregular mass, tenderness.

 Per vaginal exam- uterus may be normal/bulky, ill-defined mass may be felt

through fornix

 Unruptured

 Difficult to diagnose and high degree of clinical suspicion is needed during

laparoscopy/laparotomy

 Clinical features- delayed periods, spotting with lower abdominal discomfort

 Per abdomen- tenderness in lower abdomen

 Per vaginal- uterus normal size, small tender mass be felt in the fornix

Differential diagnoses for ectopic pregnancy in Kenya

Early pregnancy complications (threatened, incomplete, or missed abortion), placental polyp, or

hemorrhagic corpus luteal cyst are difficult to diagnose.

Any sexually active woman in the reproductive age group who presents with pain, irregular

bleeding, and/or amenorrhea should have ectopic pregnancy as a part of the initial differential

diagnosis.

Non gynecological differentials

 Appendicitis( perforated)

 Acute pancreatitis

 Myocardial infarct
  Pelvic abscess

 Splenic rupture

 Perforated gastric or duodenal ulcer

Gynecological differentials

 Septic abortion

 Threatened abortion

 Pyosalpinx pelvic abscess

 Twisted ovarian cyst

 Acute pelvic inflammatory disease

 Rupture of follicle or corpus luteum cyst

 Degenerating leiomyoma

 Retroverted gravid uterus

Diagnostic Evaluation done in Kenyan hospital to diagnose ectopic pregnancy

 Pregnancy Test.

 Ultrasound-transabdominal, transvaginal.

 Culdocentesis-hemoperitoneum.

 Uterine curettage.

 Direct visualization, which is done most commonly via laparoscopy.

 Supportive Evaluations-complete blood count, GXM

Management of ectopic pregnancy in Kenya

 Expectant management

 Medical management
  Surgical management

 Emergency management

Expectant management

Criteria for selection (RCOG-green top-21-guideline)

 Asymptomatic patient

 Hemodynamically stable

 <100ml fluid in the pouch of Douglas

 Lower beta hCG value <1000IU/ml

 Adnexal mass <3cm without cardiac activity

 Pregnancy of unknown location

These patients must be fully compliant and must be willing to accept the potential risks of tubal

rupture. Success rate is 60% with decreasing beta hCG titer.

Monitoring

 Initial follow-up: twice weekly with serial hCG measurements weekly by TVS

 By the first week: drop in hCG level, adnexal mass size, otherwise reassess the options

(medical/surgical)

 If the fall of hCG and reduction in size of adnexal mass satisfactory: weekly hCG and

TVS till hCG falls <20IU

 45-70% of PUL resolve spontaneously with expectant management

Medical management

Selection criteria
  Minimal symptoms/ hemodynamically stable

 No signs or symptoms of active bleeding/ hamoperitoneum

 hCG <3000IU

 Normal CBC,RFT, LFT

 Size <4cm

 Absence of cardiac activity

 Persistent ectopic after conservative surgery

 Good compliance ad follow up can be assured

Exclusion criteria

 Any hepatic dysfunction

 Thrombocytopenia (<100000)

 Blood dyscrasia (WBC<2000)

 Difficulty/unwillingness of patient for prolonged follow up

 Ectopic mass >4cm

 Presence of cardiac activity

 Women on concurrent corticosteroid therapy

Systemic management

IV, IM or orally- methotrexate

Folic acid antagonist that inhibits DHFR enzyme thus depleting the stores needed for DNA/RNA

synthesis during trophoblast proliferation.

Locally management
Salphingocentesis (laparoscopic direct injection, retrograde salpingography)

RU-486, PgF2 alpha, MTX, KCl, hyperosmolar glucose, antinomycin D

 Advantages

 Increased concentration at local site

 Lesser systemic side effects

 Increased fertility

 Shorter hospital stay

 Disadvantages

 Beta hCG twice weekly till <10IU/l

 TVS weekly till 4-6 weeks

 hCG after 6 month

Surgical treatment

Indications

 Not a suitable candidate for medical therapy

 Failed medical therapy

 Heterotrophic pregnancy with viable intrauterine pregnancy

 Hemodynamically unstable and needs immediate treatment

Surgical approach- laparoscopy or laparotomy

 Hemodynamically stability

 Size and location of ectopic mass

 Surgeons expertise
Conservative and extirpative

Complications of ectopic pregnancy in Kenyan women

 Hemorrhagic shock- coma

 Anemia

 Pelvic adhesions

 Secondary infertility

 Increased risk of repeat ectopic

 Septicemia- renal failure

Prevention and prognosis

Prevention of ectopic pregnancy involves reducing risk factors such as sexually transmitted

infections, smoking, and multiple sexual partners. Women who have had previous ectopic

pregnancy should be monitored closely during subsequent pregnancies.

The prognosis of ectopic pregnancies depends on size and location of the pregnancies as well as

the patient overall health. With early diagnosis and treatment, the prognosis is generally good.