A couple of days ago, I got this phone call from a retired military officer, a good friend of mine who we enjoyed beer drinking together. His likes a particular brand and never went beyond two bottles. He would get up, raise his right hand and say ‘hail Hitler’ and then take a bow.
Sam has no problems, always a jolly fellow. So when his call came through that his friend’s wife had ectopic pregnancy, my first reaction was whether he knew what he was talking about. He said they had already done an ultrasound scan, which confirmed the diagnosis. Then the next question from him: What was likely to be the financial implication? These days, because of the current hardship, it always boils down to that. I was polite and told him that I couldn’t put a figure on a patient I had not seen. He pleaded with me that I should be lenient when they came. I told him there would be no problem with that.
After more than 24 hours of waiting, I called my friend to inform him that I had not seen his people. He said he would check on them and get back to me. His response later was that they were not at home and wouldn’t pick their calls. Apparently, they had moved on to a supposedly clement weather where they would be favoured.
Just when their narrative was fading away from my trending challenges. I had an emergency call from a sister health facility to come and perform a laparotomy on a woman who had ectopic gestation. And here she was! As a professional, you just look at the records, confirm your diagnosis and proceed with the surgery. I did just that. Patients have their ways and mentality. Wait for it. The deposit for the surgery was even more than the total bill my friend was negotiating for. Lesson? Do not shave a man’s hair in his absence.
Ectopic gestation is a complication of pregnancy in which the developing embryo is attached outside the uterus. Usually, there is a history of the patient missing her period; then abdominal pains with sometimes bleeding from the vagina. The nature of the pains varies from sharp, dull to just cramps. In advanced cases, with massive intra-abdominal bleeding, the patient may present in shock and shoulder pains if the pool of the bleeding has extended to the Morrison’s pouch, a space between the visceral organs and the diaphragm.
Ectopic pregnancy results, when hair-like CILIA, located on the internal surface of the fallopian tube, fails to propel the fertilised egg into the uterine cavity. This largely results when there is depletion as a result of inflammation of the fallopian tube known as salpingitis.
In our environment, especially during the 80s, the organism implicated in this lesion is Neissera gonorrhea. When a man is infected with this organism, the symptoms of pains and purulent discharge from the penis usually manifest within 24 hours after contracting the bacteria. In females, the situation is different where the infection goes unnoticed in terms of clinical symptoms for sometimes until perchance the next partner comes complaining. This delay in therapeutic intervention means chronic inflammation and further damage to the tubes. Other factors associated with ectopic gestation include pelvic inflammatory disease. This is an umbrella term for any infection that affects the genital tract of the female, starting from the vagina through the uterine cavity to the fallopian tubes. Any organism can be implicated in PID. Tubal surgeries, management of infertility, previous iatrogenic abortion (D&C), smoking and previous exposure to steroid, like Diethyl Stilboesterol, are all associated ectopic pregnancy.
When the tube is damaged, the movement of fertilised egg is halted and it becomes implanted there and continues to grow. At a point in time, the future placenta tissue will burrow through the fallopian tube rupturing it and leading to intra-abdominal bleeding. The onset of symptoms to a large extent depends on the location of pregnancy. Those at cornal end, close to the uterine artery usually present early while those at the Fimbriae end have insidious onset.
The diagnosis of ectopic pregnancy in our environment, in the early stage of the condition, is based on a high index of suspicion. As a rule, the presence of Human Chorionic Gonadotropins in the blood is indicative of the presence of pregnancy. With a positive pregnancy test, an ultrasound scanning should be done. The preferred route is the one done with a probe in the vagina known as TRANSVAGINAL ULTRASONOGRAPHY. The diagnosis is made when if there is a mass at the flank of the uterus and the uterus itself is empty. One be cautious because both intra uterine and extra uterine pregnancy can coexist.
Until lately, most astute care givers after obtaining a good history and physical examination would simply stick a needle into the abdomen and aspirate unclotted blood. That was the gold standard them. In making a diagnosis of ectopic pregnancy the caregiver should not wear a straight jacket. Some of the conditions that can mimic ectopic gestation include twisted ovarian cyst, acute appendicitis and miscarriage. These conditions must be ruled out and in situations when diagnostic features appear murky, the caregiver will do well to use an incision that would give good exposure to pelvic organs during surgery.
The management of ectopic pregnancy in our environment currently is basically surgery. There are two procedures involved here. The first, easiest and safest, is to remove the diseased tube together with the pregnancy or rather gestational mass. This procedure is known as SALPINGECTOMY. The second approach is to open up the fallopian tube, expunge the pregnancy and then repair the tube. This is known as SALPINGOSTOMY. This in reality is a desperate procedure that should be left for very experienced surgeons and performed in centres that have adequate backups and quick response in case of emergency. As a matter of convenience if the second fallopian tube is not diseased one is better off with salpingostomy.
Lately some caregivers have been trying to popularize LAPARASCOPIC SURGERY for ectopic gestation because of its cosmetic appeal Good when diagnosis is made early and safe for those trained for it. By and large ectopic gestation is becoming common among married mothers these days. Even though there are no readily available statistics to boot for now, the prevalence of gonorrhea has gone down. Chlamydia trachomatis another culprit is not that virulent, yet the disturbing trend. One wonders whether there is anything we are not doing right? Or when reversed, are we neck deep in something sinister?