-COMPLICATIONS OF ECTOPIC PREGNANCIES
--IMMEDIATE OR SHORT TERM COMPLICATIONS
--MEDIUM AND LONG TERM COMPLICATIONS
An ectopic pregnancy is an abnormal pregnancy in which a fertilized egg also known as the embryo, attaches itself into any other parts of the female genital tract or the abdomen other than the endometrium or the inner lining of the uterus. While they can be divided into various types, based on location of the ectopic pregnancy in the female genital tract, see DEFINITION AND TYPES OF ECTOPIC PREGNANCIES, they can also be divided based on presentation at the hospital into ruptured, non ruptured and slow leaking ectopic pregnancies. Most of the complications of ectopic pregnancies are seen following an unsuspected ruptured ectopic pregnancy. A ruptured ectopic pregnancy refers to an ectopic pregnancy that has outstretched its confining structures resulting in a significant tear followed by sudden and massive bleeding into the abdomen, often times, presenting with a history of sudden and severe abdominal pain, followed by a history of collapse and fainting attacks.This bleeding, if not promptly stopped by surgery can lead to the following complications:
COMPLICATIONS OF ECTOPIC PREGNANCIES
These can be divided into immediate or short term complications to include those that occur soon after the onset of the disease if not properly managed and to long term complications to include those that develop many months or years after the treatment of ectopic pregnancy either as a result of side effect of surgery or of the disease itself.
IMMEDIATE OR SHORT TERM COMPLICATIONS
1. CARDIOVASCULAR SHOCK
This refers to sudden inability of the heart to pump blood effectively to all the organs of the body, due to massive loss of blood into the abdominal cavity associated with ruptured ectopic pregnancy. When this happens a patient may slip into unconsciousness and may not be rousable until adequate resuscitation is done with fluid and blood. Usually, an emergency surgery (laparotomy) is usually required to stop the bleeding.
This refers to a reduction in the quality and amount of red blood cells circulating in the blood. These cells transport oxygen from the lungs to the body. Following massive loss of blood, there is a reduction in the haematocrit or packed cell volume which is a measure of the amount of red blood cells in the blood. This, if not promptly and adequately corrected can lead to an acute anemic state that can can cause death as vital organs are devoid of oxygen or if sub optimally corrected can lead to a chronic anaemic state, with features of weakness, panting, fatigue and heart failure.
3. HEART FAILURE
This refers to a gradual deterioration of the heart in performing its function of pumping blood into the various organs. It also presents as being easily fatigued, leg swelling, breathlessness on doing daily chores in mild to moderate cases and breathlessness on lying flat in severe cases.
4. RENAL FAILURE
Due to the profound shock and prolonged reduction in perfusion of the kidneys with blood during the period of shock associated with the massive bleeding, the kidneys may become compromised which if treated early may be reversed, but if not corrected early can result in permanent kidney damage with dire consequences.
5. DISSEMINATED INTRAVASCULAR COAGULOPATHY
This is usually a complication of massive bleeding in one part of the body for example in the abdomen in this case, resulting in bleeding from other various body cavities including the mouth, the kidneys, and virtually across all other parts of the body. This is as a result of massive use up of blood factors and blood cells responsible for maintaining and forming blood clots at the initial site of the bleeding which in this case is in the abdomen. This can further complicate any of the above complications and may lead to death if not handled aggressively.
6. ANAESTHETIC COMPLICATIONS
In ruptured cases of ectopic pregnancy, espcially when severe, surgery is usually indicated. Such as in any other main surgical procedures, complications can occur while performing anaesthesia, which can be worsen by any of the already above complications or may not have anything to with them.
7. SIDE EFFECTS OF MEDICATIONS USED IN TREATING NON RUPTURED ECTOPIC PREGNANCY
Other uncommon complications of ectopic pregnancies include the side effects of the drugs used in the medical management of non ruptured ectopic pregnancies. They include hair loss, diarrhoea, infection from suppression of cells that fight infections in the blood i.e. the white blood cells, anaemia from damage to the cells that carry oxygen round the body i.e. red blood cells, direct damage to the liver, kidneys, easy bruising and bleeding from the skin and mouth ulcers. Luckily these side effects are uncommon and rare at the doses used for the medical treatment of ectopic pregnancies. There are also medication that can be used to prevent and treat them in severe cases.
8. Non ruptured ectopic pregnancies managed conservatively or medically are also at risk of rupture, which if not properly followed up or monitored can result in any of the above complications if it subsequently ruptures.
It may occur directly following any of the above complications. Luckily, due to the advent of ultrasound scan that facilitate early detection of many ectopic pregnancies, the improvement in blood transfusion services, improvement in the methods of giving anaesthesia and improved surgical management of ectopic pregnancies, there have been a significant reduction in cases of death due to ectopic pregnancies in recent years, but a real threat still looms in cases that present late in hospitals or in centres where the above listed facilities are absent.
MEDIUM AND LONG TERM COMPLICATIONS
As mentioned above, these are complications due either to the ruptured ectopic pregnancies or its attending surgery that occur many months to years later. They include:
1. ABDOMINAL OR PELVIC INFECTION AND ABSCESS
This refers to infection and subsequent formation of pus respectively, within the abdominal and or pelvic cavity usually following the surgical management of a ruptured ectopic pregnancy associated with massive bleeding and inadequate evacuation of intra-abdominal blood clots. The abdomen and the pelvis is a large crevice where a lot of blood can accumulate. Because of other organs and structures within this cavity, the evacuation of blood is usually incomplete during surgery, hence measures may be taken to drain off these blood after surgery, although in many cases, the body is usually able to break down these blood and reabsorb some of the fluid present in it.
2. PELVIC ADHESIONS
This is also a long term complication of the surgical management of a ruptured ectopic pregnancy that is associated with moderate to severe pelvic pain and infertility. Here scars and fibrotic bands are formed that hold the pelvic organs in unnatural position altering the normal relationship between these pelvic organs.
Ectopic pregnancy can result in direct tubal damage necessitating the removal of any of the affected tubes during surgery, therefore halving the fertility chance of a woman as she becomes limited to only one tube. With a higher than the average chance of recurrence in the same individual, if it re occur in the other tube, it may totally prevent any chance of a natural conception especially if treatment were by a surgical method requiring the surgical removal of the second tube. Such infertility can only be treated by invtro-fertilization and embryo transfer.
4. INTESTINAL OBSTRUCTION
This is usually a delayed complication of any previous abdominal surgery including that for the removal of an ectopic pregnancy. It refers to the sudden inability to move food and other intestinal contents through the intestine resulting in abdominal distension, pain, vomiting, and constipation. It may require surgical intervention to prevent further complications such as intestinal rupture and infection.
6. PERSISTENT TROPHOBLASTIC TISSUES
This refers to the continuous growth and expansion of the cells that form the placenta tissue of the ectopic pregnancy long after the death and absorption of the embryo. This can result in bleeding into the abdominal cavity, pain and discomfort. It is associated with persistent positive pregnancy test long after the treatment of the ectopic pregnancy. The treatment of choice is with methotrexate injection to destroy the placental cells until the pregnancy test is negative.
Having discussed extensively the various grave side effects of ectopic pregnancies, it is important to ensure that ectopic pregnancy is not left undiscovered until after it becomes complicated by bleeding. In order to prevent such, any woman who misses her period should confirm the pregnancy by doing a pregnancy test within 4 weeks and if positive should do a transvaginal scan at about 5 to 6 weeks of missing her menses in order know the exact location of the pregnancy. This will afford us the opportunity of detecting and treating early an unruptured ectopic pregnancy before any of the above complications arises. Measures to prevent ectopic pregnancies include lifestyle bahaviour tailored to avoiding the common risk factors of ectopic pregnancies, which include smoking, sexually transmitted diseases, among many others. Although in some people, no known risk factors are identified. For more information on this please read TUBAL ECTOPIC PREGNANCY: AN OVERVIEW OF THE CAUSES, RISK FACTORS, PRESENTATION AND COMPLICATIONS.