Early Diagnosis of Ectopic Pregnancy to Prevent Complications - Essay Example

?Ectopic pregnancy: Preventing complications through early diagnosis Introduction Challenges on health care for women have always been the concern ofthe global health community. Maternal and child health has been a focus of innovations to improve the health of child-bearing mothers worldwide to ensure optimum child birth. The increasing number of mortality and morbidity rate of maternal cases are still on the verge of hitting the scale and health care professionals and organizations are on the race to outwit and outran the growing maternal complication numbers and to finally suppress and not just to decrease its prevalence. According to a worldwide systematic analysis on the causes of maternal death, haemorrhage is the leading cause of maternal death in Africa and Asia having more than 30% deaths while ectopic pregnancy accounts to less than 1% of deaths in developing countries and almost 5% in developed countries (Khan et al., 2006, p. 1072). Although ectopic pregnancy only accounts to just a little percent of maternal deaths still the reality of having a percent of number of maternal deaths every year globally due to a condition that could have been prevented is inexcusable. And taking into account haemorrhage as the most common complication of ectopic pregnancy which is noted as one of the leading cause of maternal deaths in the world, hence ectopic pregnancy is a life threatening situation if not diagnosed early and correctly. Avoiding and decreasing the number of maternal deaths is possible, but it requires the right kind of information on which to base programmes. Case rate finding of maternal mortality is not enough but understanding the underlying factors is very important. Each maternal case has a story to tell and can provide indications on practical ways of addressing causes and determinants so that recurrence can be prevented. Maternal morbidity reviews provide evidence of where the main problems may lie, produce an analysis of what can be done and highlight the key areas requiring recommendations as well as guidelines for improving clinical outcomes. The information gained from such enquiries is an important data for change plan and a prerequisite for action (Lewis, 2003, p. 27). Early diagnosis plays a key role with better outcome and prognosis in ectopic pregnancies. Thorough history and physical examination still is remains the most basic and most accurate procedure to facilitate information needed for proper diagnosis. Early intervention reduces global morbidity thus the more drive should be made to decrease rates due to ectopic pregnancy (Marion & Meeks, 2012, p. 376). This paper will discuss on ectopic pregnancy as a disease and will note on strategies that health care providers can implement to minimize delay in the early detection and diagnosis of ectopic pregnancy. Ectopic Pregnancy: Critiquing of Literature Ectopic Pregnancy occurs when a fertilized egg grows outside of the uterus. The most common site for ectopic pregnancies occurs in the fallopian tube and rarely in the ovary or any other organ in the abdomen. Just like in a normal pregnancy the foetus will grow but tube rupture will happen when it can no longer take the growing baby causing massive bleeding and death (American College of Obstetricians and Gynaecologists, 2011). Causes: Probable and Possible Ectopic pregnancy is often caused by a condition that blocks the movement of the fertilized egg through the fallopian tube to the uterus. Causes of such blockage include: defects in the fallopian tube, ruptured appendix, endometriosis, history of previous ectopic pregnancy and scarring form infections or surgery (National Centre for Biotechnology Information, U.S. National Library of Medicine, 2012). Epidemiology According to recorded data, ectopic pregnancy occurs in 1 of every 40 to 1 in every 100 of pregnancies or a prevalence of 1%. It has been studied by Coste et al. (1996) that during the past two decades, the incidence of ectopic pregnancy has doubled or tripled in many parts of the world. In France, EP currently constitutes 2 % of live births and 1.6 % of all reported pregnancies. Further epidemiologic research is needed to identify new risk factors, to monitor incidence rates and to evaluate the effects of public health policies on EP occurrence. Moreover, a study on the epidemiology of ectopic pregnancy over a 28 year period have shown the increase in the incidence more than a two-fold from 7.7 to 16.6 per 1000 pregnancies in a decade (Kamwendo et al., 2000, p. 28) thus the more health care enthusiasts should develop plan of action to decrease these numbers. The occurrence rate of maternal death due to ectopic pregnancy lies between 0.1 to 0.5 percentage scales according to the World Health Organization report (2012). Risk Factors Conditions that increase the risk of having an ectopic pregnancy are: age above 35, intra uterine device use, surgery, having had many sexual partners, in vitro fertilization and tubal ligation (NCBI, U.S. National Library of Medicine, 2012). A health care provider can tell a person is having an ectopic pregnancy by realizing on the signs and symptoms presented. It can be ruled out through symptoms such as vaginal bleeding, low back pain, mild cramping on one side of the pelvis, no periods and pain in the pelvic area. And worst if the abnormal pregnancy ruptures and bleed thus more serious complications may happen such as fainting, hypovolemia, shock, intense pressure in the rectum, and severe sharp and sudden pain in the lower abdomen (National Institute of Health, 2012; American Pregnancy Association, 2011). Diagnosis Early diagnosis plays a major role in identifying cases and treatment that contributes to higher rates of good prognosis. The clinical symptoms can mimic non-EP conditions, thus creating a challenge for developing diagnostic criteria and new diagnostic tools is a challenge. Early diagnosis is essential in order to assess the need for urgent surgical intervention to minimize morbidity (Segal et al., 2010, p. 49). For example, women who present with pain and bleeding in the first trimester are at risk for ectopic pregnancy. A diagnostic algorithm that includes the use of transvaginal ultrasonography, hCG concentrations, and uterine curettage can definitively diagnose women at risk in a timely manner (Seeber & Barnhart, 2006, p. 399). Misdiagnosis of EP has lead to complaints and allegations of malpractice in the health care field. Careful diagnosis should be done by healthcare providers to prevent not just complains and legal implications from patients but most of all to save lives of more women. More than just the review of history, diagnostics is available for most accurate confirmation of medical inquiry regarding ectopic pregnancy. Ultrasonography and HCG: dual diagnostic standard in modern practice Ultrasonography has made its mark in the history of diagnostics that modernization has led for the improvement of diagnostic exams opted to provide accurate diagnosis non-invasively the best possible way. The diagnosis of tubal ectopic pregnancy should be based upon the positive visualization of an adnexal mass using transvaginal ultrasound rather than the absence of an intrauterine gestational sac. Compared to the traditional laparoscopy as the gold standard in the diagnosis of tubal ectopic pregnancy, substantial evidences show that transvaginal ultrasound is the diagnostic tool of choice in modern practice due to its non-invasiveness and safety execution (Coundous, 2007, p. 85). Routine pregnancy urine test cannot diagnose normal uterine pregnancy form ectopic pregnancy because definitely the body of a pregnant female whether ectopic or uterine will produce hCG. But hCG levels are being used diagnostically to detect ectopic pregnancy from the normal uterine pregnancy by detecting the serum levels and not merely by hCG pregnancy testing. A rise in quantitative HCG levels over 1 to 2 days can differentiate a normal pregnancy from an ectopic pregnancy (NCBI, U.S. National Library of Medicine, 2012). In a study to note on the effectiveness of hCG biomarkers, an investigation on the sensitivity and specificity of serial serum hCG assays was done to diagnose early ectopic pregnancy in 50 asymptomatic women at risk. A normal percentage increase or doubling time was observed in 64% of women who eventually proved to have an ectopic pregnancy. The sensitivity of these tests was 36%, with a specificity of 63-71% therefore it was concluded that the normal rise in hCG does not reliably differentiate an ectopic from an intrauterine pregnancy in the asymptomatic patient (Shepherd et al. 1990, p. 417) thus the need for another diagnostic evaluation for confirmation is highly considered. To note on the significant value of vaginal ultrasound and serum hcg level in the diagnosis of ectopic pregnancy a study was made prospectively in 200 pregnant women suspected of having an ectopic pregnancy. The result revealed that 34% women were diagnosed with ectopic pregnancy. Detection of an adnexal mass separate from the ovaries was diagnostic of ectopic pregnancy with a sensitivity of 93%, a specificity of 99%, and a positive predictive value of 98%. On the other hand, initial hCG level upon admission exceeded 1000 iu/1 in 77% of all patients and in 67% of those are surely diagnosed with ectopic pregnancies. Hence the use of these two diagnostic procedures together in combination can accurately detect and diagnose ectopic pregnancy with a high sensitivity and specificity rates of 97% and 99% respectively and a positive predictive value of 98% (Cacciatore et al., 2005, p. 907) Clinical Examination Any adolescent woman presenting with vaginal bleeding must be considered pregnant since the differential diagnosis and the treatment are utterly different for vaginal bleeding with pregnancy and without. Urine pregnancy test is adequate to identify pregnancy after missed menses. And despite negative pregnancy urine test if there is any suspicion of ectopic pregnancy a serum hCG level must be obtained. 605 to 805 of ectopic pregnancies present with vaginal bleeding hence the most important diagnosis to rule out is ectopic pregnancy to prevent complications. Classically, ectopic pregnancy presents with amenorrhea, abdominal pain and vaginal bleed that can be mild or even absent. History may also include delayed menses, syncope, shoulder or abdominal pain, and pelvic pain (Barrett et al., 2011, p. 335). Keen clinical examination is very important in the diagnosis of ectopic pregnancy because it masks signs and symptoms that can falsely lead health care examiners to misdiagnosing ectopic pregnancy. In an article by Sara Bird (2005, 175), medical negligence claims against failure to diagnose ectopic pregnancy was filed by a patient. In the case history, the patient who is 35 years old who have had a history of endometriosis and previous in vitro fertilization, presented with nausea, increase urinary frequency and dull lower abdominal pain. A provisional diagnosis of Urinary tract infection was made by the doctor and was given oral cephalexin and advised follow up. During the review the patient have reported that the abdominal pain and nausea is unchanged but the period had just commenced. The following day the patient re-presented with increasingly severe lower abdominal pain, this time the physician suspected for ectopic pregnancy and have the patient schedule for an ultrasound and serum hCG and a follow up. The night of the following day, patient collapsed and was brought to the emergency department due to ruptured ectopic pregnancy and underwent an emergency laparotomy and salpingectomy. The patient commenced legal proceedings against the doctor alleging failure to diagnose ectopic pregnancy. If only the GP have considered the diagnosis of ectopic pregnancy by looking over the patients history the early treatment would have been considered and was given before complications have aroused. According to Bird, medical negligence claims alleging failure to diagnose ectopic pregnancy is not uncommon. A review of data reveals common causes such as: failure to consider possibility or maintain high index of suspicion; atypical presentation of the condition; failure to obtain complete and adequate history or perform an appropriate physical examination; and failure to follow up test results and investigations (Bird, 2005, p. 175). Management: Medical versus Surgical There are two methods to treat an ectopic pregnancy: either by medication or surgery. Medical treatment is composed of using systemic methotrexate intramuscular regimens. Studies have shown that it has a non significant tendency to a higher treatment success than laparoscopic salpingostomy (NCBI, U.S. National Library of Medicine, 2012). Medical management with methotrexate is a commonly used and safe alternative to surgical management. It is given single-dose, two-dose, and multidose regimens (Barnhart, 2009) Medical management stops the growth of the pregnancy and permits the body to absorb it over time and prevents the use of surgical measures that could lead to removal of the fallopian tube (ACOG, 2011). Factors that are associated with failure of medical management include ultrasonographic detection of fetal cardiac activity, and an increase in the serum hCG level of more than 50% over a 48-hour period (Barnhart, 2009). On the other hand, surgical management is imperative of a ruptured ectopic pregnancy. A laparoscopic approach is preferable to an open approach in a patient who is haemodynamically stable and it is associated with shorter operative times, less intraoperative blood loss, shorter hospital stays and lowers analgesia requirements. According to studies laparotomy should be reserved for patients who present with rupture and are in a state of hypovolaemic shock and compromise. But if the contralateral tube is healthy, the preferred option is salpingectomy, where the affected segment is removed and is associated mostly with decrease capability to be pregnant again. A salpingostomy is the removal of the ectopic pregnancy with an attempt to preserve fertility (Sivalingam et al., 2011). Moreover, laparoscopic salpingostomy is significantly less successful than the open surgical approach in the elimination of tubal ectopic pregnancy (NCBI, U.S. National Library of Medicine, 2012). According to randomized trials authored by Barnhart in comparing medical therapy with laparoscopic salpingostomy have shown none significant higher success rate with methotrexate as compared with salpingostomy. A cost-effectiveness analysis showed that systemic methotrexate therapy is less costly than laparoscopic surgical therapy only if the diagnosis of ectopic pregnancy does not require laparoscopy and if serum hCG values are greater than 1500 mIU per millilitre. Observational studies suggest that rates of tubal patency and recurrence of ectopic pregnancy are similar after medical and surgical treatment (Barnhart, 2009). Prognosis The common notion people think after having ectopic pregnancy especially when surgical intervention was made is that the chances of being pregnant again is significantly decreased but on the contrary, according to NCBI, U.S. National Library of Medicine (2012) one-third of women who have had one ectopic pregnancy are later still able to have a baby. Overall the subsequent conception rate of women after ectopic pregnancies is about 60%. The chances of recurrence are high in one-third of women and unfortunately some do not become pregnant again. The likelihood of a successful pregnancy after an ectopic pregnancy depends on the age, whether she has already had children and why the first ectopic pregnancy occurred (NCBI, U.S. National Library of Medicine 2012). Recommendations: After careful studies and wide readings regarding ectopic pregnancies the author of this study is deemed with all the possibilities of recommending ways for health care providers to detect ectopic pregnancy the soonest possible time to avoid complications and legal mitigations. From the most basic assessment all healthcare providers should act upon in dealing with patients to avoid misleading information that could lead to further improper diagnosis. First, healthcare providers should always take into consideration the subjective complaints of clients because these feelings are the most accurate information taken from the one experiencing the situation. In a study mentioned earlier, the feeling of pain was not given much attention. The possibility of pregnancy should be considered in any female patient between menarche and menopause (Bird, 2005, p. 176). It is recommended that all adolescent women presenting with abdominal pain and other symptoms capable of ovulation and conception should be suspected for pregnancy even if the possibility contradicts. It is better to rule out than to misdiagnose because sometimes symptoms masks ectopic pregnancy which is more serious and fatal. Second, risk assessment should always be considered in diagnosing ectopic pregnancy. A failure to identify risk factors has also been reported as a significant reason for misdiagnosis. Risk factors include: pelvic inflammatory disease, previous ectopic pregnancy, endometriosis, previous tubal or pelvic surgery, infertility and treatments, utero tubal anomalies and smoking. Identification of these factors can increase the index of suspicion and lead significance to otherwise minor symptoms (Bird, 2005, p 176). Third, health care providers especially in the hospital set up should provide clinical pathway guidelines that would determine patients who fit the criteria for having ectopic pregnancy. For example, a patient presenting with hypo gastric pain with history of IUD use will be considered for ectopic pregnancy and must be admitted for further investigations. Fourth, alongside with this clinical pathway guideline is of course the diagnostics that must be done at once to confirm the diagnosis. Again it is better to overdo diagnostics if suspicions lead to doing such than to fail in diagnosing ectopic pregnancy that could lead to death. Health Care providers must always remember that early detection is better than treatment and cure. Conclusion Ectopic pregnancy can be difficult to diagnose, in fact almost 50% of ectopic pregnancies are not detected on the initial assessment. Follow up and considerations should always be present. Having a keen clinical eye is significant not to miss on details and suspicions. It is concluded that most of the cases of misdiagnosed case of ectopic pregnancy can be attributed to failure to do diagnostics exam during the first visit for confirmation. Some health care providers would base treatment on assessment or with lack diagnostics findings that would support a definite diagnosis. In a situation of a 37 year old polygamous woman comes into the ER presenting with vaginal spotting and dull abdominal pain with history of smoking and pelvic inflammatory disease. With all these information in mind the health care provider should advise tests according to the clinical pathway guidelines such as pregnancy test, serum hCG level and transvaginal ultrasound to rule out the presence of ectopic pregnancy and be admitted with consent. This way the health care provider have helped saved the life of the woman from possible death. References: American College of Obstetricians and Gynaecologists (2011) Frequently Asked Questions 155: about Ectopic Pregnancy. Retrieved from: http://www.acog.org/~/media/For%20Patients/faq155.pdf?dmc=1&ts=20121008T1831130675 American Pregnancy Association (2011) Ectopic Pregnancy. Retrieved from: http://www.americanpregnancy.org/pregnancycomplications/ectopicpregnancy.html Barnhart K. (2009) Ectopic Pregnancy. The New England Journal of Medicine. 361; 379-387 Barrett B., Shandro J. & Yen S. (2011) Ch. 76 Vaginal Bleeding in Practical Guide to Pediatric Emergency Medicine: Caring for Children in the Emergency Department. Cambridge University Press, p. 335 Bird S. (2005) Failure to Diagnose: ectopic pregnancy. Australian Family Physician 34 (3); 175-76 Cacciatore B., Stenman U. & Ylostalo P. (2005) Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hCG level og 1000 IU/1 (IRP). BJOG: An international Journal of Obstetrics and Gynaecology. 97 (10); 904-908 Coundous G.S. (2007) Ultrasound diagnosis of ectopic pregnancy. Seminar in Reproductive Medicine. 25 (2); 85-91 Coste J., Bouyer J. & Job-Spira N. (1996) Epidemiology of Ectopic Pregnancy: incidence and risk factors. Contraception, Fertility, sexuality. 24(2); 135-139 Khan K., Wojdyla D., Say L., Gulmezoglu A.M. & Van Look P. (2006) WHO analysis of causes of maternal death: a systematic review. Lancet, 367; 1066-74 Kamwendo F., Forslin L., Bodin L. & Danielson D. (2000) Epidemiology of Ectopic Pregnancy during a 28 year period and the role of pelvic inflammatory disease. Sex Transm Infect 2000 76: 28-32 Lewis G. (2003) Beyond the Numbers: reviewing maternal deaths and complications to make pregnancy safer. British Medical Bulletin, 67 (1); 27-37 Marion L. & Meeks G. (2012) Ectopic Pregnancy: History, Incidence, Epidemiology, and Risk Factors. Clinical Obstetrics & Gynecology, 55(2); 376-386 National Center for Biotechnology Information, U.S. National Library of Medicine (2012) Ectopic Pregnancy. Pubmed Health. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/ National Institute of Health (2012) Ectopic Pregnancy. Medline Plus. Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/000895.htm Seeber B. & Barnhart K. (2006) Suspected Ectopic Pregnancy. Obstetrics & Gynecology 107(2); 399-413 Segal S., Mercado R. Rivnay B. (2010) Ectopic Pregnancy early diagnosis markers. UK Pubmed Central. ukpmc.ac.uk/abstract/MED/20186114 Shepherd R.W., Patton P. & Burry K.A. (1990) Serial beta-hCG measurements in the early detection of ectopic pregnancy. UK Pubmed Central. Retrieved from: http://ukpmc.ac.uk/abstract/MED/1689477/reload=0;jsessionid=TqQPRfBTd0EP6mPrgJsw.0 Sivalingam V., Duncan W., Kirk E., Shephard L. & Horne A. (2011) Diagnosis and management of ectopic pregnancy. J Fam Plann Reprod Health Care; 37:231-240 doi:10.1136/jfprhc-2011-0073 World Health Organization (2012) Maternal and Perinatal health. Retrieved from: https://www.google.com.ph/#q=epidemiology+of+ectopic+pregnancy+in+the+world&hl=en&safe=off&prmd=imvns&ei=1mJzUP2gMcmemQWE6ICQBw&start=10&sa=N&bav=on.2,or.r_gc.r_pw.r_cp.r_qf.&fp=3dc3e9bb4fcea777&biw=1366&bih=598 Read More