Advanced Obstetrics for Critical Care Paramedic: Ectopic Pregnancy - Essay Example

? Advanced Obstetrics for Critical Care Paramedic: Ectopic Pregnancy of the of the Health Sciences and Medicine September22, 2012 Describe the strategies health care providers can implement to minimise the possibility of an adverse patient outcome arising from a delay in diagnosing an ectopic pregnancy. Discuss how these findings can improve pre-hospital care and management of an ectopic pregnancy. Ectopic pregnancy Introduction Implantation of a fertilized ovum in places other than the endometrial lining of the uterus results in an ectopic pregnancy. As the blastocyst grows and expands at aberrant sites, it can cause rupture of those tissues with the potential for torrential bleeding (Braen & Krause, 2009; Jacob, 2012). An ectopic pregnancy is one of the few obstetric conditions that may end up being true surgical emergencies. As much as a high index of suspicion, an early diagnosis and management of an unruptured ectopic is important, even more crucial is the quick identification and surgery for a patient with a ruptured ectopic in shock. Failure to diagnose an ectopic pregnancy can lead to malpractice litigation as it can be potentially fatal, apart from causing significant morbidity and psychological distress to the patient (Bird, 2005; Longmore, 2010). Although, the definitive management of a ruptured ectopic is institute based and can be expectant, medical or operative; supportive management in pre-hospital scenario can mean the difference between life and death situations (Hajenius et al, 2007, Lozeau & Potter, 2005). Also, it can impact on the future fertility of the patient since newer conservative modalities with fewer complications can be used if ectopic pregnancy is diagnosed in time (Kopani, Rrugia & Manoku, 2010; Hajenius et al, 2007). Thus, the epidemiology, risk factors and clinical presentation of the condition have been reviewed from a paramedic perspective along with recommendations that can be implemented in the prehospital care of such patients. Epidemiology and Risk factors Incidence of ectopic pregnancy has been reported to be 11 to 15 per one thousand pregnancies in most of the developed nations and it is the leading cause of first trimester deaths in women (Braen & Krause, 2009; Tay, Moore & Walker, 2000). Incidence is higher in the age group above 35 years and most common site for implantation of an ectopic is the fallopian tube, followed by ovary and abdomen(Kopani, Rrugia & Manoku, 2010). Structural abnormalities of the fallopian tubes are the most common causes of ectopic pregnancy (Braen & Krause, 2009). Sexually transmitted infections like chlamydia and gonorrhoea cause tubal infection and scarring and lead to tubal pathology. Other factors which predispose to ectopic pregnancy are history of infertility and assisted reproductive techniques, pelvic inflammatory disease, previous dilation and curettage (D & C), tubal ligation and recanalisation, history of previous ectopic, use of intra-uterine device (IUD), smoking, pelvic surgery and genital tuberculosis (Varma & Gupta, 2009). Also, it has been found that the rate of ectopic pregnancy has decreased in women using contraception like oral contraceptives and has increased in women with reproductive failure (Varma & Gupta, 2009). There are certain implications of these risk factors, thus, health care providers should be aware of them. These risk factors can help in assessment of the likelihood of diagnosis of ectopic pregnancy. Nevertheless, it should be kept in mind that up to 42% of women with a positive diagnosis have had no risk factors (Braen & Krause, 2009; Varma & Gupta, 2009). Secondly, a history of contraceptive use or tubal ligation and sterilisation should not deter a paramedic from making a diagnosis of obstetric emergencies. In fact, a positive urine pregnancy test in the presence of an IUD in situ should alert the health care provider about the possibility of an ectopic. Symptoms of pain and discomfort in the abdomen should not be ignored as being instigated by an IUD. Neglecting these symptoms and risk factors can lead to a delay in diagnosis. Diagnosis The diagnosis of ectopic pregnancy requires a combination of history, physical examination findings, laboratory investigations and radiological modalities. It would seem an obvious fact the there are more women with pain in the abdomen and vaginal bleed who have normal pregnancies than ectopic pregnancy (Downey & Zun, 2011). Thus, herein the need arises to differentiate women with ectopic pregnancy from those with normal pregnancy amongst asymptomatic, minimally symptomatic or significantly symptomatic women. Also, an accurate and speedy identification can mean more conservative medical or laparoscopic management as opposed to laparotomy and salpingectomy for a patient with a ruptured ectopic (Condous, 2011). History Gutman and Lindsay (2000) determined in their critical appraisal that ectopic pregnancy cannot be ruled out on the basis of history and physical examination alone. Even emergency department physicians were found to have a decreased ability and low accuracy in detecting ectopic pregnancy in women presenting with lower abdominal pain to the emergency department (Gilling-Smith et al, 1995). Nowadays, few women present with overt shock and life threatening haemodynamic instability. Instead, most of the time, the presentation is more benign, atypical or asymptomatic (Hjenius et al, 2007, Condous, 2011). Classical triad of abdominal pain, amenorrhoea and vaginal bleeding has been described for diagnosis of ectopic pregnancy. However, it has low sensitivity and specificity for ectopic pregnancy and not many women present with these classical symptoms (Braen & Krause, 2009). Atypical presentations are common and absence of amenorrhoea does not rule out the diagnosis of ectopic pregnancy. In the retrospective study of Downey and Zun (2011), abdominal pain and vaginal bleeding were positive findings in only 75.7% and 51.9% patients respectively. A patient with an unruptured ectopic may present with varying severity of abdominal and pelvic pain, nausea and or vomiting, vaginal spotting or bleeding, and amenorrhoea, along with the likely presence of above mentioned risk factors. In case of a ruptured ectopic pregnancy, there can be massive hemorrhage resulting in shock and haemoperitoneum. Patient may have had repeated syncopal or fainting episodes or complete collapse. Shoulder tip pain (Kehr’s sign) can occur as referred pain because of peritoneal irritation. No predictors have been found useful to detect ectopics with the potential for rupture (Downey & Zunn, 2011). Quantitative ?-HCG determination is the closest variable that can help to determine this potential as stated by Downey and Zunn (2011), in accordance with the fact that less HCG is produced by the ectopic tissue as compared to an intrauterine pregnancy. The implication of the fact that rupture potential of an ectopic can not be predicted with certainty is that no woman, who is suspected of an ectopic which is not yet ruptured, should be left without medical supervision. Physical examination Physical findings occur in consonance with the status of the ectopic, whether ruptured or not. Obvious finding of haemorrhage and shock such as hypotension, tachycardia, weak pulses, diaphoresis and cold clammy skin are present with ruptured ectopic. Positive abdominal and pelvic examination findings are present in many patients. Again, the role of bimanual pelvic examination for diagnosis of ectopic pregnancy is suspect (Tay, Moore & Walker, 2000). In fact, reviewers have termed it as a medical myth (Brown & Herbert, 2003). Parameters such as tenderness on cervical movement, adenexal mas and adenexal tenderness have been found to have poor reproducibility among different health care providers (Brown & Herbert, 2003). Nevertheless, in a patient with acute abdomen, it is expected that a health care provider proceeds with history, physical examination and investigations in a sequence. The caveat to this is that hospital referrals for further investigations are compulsory (Tay, Moore & Walker, 2000). Ultrasound and pregnancy test Most reliable methods for the diagnosis of ectopic pregnancy are pregnancy tests (urine or serum) and ultrasound (transvaginal or transabdominal) (Hajenius, 2007; Lozeau & Potter, 2005). Further guidelines exist for utilisation of ultrasonography and ?- HCG in evaluation of patients with suspected ectopic pregnancy but these are under followed by the emergency department or gynaecological health care providers one the patient is under their purview (Lozeau & Potter, 2005). A urine dipstick HCG pregnancy test is sensitive and quick. Thus, it has been strongly suggested that all women with unexplained abdominal pain should have this test. Lower reliability of urine pregnancy tests has been shown by earlier authors (Giling-Smith et al, 1995). However, a current generation negative monoclonal based antibody pregnancy test can reliably rule out ectopic pregnancy (Condous, 2011). Kits are easily available and the test is easy and non invasive. If the urine test for pregnancy is negative but there is a strong suspicion of ectopic pregnancy, serum ? HCG and ultrasound can confirm the diagnosis. In short, no single negative test should be used to exclude the diagnosis of ectopic. A pelvic ultrasound can detect an ectopic pregnancy and intraperitoneal blood in most of the cases and has transformed the assessment of patients with a probable diagnosis of ectopic pregnancy as reviewed by Murray et al (2005). However, at present, paramedic role in ultrasound detection and utility of ultrasound in prehospital environment for ectopic pregnancy has not been defined. The studies which have evaluated the role of paramedics in performing ultrasound in the prehospital settings have been few and they have mainly concentrated on trauma patients (Heegaard et al, 2010; Nelson & Chason, 2008). Whether requisite skills can be imparted to paramedics in performing ultrasound examination, especially transvaginal, in obstetrical patients or to detect intraperitoneal hemorrhage on ultrasound needs to be assessed. Other issues which need more research are the level of training and the optimal training criteria, time spent on performing ultrasound during transportation and on scene delays, and changes and transformation that can be brought about in the decision making by using this intervention. Although, the first line radiological investigation is ultrasound, authors have also reported the utility of CT scan in equivocal ultrasound findings (Michalak et al, 2010). Differential diagnosis Other diagnoses which can present with similar findings of acute abdomen and pelvis are obstetrical such as miscarriage, ruptured ovarian or corpus luteum cyst and torsion of ovarian cyst; and gastrointestinal like appendicitis and intestinal volvulus. Immediate transportation and further investigations are anyhow required if these pathologies are being considered (Braen & Krause, 2009; Lozeau & Potter, 2005). Assessment and Clinical examination Before anything else, it is important to recognise that an ectopic pregnancy is emotionally very traumatic and can have long term psychological effects, especially if the there has been a history of infertility. The person performing the clinical examination should keep this in mind and should be gentle and supportive to the patient and the family. Assessment can classify the patient in to stable, unstable and decompensated patients. Accordingly the patient status should be conveyed to the transporting hospital. Patient is assessed for the above mentioned clinical manifestations such as lower abdominal or pelvic pain, shoulder pain or fainting. Clinical examination comprises of vital parameters such as blood pressure, heart rate, respiratory rate and oxygen saturation; per abdomen examination, and pelvic examination. Vital parameters are normal in patients with unruptured ectopic while features of shock are evident in a ruptured ectopic. Presence of blood in the peritoneal cavity causes abdominal, distension, guarding and rigidity. It is prudent to perform a pelvic examination in those whom an ectopic pregnancy is suspected on the basis of symptoms. However, overaggressive examination can itself cause rupture of the ectopic and should be refrained from. In patients with an obvious rupture with features of shock, this examination should be deferred and patient should be urgently transported to a centre with gynaecological operative facilities. Physical signs such as pulse rate, blood pressure, per abdominal findings of tenderness and peritoneal irritation, and tenderness on cervical motion and adenexal palpation can help to detect and confirm the diagnosis of a ruptured ectopic pregnancy. Pre-hospital management As other diagnostic modalities as well as technical facilities are usually not available in the prehospital environment, paramedics should be aware of the fact that decision to transport and refer the patient will rest on their inkling as well as history and clinical examination. As opposed to Brown and Herbert (2003), Isoradi (2009) states that pelvic examination can provide diagnostic information in situations where ultrasound and ? HCG are not available. This can be applied to prehospital environment also. Most of the times, the deaths are caused due to misdiagnosis of condition on presentation (Condous, 2011). To be careful to begin with, patient’s privacy should be respected and maintained as much as is possible in prehospital circumstances while eliciting history and performing clinical examination. This is especially true in case of adolescents and those with a history of sexually transmitted infections. On encountering a patient who is demonstrating signs and symptoms suggestive of ectopic pregnancy, due regard should be given to patient’s history. It’s better to be overcautious than ignore the warning signs. On the other hand, patient’s own diagnosis such as ‘gastric’ pain should not become or lead the paramedic’s diagnosis. Also, patients are likely to confuse or hide the details regarding sexual activity and menstrual history. If the symptoms are present or clinical condition is suggestive, an ectopic pregnancy should be considered and ruled out despite patient’s confounding history. History of passage of tissues per vaginum can lead towards a diagnosis of abortion. Still, the patients may not be able to differentiate blood clots from other tissues. Physical examination is performed to support the diagnosis as well as assess the clinical status of the patient. An apparently stable patient with a possible diagnosis is transported to the hospital under clinical supervision with all the resuscitative equipment and drugs. Patient and the relatives should be explained about the condition and the possibility of further investigations and imaging for confirmation. A patient with vaginal bleeding should be provided with sanitary napkins or pads to absorb blood. This, apart from providing comfort to the patient, helps to quantify amount of bleeding. No intra-vaginal packing should, however be done. In a decompensated patient, priorities are same as in any trauma or medical emergency management, which are airway, breathing and circulation. Patient is given high flow supplemental oxygen via mask, nasal prongs or an endotracheal tube as the case may be, and respiration is supported as required. However, the most important step is the management of hypovolemic, hemorrhagic shock which proceeds side by side. Two large bore intravenous accesses are obtained and fluid infusion is commenced. Warmed isotonic crystalloids and colloids both can be used. Patient should be kept warm while transportation and depending upon the degree of shock, vasopressors and slight upward tilt of the lower extremity (Trendelenburg position) can be used. Depending upon the availability, O negative blood can be transfused. If the pain is severe or the patient is in obvious discomfort, analgesics as per local protocol should be given. Referral hospital should be informed about the patient’s condition so that resources such as ultrasound, blood bank and operation theatre personnel can be mobilised. Prognosis In Australia and rest of the developing world, mortality due to ectopic pregnancy has significantly decreased due to a combination of improved detection rate and management measures (Varma & Gupta, 2009). Morbidity in terms of hospital, and sometimes intensive care unit stay, need for surgery and blood transfusion, infertility and higher risk of a repeat ectopic pregnancy remain. Long term sequelae of ectopic pregnancy can be infertility and resultant psychological disorders. Recommendations The current focus is to evolve strategies for the health care providers that can prevent the misdiagnosis of ectopic pregnancy. Misdiagnosis occurs because the symptoms are very non specific and health care provider may feel that further consultation and referral is not warranted for every case of abdominal pain which can have numerous, more benign causes. Usually, infections like pelvic inflammatory disease or urinary tract infection are suspected, culture is performed and antibiotics are prescribed. This delay in diagnosis leads to complications and emergency surgery and can cause the patient her life. Following recommendations can help to steer clear of such blunders. The foremost thing is to keep a high index of suspicion of ectopic pregnancy in the prehospital management of any female patient of child bearing age with any of the above mentioned symptoms or complaints. History given by the patient regarding menstruation and sexual activity should be documented and kept in mind, but not exclusively relied upon while making a diagnosis. Patients may themselves be unaware that they are pregnant. Vaginal bleeding may be confused with normal menstrual period. The only complaint could be a vague abdominal pain. Urine pregnancy test should be performed in reproductive age women with lower abdominal pain at all times. It’s a useful thing to keep in the armamentarium of health care providers. Young patients have good cardiovascular reserve and may appear stable even with large amounts of blood in the peritoneal cavity. Initial stages of shock may go unnoticed. Also, absence of tachycardia does not eliminate shock. Once the assessment is complete and condition is recognised or suspected, rapid transport is essential to a centre where facilities for diagnosis and management such as gynaecologist, ultrasound and colposcopic puncture, anaesthesiologist and laparoscopic and operative facilities are available. In case of internal bleeding, only surgical intervention is going to help. So, carrying out of procedures should not lead to delay in transportation. Transportation plan must be formulated according to the patient’s status. Patient should have large bore intravenous cannula in situ and application of monitors like ECG, blood pressure and oxygen saturation. Resuscitation should continue en route with fluids and blood for a patient in shock. Information about the patient should be pre-conveyed to the target hospital. Upon reaching the hospital, the paramedic should hand over the findings and summary of the case to the emergency department health personnel along with details of any interventions performed. Conclusion Ectopic pregnancy results from implantation of a fertilised ovum outside the normal location that is the uterine endometrium. On one hand, there are typical risk factors for this condition. On the other hand, many women present with it in the absence of any risk factors. Failure to diagnose ectopic pregnancy can give rise to medical negligence claims. Apart from litigation issues, it is the clinical, moral and ethical responsibility of a health care provider to accurately detect a condition which, if missed, can be lethal in addition to entailing considerable physical and psychological morbidity. Adding up to the significance of diagnosis is the management of a possible ruptured ectopic or a patient in shock and swift transportation to a centre where this condition and its complications can be managed. Prehospital diagnosis and care are crucial in the management of this disease. References Bird, S. (2005). Failure to diagnose: ectopic pregnancy. Australian Family Physician, 34(3), 175 -176. Retrieved from http://www.racgp.org.au/afp/200503/200503bird.pdf Braen, G. R., & Krause, R. S. (2009). Ectopic pregnancy. In A. B. Wolfson (Ed.), Harwood Nuss' Clinical Practice of Emergency Medicine (pp. 682- 685). Philadelphia: Lippincott Williams & Wilkins. Brown, T., & Herbert, M. E. (2003). Medical myth: Bimanual pelvic examination is a reliable decision aid in the investigation of acute abdominal pain or vaginal bleeding. Canadian Journal of Emergency Medicine, 5(2), 120-122. Retrieved from http://www.cjem online.ca/sites/default/files/pg120.pdf Condous, G. (2006). Ectopic pregnancy: Risk factors and diagnosis. Australian Family Physician, 35(11), 854-857. Retrieved from http://www.racgp.org.au/afp/200611/20061103condous.pdf Downey, L. V., & Zun, L. S. (2011). Indicators of potential for rupture for ectopics seen in the emergency department. Journal of Emergency, Trauma and Shock, 4(3), 374-377. Retrieved from http://www.onlinejets.org/article.asp?issn=0974-2700;year=2011;volume=4;issue=3;spage=374;epage=377;aulast=Downey Isoradi, K. (2009). Review article: the use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding. Emergency Medicine Australasia, 21(6), 440-448. Kopani, F., Rrugia, A., & Manoku, N. (2010). Ectopic pregnancy comparison of different treatments. Journal of Prenatal Medicine, 4(2): 30–34. Retrieved from file:///G:/obstetric%20paramedic/Ectopic%20pregnancy%20comparison%20of%20diffe ent%20treatments.htm Gilling-Smith, C., Panay, N., Wadsworth, J., Beard, R. W., & Touquet, R. (1995). 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Prehospital ultrasound by paramedics: results of field trial. Academic Emergency Medicine, 17, 624 -630. doi: 10.1111/j.1553-2712.2010.00755.x Longmore, J. (2010, April 13). Emotional end to ectopic pregnancy inquest. ABC News. Retrieved from http://www.abc.net.au/news/2010-04-16/emotional-end-to-ectopic-pregnancy inquest/398376 Lozeau, A., & Potter, B. (2005). Diagnosis and management of ectopic pregnancy. American Family Physician, 72(9), 1707-1714. Retrieved from http://www.aafp.org/afp/2005/1101/p1707.pdf Michalak, M., Zurada, A., Biernacki, M., & Zygmunt, K. (2010). Ruptured ectopic pregnancy diagnosed with computed tomography. Polish Journal of Radiology, 75(4): 44-46. Retrieved from http://www.polradiol.com/fulltxt.php?ICID=881340 Murray, H., Baakdah, H., Bardell, T., & Tulandi, T. (2005). Diagnosis and treatment of ectopic pregnancy. Canadian Medical Journal, 173(8), 905-912. doi:10.1503/cmaj.050222. Nelson, B. P. & Chason, K. (2008). Use of ultrasound by emergency medical services: a review. International Journal of Emergency Medicine, 1, 253–259. doi: 10.1007/s12245-008 0075-6 Tay, J. I., Moore, J., Walker, J. J. (2000). Ectopic pregnancy. BMJ, 320, 916–919. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117838/pdf/916.pdf Varma, R., & Gupta, J. (2009). Tubal ectopic pregnancy. Clinical Evidence, 04, 1406. Retrieved from http://www.clinicalevidence.bmj.com/x/pdf/clinical-evidence/en-gb/systematic review-archive/2009-04-1406.pdf Read More