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Ectopic Pregnancy Presents a Major Health Problem for Women Of

Ectopic Pregnancy Presents a Major Health Problem for Women Of

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Published by chaSeph

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Published by: chaSeph on Sep 29, 2009
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Ectopic pregnancy presents a major health problem for women of childbearing age. It isthe result of a flaw in human reproductive physiology that allows the conceptus toimplant and mature outside the endometrial cavity, which ultimately ends in death of thefetus. Without timely diagnosis and treatment, ectopic pregnancy can become a life-threatening situation.Ectopic pregnancy currently is the leading cause of pregnancy-related death during thefirst trimester in the United States, accounting for 9% of all pregnancy-related deaths. Inaddition to the immediate morbidity caused by ectopic pregnancy, the woman's futureability to reproduce may be adversely affected as well.
Ectopic pregnancy. Laparoscopic picture of an unruptured right ampullary tubalpregnancy with bleeding out of the fimbriated end resulting in hemoperitoneum.
Ectopic pregnancy. Laparoscopic picture of an unruptured right ampullary tubalpregnancy with bleeding out of the fimbriated end resulting in hemoperitoneum.
History of the Procedure
Ectopic pregnancy was first described in the 11th century, and, until the middle of the18th century, it was usually fatal. John Bard reported the first successful surgicalintervention to treat an ectopic pregnancy in New York City in 1759.The survival rate in the early 19th century was dismal. One report demonstrated only 5 patients of 30 surviving the abdominal operation. Interestingly, the survival rate in patients who were left untreated was 1 of 3.In the beginning of the 20th century, great improvements in anesthesia, antibiotics, and blood transfusion contributed to the decrease in the maternal mortality rate. In the earlyhalf of the 20th century, 200-400 deaths per 10,000 cases were attributed to ectopic pregnancy. In 1970, theCenters for Disease Control and Prevention (CDC)began torecord the statistics regarding ectopic pregnancy, reporting 17,800 cases. By 1992, thenumber of ectopic pregnancies had increased to 108,800. Concurrently, however, thecase-fatality rate decreased from 35.5 deaths per 10,000 cases in 1970 to 2.6 per 10,000cases in 1992.
Ectopic pregnancy is derived from the Greek word
meaning out of place, and itrefers to the implantation of a fertilized egg in a location outside of the uterine cavity,including the fallopian tubes, cervix, ovary, cornual region of the uterus, and theabdominal cavity. This abnormally implanted gestation grows and draws its blood supplyfrom the site of abnormal implantation. As the gestation enlarges, it creates the potentialfor organ rupture because only the uterine cavity is designed to expand and accommodatefetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death.
Since 1970, the frequency of ectopic pregnancy has increased 6-fold, and it now occurs in2% of all pregnancies. An estimated 108,800 ectopic pregnancies in 1992 resulted in58,200 hospitalizations with an estimated cost of $1.1 billion.
Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anythingthat hampers the migration of the embryo to the endometrial cavity could predisposewomen to ectopic gestation. The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection; however, most patients presenting with anectopic pregnancy have no identifiable risk factor. The following risk factors have beenlinked with ectopic pregnancy:
Pelvic inflammatory disease
The most common cause is antecedent infection caused by
Chlamydia trachomatis.
Patients with chlamydial infection have a range of clinical presentations, from asymptomaticcervicitis tosalpingitisand florid pelvic inflammatory disease (PID). More than 50% of women who have been infected are unaware of the exposure. Other organisms causing PID, such as
 Neisseria gonorrhoeae,
increase the risk of ectopic pregnancy. A history of salpingitis increases the risk of ectopic pregnancy 4-fold. Theincidence of tubal damage increases after successive episodes of PID (ie, 13% after 1episode, 35% after 2 episodes, 75% after 3 episodes).
History of prior ectopic pregnancy
After one ectopic pregnancy, a patient incurs a 7- to 13-fold increase in the likelihood of another ectopic pregnancy. Overall, a patient with prior ectopic pregnancy has a 50-80%chance of having a subsequent intrauterine gestation, and a 10-25% chance of a futuretubal pregnancy.
History of tubal surgery and conception after tubal ligation
Prior tubal surgeryhas been demonstrated to increase the risk of developing ectopic pregnancy. The increase depends on the degree of damage and the extent of anatomicalteration. Surgeries carrying higher risk of subsequent ectopic pregnancy includesalpingostomy, neosalpingostomy, fimbrioplasty, tubal reanastomosis, and lysis o peritubal or periovarian adhesions.Conception after previous tubal ligation increases a women's risk of developing ectopic
. Thirty-five to 50% of patients who conceive after a tubal ligation arereported to experience an ectopic pregnancy. Failure after bipolar tubal cautery is morelikely to result in ectopic pregnancy than occlusion using suture, rings, or clips. Failure isattributed to fistula formation that allows sperm passage. Ectopic pregnancies followingtubal sterilizations usually occur 2 or more years after sterilization, rather thanimmediately after. In the first year, only about 6% of sterilization failures result in ectopic pregnancy.
Use of fertility drugs or assisted reproductive technology
Ovulation induction with clomiphene citrate or injectable gonadotropin therapy has beenlinked with a 4-fold increase in the risk of ectopic pregnancy in a case-control study. Thisfinding suggests that multiple eggs and high hormone levels may be significant factors.One study has demonstrated that infertilitypatients with luteal phase defects have a statistically higher ectopic pregnancy rate than patients whose infertility is caused byanovulation. The risk of ectopic pregnancy and heterotopic pregnancy (ie, pregnanciesoccurring simultaneously in different body sites) dramatically increases when a patienthas used assisted reproductive techniques to conceive, such as in vitro fertilization (IVF)or gamete intrafallopian transfer (GIFT). In a study of 3000 clinical pregnancies achievedthrough in vitro fertilization, the ectopic pregnancy rate was 4.5%, which is more than

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