Illness or Disorder: Tubal pregnancy Essay
Epidemiology
Definition: Tubal pregnancy is a type of ectopic pregnancy in which the developing fetus becomes rooted in a site other than the endometrium of the uterus. The fallopian tube, which accounts for 96 percent of all ectopic pregnancies, is the most prevalent extrauterine site. (Tulandi, 2020b) Tubal pregnancy
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Demographics: The incidence of tubal pregnancies has varied significantly through time and patient populations. Recent studies have described a rate of tubal pregnancies at 20.7 per 1000 pregnancies. An increase in prevalence seems to correlate with an increase in age: 15 to 19 years (2.8 per 1000), 20 to 24 (4.4), 25 to 29 (7.4), 35 to 39 (9.9), and 40 to 44 (9.8). Tubal pregnancies can affect women of all different races, ethnicities, and ages Tubal pregnancy Essay. However, there is a notable higher prevalence in African American patients compared to White patients where African American patients had a 1.5-fold risk compared with White patients (Tulandi, 2020b).
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Causative agent: It is commonly accepted that the etiology of tubal pregnancies is the result of conditions that delay or inhibit the passage of the fertilized oocyte into the uterine cavity or due to embryo-inherent factors that result in premature implantation. Several recent studies of tubal pregnancies have discovered various factors that may influence implantation which include the following: chronic salpingitis, salpingitis isthmica nodosa, varying depths of implantation of the gestational sac in the fallopian tubes, serum or extracellular factors such as lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors, cytokines, and modulator proteins may cause premature implantation in the tube, and lastly embryonic/chromosomal abnormalities (Tulandi, 2020b).
Risk Factors & Exposures: There are many risk factors for tubal pregnancy. Prior tubal pregnancy and a history of tubal surgery are the highest risk factors for tubal pregnancy. Other risk factors include pelvic inflammatory diseases such as nonspecific salpingitis, chlamydia, and gonorrhea in which all can lead to scarring of the fallopian tubes, endometriosis, intrauterine devices, infertility, and in vitro fertilization (Green, 2019). Smoking during the period before conception is associated with a higher risk of tubal pregnancy. A history of smoking is associated with a two- to threefold increase in the risk of tubal pregnancy, and a two- to fourfold risk is associated with current use. The reasoning for this is that smoking may impair tubal motility or impair immunity, thus predisposing the patient to pelvic inflammatory disease. Tubal pregnancy Essay Lastly, regular vaginal douching has a three times greater risk of tubal pregnancy as well as increase age. There is an associated increased risk for tubal pregnancies as the patient ages (Tulandi, 2020b).
Time Course
Duration: Acute
Pattern or Prodrome of Symptoms: First-trimester vaginal bleeding and/or abdominal pain is the most common clinical presentation of tubal pregnancy. Tubal pregnancy can also be asymptomatic. Clinical manifestations of tubal pregnancy characteristically appear six to eight weeks after the last normal menstrual period but can occur later. Tubal pregnancy Essay Normal pregnancy discomforts such as breast tenderness, frequent urination, and nausea are sometimes present. A tubal pregnancy can be unruptured or ruptured at the time the patient seeks care. Tubal rupture can lead to life-threatening intra-abdominal bleeding. Rupture may present with severe or persistent abdominal pain or symptoms suggestive of hypovolemia/shock due to blood loss (Tulandi, 2020a) Tubal pregnancy Essay.
Clinical Presentation with Classic S&S
Key & Differentiating Features: Signs and Symptoms suggestive of tubal pregnancy: Vaginal bleeding and/or abdominal pain early in pregnancy, typically weeks six to eight, along with a positive pregnancy test.
Vaginal bleeding and abdominal pain are the two most common features of a tubal pregnancy. Vaginal bleeding is present, but the volume and pattern of vaginal bleeding varies. Bleeding may range from light brown staining to profuse bleeding. Bleeding can occur as a single incident or it can be continuous, however, it is usually intermittent. Vaginal bleeding that occurs with tubal pregnancy is stereotypically led by amenorrhea. Abdominal pain also varies with timing, character, and severity of the pain. Abdominal pain is usually described as continuous or intermittent that is described as dull or sharp. The pain also ranges from mild to severe. The pain usually presents in the pelvis region or lower abdomen that may be diffuse or contained to one side of the lower abdomen. The onset of abdominal pain typically presents anywhere between five and seven weeks of pregnancy. Tubal rupture may be accompanied with sudden onset of severe pain (Tulandi, 2020a).
Must Have Features: A positive pregnancy test. Visualization of an extrauterine (fallopian tube) gestational sac with a yolk sac or embryo on a transvaginal ultrasound. A positive serum human chorionic gonadotropin (hCG) and no products of conception on uterine aspiration with subsequent rising hCG (rises <35 percent every two days across three different measurements) or plateauing hCG levels. If patient is hemodynamically unstable, visualization during surgery with histologic confirmation of tubal pregnancy (Tulandi, 2020a).
Rejecting Features: Negative serologic pregnancy test. Transvaginal ultrasound showing no evidence of extrauterine gestational sac with a yolk sac or embryo. Transvaginal ultrasound showing evidence of intrauterine pregnancy. A positive serum hCG with products of conception from uterine aspiration with subsequent rising hCG levels (hCG levels rising greater than or equal to 35 percent). In normal early intrauterine pregnancies hCG levels will rise by at least 35 percent every two days (Tulandi, 2020a) Tubal pregnancy Essay.
Mechanism of Disease Process
Pathophysiology: Tubal pregnancy is the implantation of an embryo within the fallopian tube which is outside of the uterus. Through smooth muscle contraction and ciliary beat, the fallopian tubes facilitate the transport of an oocyte and embryo. Tubal dysfunction occurs when there is damage or injury to the fallopian tubes, usually due to inflammation, which then results in retention of an oocyte or embryo. Inflammation is caused by several local factors, such as toxic, infectious, immunologic, and hormonal. As inflammation persists there is then upregulation of pro-inflammatory cytokines following tubal damage. This then promotes embryo implantation, invasion, and angiogenesis within the fallopian tube. Infection from Chlamydia trachomatis causes an inflammatory response which results in the production of interleukin 1 by tubal epithelial cells. This happens to be a crucial factor for embryo implantation within the endometrium. Interleukin 1 also has a part in downstream neutrophil recruitment which further contributes to fallopian tubal injury. Cilia beat function is destroyed by smoking and infection. Hormonal alterations during the menstrual cycle has also proven effects on cilia beat function in which all can cause oocyte and embryo retention. The retained embryo tries to grow and develop within the small space of the fallopian tube which ultimately leads to a nonviable pregnancy and possible tubal rupture (Mummert & Gnugnoli, 2020).
Diagnostic Test(s) & Findings
Transvaginal ultrasound imaging is fundamental in diagnosing suspected tubal pregnancy. Serial testing with transvaginal imaging and serum hCG level measurements are both required to confirm the diagnosis (Tulandi, 2020a).
Transvaginal ultrasound results: Performed at the time of presentation of a suspected tubal pregnancy. Findings to confirm diagnosis of tubal pregnancy would include visualization of an extrauterine, in this case within the fallopian tube, gestational sac with a yolk sac or embryo (Tulandi, 2020a).
Serum hCG measurements: Serum hCG is measured serially, typically every 48 to 72 hours, to determine whether the change is consistent with a normal or an abnormal pregnancy. Diagnosis of tubal pregnancy cannot be confirmed by a single hCG measurement. A positive serum hCG and no products of conception on uterine aspiration with subsequent rising hCG (hCG that rises <35 percent every two days across three different measurements) or plateauing or decreasing hCG levels can help confirm ectopic pregnancy along with transvaginal ultrasound findings (Tulandi, 2020a) Tubal pregnancy Essay.
References
Green, K. (2019). Assessment of the pregnant woman. In H.A. Carcio & R.M. Secor (Eds.), Advanced health assessment of women: Clinical skills and procedures (4th ed., pp. 119-148). Springer.
Mummert, T., & Gnugnoli, D.M. (2020). Ectopic pregnancy. StatPearls. Retrieved November 12, 2020 from https://www.ncbi.nlm.nih.gov/books/NBK539860/Tubal pregnancy Essay
Tulandi, T. (2020a). Ectopic pregnancy: Clinical manifestations and diagnosis. UpToDate. Retrieved November 12, 2020 from https://www.uptodate.com/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis?search=tubal%20pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Tulandi, T. (2020b). Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites. UpToDate. Retrieved November 12, 2020 from https://www.uptodate.com/contents/ectopic-pregnancy-epidemiology-risk-factors-and-anatomic-sites?search=tubal%20pregnancy&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H3 (Links to an external site Tubal pregnancy Essay.)