Tubal Pregnancy Essay

Tubal Pregnancy Essay

Epidemiology

Definition: Tubal pregnancy, also known as an ectopic pregnancy, occurs when the developing fetus attaches itself in a location other than the endometrium of the uterus. Among ectopic pregnancies, the fallopian tube is the most common site, accounting for 96 percent of cases (Tulandi, 2020b).

Demographics: The incidence of tubal pregnancies varies across different time periods and patient populations. Recent studies have reported an incidence of 20.7 tubal pregnancies per 1000 pregnancies. The prevalence of tubal pregnancies increases with 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 races, ethnicities, and ages. However, African American patients have a notably higher prevalence compared to White patients, with a 1.5-fold increased risk (Tulandi, 2020b).

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Causative Agent: Tubal pregnancies are generally believed to result from conditions that hinder the passage of the fertilized egg into the uterine cavity or due to factors within the embryo itself that lead to premature implantation. Recent research has identified various factors that may influence implantation, including chronic salpingitis, salpingitis isthmica nodosa, variations in the depth of implantation in the fallopian tubes, and the influence of serum or extracellular factors like lectin, integrin, matrix-degrading cumulus, prostaglandins, growth factors, cytokines, and modulator proteins. Additionally, embryonic and chromosomal abnormalities may play a role (Tulandi, 2020b).

Risk Factors & Exposures: Several risk factors are associated with tubal pregnancies. The highest risk factors include a history of prior tubal pregnancy and tubal surgery. Other risk factors include pelvic inflammatory diseases such as non-specific salpingitis, chlamydia, and gonorrhea, which can lead to scarring of the fallopian tubes. Endometriosis, intrauterine devices, infertility, and in vitro fertilization are also linked to increased risk. Smoking before conception is associated with a higher risk of tubal pregnancy, with a two- to threefold increase in risk for those with a history of smoking and a two- to fourfold increase for current smokers. Regular vaginal douching and increasing age are also associated with a higher risk of tubal pregnancy (Green, 2019; Tulandi, 2020b).

Time Course

Duration: Acute

Pattern or Prodrome of Symptoms: The most common clinical presentation of tubal pregnancy is first-trimester vaginal bleeding and/or abdominal pain. Tubal pregnancy can also be asymptomatic. Symptoms typically appear six to eight weeks after the last normal menstrual period but can occur later. Patients may also experience normal pregnancy discomforts like breast tenderness, frequent urination, and nausea. Tubal rupture, a serious complication, can lead to life-threatening intra-abdominal bleeding and presents with severe abdominal pain or symptoms suggesting hypovolemia/shock due to blood loss (Tulandi, 2020a).

Clinical Presentation with Classic S&S

Key & Differentiating Features: Signs and symptoms suggestive of tubal pregnancy include early vaginal bleeding and/or abdominal pain during the first trimester of pregnancy, typically between 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. The volume and pattern of vaginal bleeding can vary from light brown staining to profuse bleeding, occurring as a single incident or intermittently. Abdominal pain varies in timing, character, and severity, described as dull or sharp, and ranging from mild to severe. It typically presents in the pelvis or lower abdomen, either diffuse or on one side. Abdominal pain usually appears between five and seven weeks of pregnancy. Sudden onset of severe pain may indicate tubal rupture (Tulandi, 2020a).

Must-Have Features: Confirmation of a tubal pregnancy includes a positive pregnancy test, visualization of an extrauterine gestational sac with a yolk sac or embryo on transvaginal ultrasound, a positive serum human chorionic gonadotropin (hCG) test, and no products of conception on uterine aspiration, with subsequent rising hCG levels (rising less than 35 percent every two days across three measurements) or plateauing hCG levels. In cases of hemodynamic instability, visualization during surgery with histologic confirmation of tubal pregnancy may be necessary (Tulandi, 2020a).

Rejecting Features: Negative serologic pregnancy test, transvaginal ultrasound showing no evidence of an extrauterine gestational sac with a yolk sac or embryo, transvaginal ultrasound showing evidence of an intrauterine pregnancy, and a positive serum hCG with products of conception on uterine aspiration with subsequent rising hCG levels (rising equal to or greater than 35 percent). In normal early intrauterine pregnancies, hCG levels increase by at least 35 percent every two days (Tulandi, 2020a).

Mechanism of Disease Process

Pathophysiology: Tubal pregnancy occurs when an embryo implants within the fallopian tube rather than the uterus. Normally, the fallopian tubes facilitate the transport of an oocyte and embryo through smooth muscle contraction and ciliary beat. Tubal dysfunction arises when the fallopian tubes are damaged or injured, often due to inflammation, leading to the retention of an oocyte or embryo. Inflammation can result from various factors, including toxins, infections, immune responses, and hormonal changes. Persistent inflammation triggers the release of pro-inflammatory cytokines, promoting embryo implantation, invasion, and angiogenesis within the fallopian tube.

Infections, such as Chlamydia trachomatis, can induce an inflammatory response, producing interleukin 1, which is crucial for embryo implantation within the endometrium. Interleukin 1 also contributes to neutrophil recruitment, further damaging the fallopian tubes. Smoking and infections can destroy ciliary beat function, while hormonal alterations during the menstrual cycle can affect cilia beat function and contribute to oocyte and embryo retention. Retained embryos attempt to develop within the limited space of the fallopian tube, leading to a nonviable pregnancy and potential tubal rupture (Mummert & Gnugnoli, 2020).

Diagnostic Test(s) & Findings

Transvaginal ultrasound imaging is essential for diagnosing suspected tubal pregnancies. Confirmation of the diagnosis typically requires serial testing with transvaginal imaging and serum hCG level measurements (Tulandi, 2020a).

Transvaginal ultrasound results: Performed when a suspected tubal pregnancy is presented. Confirmation of a tubal pregnancy involves visualizing an extrauterine gestational sac with a yolk sac or embryo within the fallopian tube (Tulandi, 2020a).

Serum hCG measurements: Serial measurements of serum hCG, typically every 48 to 72 hours, help determine whether the changes are consistent with a normal or abnormal pregnancy. Diagnosis of a tubal pregnancy cannot rely on a single hCG measurement.

Confirmation is achieved when there is a positive serum hCG test, no products of conception on uterine aspiration, and subsequent rising hCG levels (rising less than 35 percent every two days across three measurements) or plateauing or decreasing hCG levels, in conjunction with transvaginal ultrasound findings (Tulandi, 2020a).

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/

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