The patient, an eighteen-year-old female, is seen at the emergency room of a local hospital complaining of severe abdominal pain, vaginal bleeding, and delay in her expected menstrual period. She notes that she had unprotected vaginal intercourse about seven weeks prior and is concerned about a sexually transmitted disease. She experienced coitarche (initial sexual intercourse) at age fifteen and has been sexually active since that time with a variety of partners. She states that usually barrier protection was used by the male (condoms) but they did sometimes “forget.” She notes that she has been seen in a venereal disease clinic several times in the past and was diagnosed with both gonorrhea and chlamydia infections for which she received antibiotic therapy “several times.” A rapid pregnancy test is ordered, which is positive. Transvaginal ultrasound detects signs of an ectopic pregnancy (the fetuses is implanted in a site other than the uterus) located in the fallopian tube (oviduct), a so-called tubal pregnancy. She suffers a decrease in blood pressure with hemorrhage (hemorrhagic shock) and is rushed to surgery. At surgery blood is found in the abdominal cavity (hemoperitoneum) and an 8 cm left mass was found that encompassed both the left fallopian tube and ovary. The mass contained a nonviable fetus judged to be of eight weeks gestational age (FIGURE 10-10). Both the left ovary and fallopian tube were removed (salpingo-oophorectomy). The contralateral fallopian tube and ovary showed numerous adhesions that distorted their anatomy and were considered to be consistent with long-standing pelvic inflammatory disease. Recovery was complicated by ongoing infections, but she eventually recovered.
FIGURE 10-10
Discussion
Ectopic pregnancies have been observed since before 1000 CE. Because the developing fetus is detectable as a mass during examination in only about 50 percent of cases, the use of very sensitive assays for human chorionic gonadotrophin (hCG) to determine pregnancy combined with transvaginal ultrasound makes location of the conceptus possible very early in pregnancy. This has allowed for much improved medical management. In cases where no fetal heartbeat is detected and the fetus is small, it is possible to chemically terminate the ectopic pregnancy without the need for (often laparoscopic) surgery. However, extrauterine pregnancy accounts for about 9 percent of maternal deaths currently and a ten times greater risk than delivery in the third trimester. Hemorrhage and infection (as in the case) are the major risks, and medical or surgical intervention is necessary, even in the case of more advanced fetuses. Currently ectopic pregnancies account for about 2 percent of all recognized conceptions. There is evidence that the frequency is increasing, and this is due, in part, to an increasing incidence of pelvic inflammatory disease (PID) related to untreated or recurrent infections with Chlamydia trachomatis and Neisseria gonorrhea. Any factor that causes anatomic obstruction or other abnormalities in tubal structure that delay or prevent passage of the embryo increase the risk of ectopic pregnancy. PID is a preventable but increasingly diagnosed condition that affects more than 1 million women (about 8 percent of all of reproductive age). It is clearly most frequent in adolescents (about 1 in 5 cases occurring before the age of nineteen). Multiple sexual partners and early coitarche are also risk factors. Infection related to either of the above mentioned organisms can, if not properly treated, result in acute followed by chronic inflammation of the salpinx (fallopian tube, salpingitis), which, as was noted in the case, can lead to scarring distortion and adhesions of and within the tube affecting passage of the embryo (FIGURE 10-11).
FIGURE 10-11
Etiology and Pathogenesis
Ectopic pregnancy (tubal pregnancy) most likely resulting from tubal scarring and adhesions as a result of pelvic inflammatory disease subsequent to Neisserial and chlamydial infection.
Questions
1. What actions could the patient have taken prior to being seen in the emergency room to have prevented the tubal pregnancy?
2. Many venereal disease clinics monitor patients as they take prescribed drugs. Do you think this is a reasonable approach and why?
3. There is increasing concern about antibiotic resistance developing in several of the pathogens responsible for venereal disease. Why is the problem increasing?