08 Apr

Broadly speaking, an ectopic pregnancy is a fertilised egg called an embryo that is implanted and constrained to grow outside of the womb. It is one of the very earliest complications of a pregnancy and one of the most feared. When it ruptures, as most are prone to doing, it often means the difference between life and death. A high index of suspicion is required to deal with the problem and experience in the emergency room also counts for the difference between death and survival. Almost all ectopic pregnancies are found within the fallopian tube and have been alternatively called tubal pregnancy as a result.

When a pregnancy occurs within the fallopian tube, the thin walls of the tube stretch out and eventually rupture. Catastrophic bleeding into the abdomen that rapidly degenerates from pain to profuse sweating and sudden collapse could be the sequence of events that might lead from the kitchen or bathroom straight into the operating room. Delay is dangerous and the withholding of vital information may lead to death as a result of delays in confirming the diagnosis. It is important to our discourse to examine some scenarios that have played out in the course of my career.

Long ago, as a medical officer in a hospital in Niger state, a 24-year-old woman was admitted for typhoid fever. Further examination by the most senior doctor in the hospital established that she had a ruptured ectopic pregnancy. She was rushed into the operating room without delay and the point of bleeding was rapidly identified and dealt with. Further examination revealed that another ectopic pregnancy was contained in the other fallopian tube. In a twinkle of an eye, that tube was cut off and the stump tied off. The young woman would never have children.

A mere one week ago, yours truly was walking out of an emergency room when a young woman of 34 years of age was rushed in; she was panting for air and demanded a bed so she could be comfortable. Soon afterwards, she laid flat on the floor and continued to demand a bed. She was sweating profusely. The attending doctors asked her what the problem was and she exclaimed stomach pain. That abdomen was full, like a pot belly and, she was repeatedly denying that she was pregnant.

A quick examination, however, showed she was bleeding into the abdomen and she was prepared for transfer to another hospital that could handle her condition. Needless to say, valuable time had been lost by the strenuous denials of her companions and herself so that by the time the diagnosis was made and her transfer effected, she was soon to die on the operating table.

Some years ago, while working as a medical officer at a hospital at Ebute Metta, a 29-year-old mother of two was rushed in by her husband from a tertiary institution in Lagos where she had just been admitted for undergraduate studies. The husband, a wealthy businessman, provided every comfort for her and ensured she stayed within the campus so as to enjoy proper student life. He was told that his wife was pregnant, that the pregnancy was in the wrong place and had ruptured as a result with bleeding into the abdomen which made an emergency operation necessary. He swore that he had made no sexual contact with his wife for almost four months and that we could not possibly be right. By the wife’s account, her last menstrual period was six to seven weeks previously. Nonetheless, he gave his consent for the operation to proceed and her life was saved. He was presented with the small embryo at the conclusion of the operation.

That act of indiscretion was to permanently scar their marriage as the wife had no explanation for how the pregnancy occurred outside of their matrimonial home. It can be seen from these examples that many women who suffer from this catastrophe are seldom the same; one died, one lost her home and another became barren. Deaths are easier to find in our part of the world in association with this strange problem but constitute less than 0.5 per cent of all cases in the advanced countries of the world. Ectopic pregnancies are made more likely by some of the following features in a woman.

1) An infection or inflammatory reaction that can cause the fallopian tube to become partially or completely blocked is a likely way to become more prone to developing this condition. This is usually seen often in association with pelvic inflammatory disease, a constant feature seen today in many young women.

2) A previous operation on the fallopian tubes or in the pelvic region of the body that leads to the formation of scars can cause adhesions and lead to this condition following the example above.

3) Abnormal growths or a birth defect can result in an abnormality developing in the shape and caliber of the fallopian tubes thereby making this complication more likely.

4) A previous ectopic pregnancy makes it much more likely to happen in the same woman.

5) Women who are in the age bracket 35-44 years are particularly prone but in our part of the world, most cases seen within the emergency room are at least 10 years younger than that on the average.

6) Lastly, a scar tissue developing from a previous operation or infection in the past may deform the lumen of the fallopian tube and impede the movements of the fertilised egg within them. When this happens, the egg is arrested anywhere along the length of the tube.

The features of this condition are often deceptive. These features are made even harder to fathom when women are evasive in providing answers to direct questions. Often, a sharp abdominal pain is present. There may also have been vaginal bleeding typically occurring about a fortnight after a usual period has been missed. That kind of bleeding is typically heavier than the normal period. There may be episodes of dizziness which are associated with some of the very early symptoms of pregnancy.

A needle examination of the abdomen, which draws frank blood as well as a rapidly performed pregnancy test often clinch the diagnosis. Where the equipment is standard, a similar needle examination will provide the same result when inserted into a space above the vagina.

Once rupture is proven, an emergency operation is life-saving. When there is no rupture, drug treatment is possible using medications which encourage the body to digest the developing embryo.

Ask the doctor

Dear doctor, thank you for your article on cracking the knuckles. It was an interesting topic because I do it a lot. It is a relief to know it is harmless. However, for some time now I feel pain when I crack my index finger and it does not crack. What can cause it? 0803xxxxxxx

I am glad you found it useful. When your finger fails to crack, there may be a reduced volume of synovial fluid in that joint so that lubrication is not optimal and some arthritis may have set in. sometimes, it is the surrounding tendons that have become impregnated with calcium thereby making them harder and less supple. That makes routine movements painful. So either of these may be the problem and you just will have to see a doctor for examination so that the specific problem can be identified and treated.

Dear doctor, like my last message to you, in the process of trying to make my marriage more healthy doing more physical, more erotic contact and more foreplay before attempting to have sex, days later I started feeling an uncomfortable feeling in my dick. There is this tingling feeling in my dick, towards the down head of my penis. It feels like the inside of my penis to my scrotum feels ticklish so that I would need to use my hand in a rubbing manner to subdue it from the shaft to the dickhead. To me, it like feels like something was sucked out from its place to that region which causes a bit of pain or tingling feeling when urine passes through that pipe. I thought it was something that would wear out over time but it has been up to three weeks now and I still feel it. Besides, I even discovered it makes my dick leak, as in I noticed even when I am not going to ease myself, I feel a bit watery at the tip of the dick. I used to think it is water somewhat like urine but it was just yesterday while checking it out well, I discovered it feels kind of slimy and sticky. Please doctor, what do you think this is again? xxx@xxx

Well now that slimy discharge could actually be semen and it may be so because you seem to be dwelling a lot on your sexuality at this time. An infection is also possible. See your doctor for examination. Such an examination will ultimately help determine whether you should continue to worry yourself or not.

Dear doctor, for years, several doctors had told me that I was suffering from fibroids because of a large area of hardness under my belly button. I bled heavily during my periods and felt weak often. Finally, I agreed to have a blood transfusion from a surgeon who did a lot to allay my fears about having blood transfusion safely. I did so and felt stronger but he delivered some news that was quite a blow: he told me he suspected I had cancer. He also said that if that was the case, the transfusion I got would make my situation worse ultimately. He then advised me to see a gynaecologist who arranged a biopsy that confirmed those fears. Now sir, what is the way forward? I am 46 years old, unmarried and no child. Please help me. 0803xxxxxxx

Arrangements were made for this young woman and I to meet but the sad news came to me a week ago that she had gone to be with her maker. It is something of a downer that she was too late to be helped. Rest in peace.

Dear doctor, how are you doing? Please what are the following drugs used for? They are avonum; promethazine and doxycap? I ask because my 17- year-old son has got a bad cough and tonsillitis and he was given those medicines at a hospital we visited. Is that a good combination and if not, what can he use? Thank you for always being there sir. 0809xxxxxxx

Good day. I will start by answering the last part of the question first. If you are certain that your son has got tonsillitis the proper thing to do is to have him use broad spectrum antibiotics as well as pain relievers. I am constrained to leave it at that so as to prevent abuse of certain medications because what you ought to do is to have a confirmatory examination by a doctor. That said, doxycap which I imagine is a trade name for doxycyline is not a broad-spectrum antibiotic and does not have the breath of coverage for the possible micro-organisms known to be responsible for causing tonsillitis. Avonum is probably another trade name for avomine which is, like promethazine, an antiemetic, namely a drug which can stop vomiting or at least limit it in bad cases.

Dear doctor, I am a virgin. I love playing with females and anytime I play with them, my penis will become erect but within five minutes, my belly will start to pain me. I told someone about it but he told me that it is because I have not had sex before. Sir, is it true because it always happens to me whenever I play too much with females? 0811xxxxxxx

Well, your question is a bit of a problem to answer directly because your lower abdominal pain is not at all typical of an erection. However, because of your status as one who has never had sex, it is possible that the erections you have are so intense that an ache could develop in your lower abdomen from the intensity of your desire rather than the erection itself. What you therefore need to do to avoid the discomfort of such pain is to avoid playing too much with females; you should play with them a little and let them be so that you can also have peace. If there is something in your environment that causes you discomfort, simply avoid it.

Dear doctor, I do hope you are doing great. I would want to consult you on something. I have been suffering from an intense burning and gnawing feeling in my stomach for several days now. It is usually below my navel, in the middle of my stomach and I always experience it when I am in my period along with the usual cramps but it sometimes starts even when I am not on. It was really bad days ago and I started having a pulsating sensation near the navel leaving me bloated the whole night. Please, kindly help me diagnose and recommend treatment. Thank you. 0813xxxxxxx

So sorry about the degree of pain you have. You may actually be suffering from peptic ulcer disease which is a spectrum of similar ailments that can be properly treated at the hands of a doctor. At the present time, I will suggest that you use some antacids pending when you are able to see a doctor who might add something to the antacid you choose to take. This is specifically chosen to deal with your bloating sensation. In the end, you will have to undergo detailed tests targeted at reaching a conclusive diagnosis. That is the only way to ensure you become free from repeat crisis similar to this one.

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