Last year, I was invited as a guest speaker to a seminar organised at the Covenant University, Ota, Ogun State on the theme, “Reversal of Medical Tourism in Nigeria.” We were 10 speakers in all, handling different topics in relation to the subject matter. I was pleasantly surprised when one young speaker spent the whole allotted 25 minutes talking about laparoscopic surgery in ectopic pregnancy. I felt that he had veered off the course.
Well, we were just told the theme of the conference and given the freedom to choose our topics. His main grudge was that when he had a demonstration session, it was only junior doctors and nurses that attended. The consultants were not there. He had been so fired up having acquired the skill in laparoscopy that he wanted to share. He forgot that those he was referring to were already consultants when he was still a medical student. Well, it is commonplace that as a young specialist, one is always fired up to prove one or two things; but as the years roll by and with more experience, this tends to be watered down by so many baptisms of fire.
Barring the cost, laparoscopic surgery should be the norm. There is virtually no surgical procedure these days that cannot be done with a laparoscope from removal of diseased gall bladder through bowel resection to spinal cord procedures. In our environment, currently in a very inclement economic climate, this is a tall dream to realise even in some secondary and tertiary health facilities.
Simply described to the uninitiated, laparoscopy involves making a small incision and entering the abdomen with a trocar and canula. Through this, the abdomen is inflated with carbon dioxide gas and a set of instruments containing fibre optic device for vision, cutting blazer, tube for saline rinsing and suction. Carbon Oxide is a safe gas that when used to inflate the abdomen helps to separate the organs for good visualisation during procedures. In our environment, with the highest prevalent rate of ectopic gestation in the world, the advocacy for the use of laparoscopy in the management of ectopic gestation may be misplaced for now. Not only is the incident highest among those in the low socio-economic bracket in the rural areas, diagnoses are often made in advanced cases. And in most cases, surgical interventions are carried out by medical officers with limited experience. Here laparotomy and auto blood transfusion is usually the safest option. In medical school, you are thought: “Open up quickly, ligate the vessels quickly, transfuse quickly and resist the temptation of performing an appendectomy.” It still holds true today. Having said this much, laparoscopy is still today’s future.
In the management of ectopic pregnancy, there is a ground swell of interest in the use of medical option. Methotrexate is an anti-neoplastic drug used in the treatment of many cancers from breast, blood and even bone. It acts by blocking the incorporation of folic acid into the building block of most cells. This makes it very effective in disrupting rapidly proliferating cells. Thus when administered in early pregnancy it can lead to an abortion of the embryo. This is particularly indicated in a tubal pregnancy that has not resulted in uterine tube rupture .The main drawback is that except around the periphery of tertiary health facilities, where cancer patients are referred, the drug is hardly readily available. Besides being very toxic, Methotrexate must be used with caution. At the other end, the church has argued that it can also affect intra-uterine pregnancy, which is against its teaching. But wait for this: the church
is not bothered if the fallopian tube, together with the embryo, is removed during salpingectomy! We leave it there.
In our environment, with increasing aggression in the management of infertility, the incidence of ectopic pregnancy and pregnancy of unknown location (PUL) is bound to increase in urban areas. For a recap, pregnancy of unknown location is when there is evidence of pregnancy, going by the presence of Human Chorionic Gonadodtropins in the blood, and the absence of pregnancy in the uterus and the fallopian tube. This may be due to an intra uterine pregnancy being too small to be picked up by the ultra sound scan or the embryo being lodged in an extant location from the uterus. The management of this condition is of cautious waiting with serial abdominal and transvaginal ultrasonography with regular estimation of blood HCG and /or simple urine test for pregnancy. Usually in no distant time, a diagnosis is eventually made if the situation did not resolve on its own and had progressed.
One of the common interventions in the management of infertility in our environment in the last three decades has been procedure carried out on uterine tubes. These include procedures like tubal insufflations or flushing, cornal re-implantation, cuffed salpingostomy, tuboplasty and so on. These procedures, no matter how well intentioned, has no effect on depleted and damaged cilia of the uterine tube. Suffice it to say that with increasing popularity of Artificial Insemination and In-vitro Fertilisation, these procedures are gradually reducing in the rate at which they are carried out. But mark it; they have not been abandoned because some successes have been reported.
This makes it obvious that ectopic gestation is going to be around with us for quite a while. Hence it is imperative that improved diagnostic tools, in terms of radio imaging, should be made available and affordable in our cottage hospitals especially in rural areas. Some of us have argued in different forums that there is a need for some of the high tech diagnostic equipment brought down here to be tropicalised and possibly have solar panels attached to them This is very doable. Besides, it is high time we started doing things. World economy now thrives on copy and produce. Very few are involved in inventing new wheels.
We cannot wrap up this piece without talking about sex education and protected intercourse. These days, the fliers and campaign about human Immunodeficiency virus, HIV prevention has almost driven sensitisation about other sexually transmitted infection into the background. This should not be the accepted narrative. The HIV challenge is a slow crippling phenomenon that has almost been effectively kept under control while on the other hand complications from gonorrhea infection can be disastrous and fatal. Thus it is the responsibility of all stakeholders to take the challenge of sex education very seriously. Take away the religious and moral angles from the discus, there is nothing as good as being healthy and feeling and knowing that one future reproductive life is secured. That is where we should be.