ECTOPIC PREGNANCY

a rebellious embryo may decide to implant itself outside the uterus!

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After the fertilization of the egg by a viable sperm, the resultant embryo travels from the fallopian tube down into the cavity of the uterus. Implantation occurs when the embryo is attached to the uterine wall and continues to develop until full term gestation.

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However, for reasons that are not fully understood, a rebellious embryo may decide to implant itself outside the uterus!

Ectopic Pregnancies (EP) account for about 11:1000 pregnancies. More than 80% of such rebels implant in the fallopian tube, hence the name “Tubal Pregnancy”, often used interchangeably with EP.

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Other recognized locations of EP are the abdominal cavity, ovaries, cervix and cesarean section scar.

Because of the limited space for growth within the tube or other ectopic sites, rupture and severe internal bleeding could occur starting from 6-8weeks. Ruptured EP is a life-threatening condition and one of the major causes of maternal mortality.

What are the risk factors for EP?

  • Previous history of EP
  • Previous history of infertility and its treatment (assisted reproductive techniques)
  • Pelvic inflammatory disease (PID)
  • Intrauterine contraceptive device use at the time of conception
  • Endometriosis (presence of the uterine lining outside of the uterus)
  • Pelvic or tubal surgery
  • Smoking

The only way to ensure prompt diagnosis and treatment of EP is to have a high index of suspicion by recognizing the telltale signs.

 

The symptoms are variable and non-specific but there is a classical triad reported by many patients:

  1. Missed period (6-8weeks)
  2. Lower abdominal pain
  3. Mild vaginal bleeding or brownish discharge. 

 Other symptoms include:Shoulder tip pain (sign of internal bleeding-ruptured EP),  Sudden collapse (due to severe blood loss)

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    A diagnosis is usually confirmed by identification via ultrasound scan, supported by the level of an early pregnancy hormone known as Human Chorionic Gonadotropin B (BHCG). The modality of treatment depends on the clinical status.

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    *Surgical management – in ruptured EP, with acute severe blood loss, emergency surgical intervention must be done, together with blood transfusion to save the patient. 

    *Medical management – using methotrexate, in clinically stable patients who are compliant 

    *Expectant/Conservative management – in small sized EP and falling BHCG where the body is expected to get rid of the “rebel” by itself. This is reserved for a select few cases.

    Below is a summary of events in a woman with ectopic pregnancy and how the doctor chooses how best to help her.

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    Depression

    You can’t love others if you don’t love yourself and you are selfish if you love yourself too much because few would embrace you. If you don’t love yourself at all, you need help, not death.

    “Since the robbery, I have cried all day and night, I can’t believe I have lost it all, ahh! I am so sad, in fact, I am depressed, she said”

    DEPRESSION IS NOT SADNESS

    Sadness, like excitement, is a normal reaction to an unpleasant situation or life difficulties. Often times, however, ‘I am depressed as used in the story above is used synonymously with I am sad. By extension reducing the reality of the illness to just a mood- sadness. This misconception is what birth statements like “snap out of it”, “man up”, “you are just making a big deal out of it”.

    Depression is a mental illness, associated with low mood, decreased energy, low self-esteem, loss of interest in previously exciting activities, appetite disorder (loss or excessive), a feeling of guilt, thoughts of death and disturbed sleep. Depression is way beyond sadness.

    Signs and Symptoms of Depression

    “It started with my being unable to sleep, but it soon got worse. I lost weight drastically and started experiencing somatization- chronic physical pains in various parts of my body, making me very weak and low-spirited, but no one at the time understood what I was talking about”.  

    Again, sadness is not depression, sadness could for some is only a small part of depression and some others may not feel sadness at all. Depression has many other symptoms, including physical ones. If you have been experiencing any of the following signs and symptoms for at least 2 weeks, you may be suffering from depression:

    • Decreased energy, fatigue, being “slowed down”
    • Difficulty concentrating, remembering, making decisions
    • Persistent sad, anxious, or “empty” mood
    • Feelings of hopelessness, pessimism
    • Feelings of guilt, worthlessness, hopelessness
    • Loss of interest or pleasure in hobbies and activities
    • Difficulty sleeping, early-morning awakening, or oversleeping
    • Appetite and/or weight changes
    • Thoughts of death or suicide, suicide attempts
    • Restlessness, irritability
    • Persistent physical symptoms, e.g. diarrhea

    Types

    There are different types of depressive disorders and based on symptom severity, depression can range from mild to severe to very severe condition

    Major depression

    Major depression is sometimes referred to as clinical depression, unipolar depression or major depressive disorder. It involves low mood and/or loss of interest and pleasure in usual activities, as well as other symptoms for at least two weeks. Symptoms of depression interfere with individual’s daily life and normal functioning. Depression can be described as mild, moderate or severe; melancholic or psychotic (see below).

    Melancholia

    This is the term used to describe a severe form of depression where many of the physical symptoms of depression are present particularly slow movement. It is also characterized by complete loss of pleasure in everything or almost everything.

    Psychotic depression

    Sometimes a depressive disorder can be accompanied by loss \of touch with reality and experience psychosis. This can involve hallucinations (seeing or hearing things that aren’t there) or delusions (false beliefs that aren’t shared by others), such as believing they are divinities, prophets or evil, or that they’re being watched or followed. They can also be paranoid, feeling as though everyone is against them or that they are bad omens.

    Antenatal and postnatal depression

    In the days or weeks following birth, many women experience ‘baby blues’ which is a common condition related to hormonal changes and affects up to 80 percent of women. The ‘baby blues’, are common experiences, but are different from depression and tend to decrease within a week or two. Depression is longer lasting and can affect not only the mother but her relationship with her child, the child’s care and development, the mother’s relationship with her partner and other members of the family. Almost 10 percent of women will experience depression during pregnancy. This increases to 16 percent in the first three months after having a baby.

    Bipolar disorder

    In bipolar disorder, the person experiences periods of depression and periods of mania, with periods of normal mood in between. Mania is the opposite of depression, characterized by extremely “high” moods, energized behavior, having racing thoughts, little need for sleep, difficulty concentrating and feeling frustrated and irritable. It may sometimes affect the person’s touch with reality and has episodes hallucinations (seeing or hearing something that is not there) or having delusions (e.g. the person believing he or she has divine powers).

    Bipolar disorder tends to run in families. Stress and conflict can trigger episodes for people with this condition and it is common for bipolar disorder to be misdiagnosed as depression, alcohol or drug abuse, attention deficit hyperactivity disorder (ADHD) or schizophrenia. A mild form of bipolar disorder is cyclothymic disorder

    Seasonal affective disorder (SAD)

    SAD is a mood disorder that has a seasonal pattern. The cause of the disorder is unclear, but it’s thought to be related to the variation in light exposure (Sunlight) in different seasons. Depression which starts in winter and subsides when the season ends is the most common.

    Causes

    “Mopelola was noticed in September in the year 2014 to be unduly withdrawn from people including keeping away from her friends on the ground that nobody loves her; almost at the same time, she has also been seen not to be participating in some of the church activities that were known to be pleasurable to her. Within a month of the onset of the condition, she has been observed to have reduced appetite for food as she claims that she has a need to engage in fasting and prayers to combat some negative thoughts that were running through her mind, such thoughts according to her include but not limited to thoughts of not “good enough, being worthless and useless and that there was nothing good about her future”. Consequently, she felt unhappy all the times and sometimes got angry at others around him. This condition has affected her ability to concentrate on her JAMB coaching class and her level of concentration has dropped significantly. Her parents in their state of being bewildered to have made many spiritual attempts to ameliorate the problem, only minimal improvement was noticed”

    The thought that depression is mood-sadness, and sufferers being individuals “who can’t just get over it” consequently make the misconstrued cause of depression to be Weakness. Religious affirmations that link spiritual weakness to depression further make appropriate treatment less sought.

    Depression like all illness have factors that play a role or make an individual vulnerable. They include;

    • Traumatic events
    • Other mental health problems
    • Physical health problems e.g. chronic or life-threatening health problems
    • Genetic inheritance
    • Childhood experiences such as neglect, loss of parent(s)
    • Medication, substance and alcohol abuse.
    • Sleep, poor nutrition, and exercise

    Treatment

    Depression – even the supposed worse cases – can be treated and individuals can recover and live a productive life. Like all illness, early detection and treatment greatly affect treatment outcome. The earlier the better.

    While many may still argue that depression is caused by spiritual weakness or attack, I advise that while deliverance and other spiritual approach are being sorted, kindly visit a doctor. The goal is to be better, isn’t it? The first step to recovery is seeking help, speak to a doctor, your doctor may then refer you to a specialist after physical problems have been ruled out.

    Depression depending on the diagnosis made can be treated with medications or psychotherapy or both. Treatment is often times individualized.

    Depression can occur to anyone and at ages

    According to the World Health Organization (WHO), depression is the leading cause of disability worldwide, and at least 350 million people are affected worldwide, this could be higher considering denial and treatment abstinence based on misconceptions or ignorance could hinder diagnosis in some sufferers. Although a common illness, it affects individuals differently

    Depression in Women.

    Women with depression do not all experience same symptoms, however, symptoms of sadness, worthlessness, and guilt are typical symptoms women have.

    Depression is twice as common among women as among men. Hormonal fluctuations during puberty, menstruation, pregnancy, childbirth and menopause are probable causes amongst other factors such as genetics and abuse.

    Depression in Men

    Men although less likely than women also suffer depression and manifestations in men differ from those in women. Men are more likely to react to life difficulties with denial, anger, violence or substance and alcohol abuse. Some men may throw themselves into their work to avoid talking about their feelings or behave recklessly. Although more women attempt suicide, many more men die by suicide.

    Depression in Children

    Children are particularly thought to be free-spirited and do not “think”, hence can’t suffer depression.

    “Most studies concur that about 1% to 2% of pre-pubertal children and about 5% of adolescents suffer from clinically significant depression at any one time and by the age of 16 years 12% of girls and 7% of boys would have had a depressive disorder at some time in their lives”.

    The implication of the above is that in a primary school of about 300 children at least 3-6 of them will be depressed at any one time. Children with depression may pretend to be sick, refuse to go to school, cling to a parent or become excessively anxious. The normalcy of children makes recognition a bit difficult, however, a change in the initial behavioral or academic pattern are major red flags to watch out for.

    Depression in Teens

    As children grow into teenagers and adolescent, parental acceptance is second to peer acceptance, coupled with hormonal changes, teenage years can be tough and irritable moods are expected.

    However, depression in teenagers often presents with persistence in irritability (hostile, easily frustrated, angry outbursts), hypersomnia, increased appetite or loss of it, extreme sensitivity to rejection (criticism). Depression if left untreated may manifest fully in reckless behavior, substance abuse or school desertion.

    Unlike in adults, children and teenagers rely on adults (parents, teachers, and caregivers) in recognizing and helping them get help as ignorance of their feelings or their natural dependence may prevent them from getting help.

    Takeaway

    Prevention is better than cure, early detection and treatment will prevent disease progression

    Self-care tips and general lifestyle modifications can help manage the symptoms of many mental health problems, and may also help to prevent some problems from developing or getting worse.

    Reference

    Depression in children and adolescents, 2015 edition by; Joseph M Rey, Tolulope T Bella-Awusah & Jing Liu pg. 2

    Shadows in the Mirror by; Dr. Vivian Ikem

     

     

     

    Rukayat Ogunbiyi is a Pharmacist and Public mental health advocate, inclined towards child and adolescent psychiatry. She was trained as an intern at the Federal Neuropsychiatric Hospital, Yaba. She is currently set to resume post graduate studies in Child and Adolescent Mental health at the Center for Child and adolescent mental health in University of Ibadan.

    Anxiety and co…

    Anxiety disorders are the most commonly encountered psychological disorders among adults

    If you have never felt anxious, something is wrong with you. It is okay to worry temporarily especially when we have to make important decisions when we are faced with a challenge or a test/exam. However, it is a different case entirely when this is blown out of proportion. Anxiety disorders are the most commonly encountered psychological disorders among adults and they interfere with performance, relationships and other healthy daily activities.  Have you read about Stress?

    Anxiety disorders are the most commonly encountered psychological disorders among adults and they interfere with performance, relationships and other healthy daily activities.

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    Nobody wants to be labeled as crazy, especially in an African society where stigmatization thrives like wild-fire. For this reasons, critical issues pertinent to assessing anxiety disorders are bordered on;

    • Sensitivity to making the diagnosis
    • Anxiety in a mask of productivity
    • Other psychiatric diagnoses associated with it
    • Medical conditions and medications that can cause or exacerbate anxiety disorders.

    Risk Factors

    • Shyness, or behavioral inhibition, in childhood
    • Being female
    • Having poor economic resources
    • Being divorced or widowed
    • Exposure to stressful life events in childhood and adulthood
    • Anxiety disorders in close biological relatives
    • Parental history of mental disorders

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    The anxiety disorders that will be examined in this write-up will include:

    1. Panic disorder
    2. Generalized anxiety disorder
    3. Obsessive compulsive disorder
    4. Post-traumatic stress disorder
    5. Social phobia and specific phobia.

    As each disorder is explored, emphasis will be placed on assessment of commonly encountered psychiatric and medical conditions that contribute to anxiety symptoms. However, before considering the specific anxiety disorders to be presented in this program, it is useful to highlight the following issues:

    Psychiatric Disorders associated with Anxiety Disorders

    • Major depressive disorder
    • Substance abuse disorders – alcohol, marijuana
    • Somatization disorders (fatigue, chest pain, headache, insomnia, non-specific GI complaints)
    • Complex anxiety disorders – ( Post-traumatic stress disorder with Panic disorder)

    Medical Conditions associated with Exacerbating Anxiety

    • Hyperthyroidism
    • Adrenal Dysfunction
    • Angina
    • Hypoglycemia

    Medications and Substances associated with Exacerbating Anxiety

    • Stimulants (Amphetamines, caffeine, cocaine, and other over the counter “natural stimulants”)
    • Withdrawal from drugs, including alcohol
    • Heavy metals and toxins
    • Steroids
    • Rapid withdrawal from some antidepressants

    General Action plan in dealing with anxiety and associated disorders

    1. Assessment for suicide risk, particularly in patients with depression and panic disorder, substance abuse or high levels of agitation.
    2. Identification of severity of anxiety disorder (chronic or episodic)
    3. Identification of substance abuse
    4. Assessment of key symptoms of panic disorder, fear of dying and/or fear of going crazy
    5. Assessment for depression or other mood disorder
    6. Inquiry as to the presence of anti-social behavior
    7. Exploration of presence of precipitating event or trauma
    8. Being alert to people with anxiety disorders who have insomnia, headache, non-specific GI complaints, cognitive complaints

    We will be talking extensively about mental health and major associative conditions in the comings weeks. Stay tuned. Read about Stress here.