نسائية (سيمنار)
عدد الاوراق (5)3/9/2012
Ectopic pregnancyobjectives
-What is ectopic pregnancy?.-The patho-physiology of the ectopic gestation.
-Discussion of the cases interdused and the choices of treatment that we have.
-the sequel of ectopic pregnancy.
An ectopic pregnancy, is a complication of pregnancy in which the fertilized ovum implants outside the uterine cavity.
Classification of the ectopic pregnancy:-
1-tubal pregnancy2-non tubal pregnancy
3-heterotopic pregnancy
4-persistant pregnancy
Ectopic pregnancy percentages of occurrence by location
Ampulla ectopic 75%_90%
Isthmic ectopic 5%_15%
Cornual/interstitial 1%_2%
Cervical ectopic 1%
Abdominal ectopic 0.3%_1%
How does the ectopic pregnancy happen
The sperm after ejaculation from the male travel from the vagina ,through the cervix, uterus and fallopian tubes where the fertilization takes place . The fertilized egg will travel back to reach the uterus. Most commonly the fertilized egg stops in the fallopian tube and implants there result in an ectopic pregnancy.The most common risk factor are:-
History of pelvic inflammatory disease (PID) and Sexually-transmitted diseases such as chlamydia and gonorrhea.Use of an intrauterine device (IUD).
Previous pelvic surgery.
Previous ectopic pregnancy.
Advanced age.
Unsuccessful tubal ligation or coagulation and tubal ligation reversal.
Use of fertility drugs.
Infertility treatments such as in vitro fertilization (IVF).
Congenital abnormality of the fallopian tube.
Pelvic adhesion and pelvic tumor.
Symptoms of ectopic pregnancy
abnormal vaginal bleeding.
Lower abdominal pain.
Sharp abdominal cramps.
Pain on one side of the body.
Symptoms of pregnancy.
Dizziness or weakness.
Pain in the shoulder or the neck.
If the fallopian tube ruptures, the pain and bleeding could be severe enough to cause collapse.
Case No. 1#
An 18 years old G2 P1 presents with abdominal pain and vaginal bleeding slight in amount containing no clots for the past day. last mc was 7 weeks agoShe confirms that she is pregnant as she did urine pregnancy test 4 weeks ago
How would you deal with this condition?
From History takingShe use an intra uterine device as a method of contraception
She did not have any pelvic surgery before nor sterilization
She did not use ovulation induction
She did not have history of PID
From physical examination
The vital signs: BP was 120/70ml/hg
pulse rate was 90
her Temperature was 37.3c
The abdomen is mildly tender with rebound
Cervical motion tenderness is not present
From investigations
Laboratory assessment: beta HCG measurement was 2200 mlU/mlThe trans_vaginal ultrasound reveals an empty uterine cavity
EMBED PowerPoint.Slide.8
Active monitoring
Done if there is:Mild symptoms
Low level of beta HCG
Tubal location
Hemodynamically stable healthy woman
Wait with follow up this is done by the B-HCG
in regular blood test and see if it is decline also monitor with the U/S the ectopic pregnancy
The disadvantage: risk of tube rupture even if the B-HCG shows low level
Methotrexate
Done if the ectopic is less than 3.5cm
Not suitable if there is:
Condition that decrease the immune system such as diabetes
Blood disorder
Liver disease
Kidney disease
The initial dose regimen(1mg/kg Im)
Monitor the B-HCG level, be aware of tube rupture
Follow up for 4_6 weeks
According to the dose as there is 2nd chance to develop ectopic pregnancy
Avoid alcohol drinking.
Deferential diagnoses of abdominal pain in woman of reproductive age are
Pregnancy-related: Ectopic pregnancy, spontaneous abortionGynecologic: Endometritis, pelvic inflammatory disease, tuboovarian abscess, endometriosis, ovarian neoplasm, ovarian torsion/rupture/hemorrhage, uterine fibroids.
Non- Gynecologic : Appendicitis, bowel obstruction, diverticulitis, IBD, UTI, pyelonephritis, nephrolithiasis.
Case No. 2#
38years old G10 P7 A2 at 8 weeks of gestation admitted to the hospital with severe lower abdominal pain for 2 hours and reports mild vaginal bleeding since 10 day agoHer BP was 90/65 ml/hg
pulse rate was 106 b.p.m.
Respiratory rate 20
Temperature 37.4 c
Physical exam findings
Enlarge uterus.
Vaginal bleeding.
Pelvic pain with manipulation of cervix.
Palpable adnexal mass.
Rad flags for rupture ectopic pregnancy:
Significant abdominal tenderness , hypotension, Guarding and rebound tenderness
The first step we should do is to correct her vital signs by establish an IV fluid for her
Doing blood sample for investigation {CBC, cross matching,CRP}
Do TVS to determine the type of her pregnancy
Transvaginal gray-scale US image obtained along the longitudinal axis shows an intrauterine pseudogestational sac (arrow); there is no yolk sac or fetal pole. Free fluid is seen in the cul-de-sac (*).
SHAPE \* MERGEFORMAT
Here the tube has been ruptured, and blood has collected in the abdomen, then emergency surgery is needed. In these cases the tube is often so badly damaged, that it has to be removed this is done by salpingectomy
The sequel of ectopic pregnancy
In case of un rupture ectopic there is high risk of become rupture and lead to deadly complication such as severe bleeding.61% of cases with tubal pregnancy can conceive:
38% from them had at least one conception resulting in A viable infant.
23% from them had recurrent Ectopic pregnancy.
3.Only 39% of cases become infertile especially after highly damaged tube that it is one of the conditions that need (IVF).
What monitoring is needed in a second pregnancy after ectopic pregnancy
Any pregnancy after an ectopic needs to be carefully monitored in the early stage to confirm the location
After the missed menstrual period or positive pregnancy test,blood HCG levels can be done to evaluate whether they are rising at an appropriate rate
By about 5_6 weeks of pregnancy TVS can be done to confirm that there is gestational sac and yolk sac within the uterine cavity
If that is not seen by 6 weeks suspicion should be high for another ectopic
Summary.
Ectopic pregnancy incidence is about 1 every 60 population that increase seriously with the risk factors.Ectopic pregnancy should take a good observation in order not to develop any un wanted complication.
Treatment of ectopic include active monitoring , medical (mtx) and surgical that vary in uses according to the case present.
Regular follow up after ectopic in the next pregnancy should take place in order to diagnose early problem and ensure normal gestation.
Take home points
The classic triad of ectopic pregnancy includes abdominal pain , vaginal bleeding, and amenorrhea.Transvaginal ultrasound is the modality of choice when diagnosing an ectopic pregnancy.
With hCG level>1500mIU/mL and no IUP identified on transvaginal ultrasound, this is high high-risk for ectopic pregnancy.
Transvaginal ultrasound is diagnostic if a true gestational sac , yolk sac, embryo, or cardiac activity is found inside or outside of the uterus
Ectopic pregnancy is the leading cause of pregnancy related death
References
Bhatt, Shweta; Hamad Ghazale, Vikram S. Dogra. Sonographic evaluation of ectopic pregnancy. Radiologic clinics of North America. 45 (2007) 549-560.
Derchi, Lorenzo E. et al. Ultrasound in gynecology. Eur Radiol. (2001) 11:2137-2155.
Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography. Seminars in Roentgenelogy, Vol XXXIII, No 4(Oct), 1998: pp 339-343.
Lozeau, M.D., M.S., Anne-Marie & Beth Potter, M.D. Diagnosis and Management of Ectopic pregnancy. American Family Physician. Volume 72, No 9; Nov. 2005.
Nelson AL, DeUgarte CM, Gambone JC. Ectopic pregnancy. In: Hacker NF, Moore JG, Gambone JC. Essentials of obstetrics and gynecology, 4th ed. Philadelphia: Saunders, 2004: 325-333.
Novelline, Robert A. Ultrasound imaging & Ectopic pregnancy. Squires Fundamentals of Radiology. Sixth edition. Pgs. 34-35 & 430-431.
Toy, MD, Eugene C., Benton Baker, MD, MSC, Patti Jayne Ross, MD, Larry C. Gilstrap, MD. Case Files: Obstetrics & Gynecology. Pgs. 63-69, 211-218, 329-333.
Yudin, MD, Mark H. MSc, FRCSC, & Harold C. Wiesenfeld, MDCM. Current Diagnosis & Treatment of Sexually Transmitted Diseases. Chapter 5: Lower Abdominal Pain in Women.