24. Ectopic pregnancy. Flashcards
what are the risk factors for ectopic pregnancy ?
salpingitis and pelvic inflammation - especially those caused by Chlamydia trachomatis
IUD
tubal surgery
Intrapelvic adhesions following pelvic surgery.
previous ectopic pregnancy
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atypical” implantations – cornual, abdominal,
cervical - ovarian following ART
what are the modes of termination of tubal pregnancy ?
tubal mole formation - abortion - pelvic hematocele through abdominal ostium ( blood so collected in the pouch of Douglas)
tubal mole - complete absorption (rare)
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tubal abortion (most common in the ampulla and infundibulum)
complete - pelvic hematocele /hemoperitoniem
incomplete diffuse intraperitoneal hemorrhage
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tubal rupture
common in isthmic and interstitial implantation
roof - diffuse intraperitoneal haemorrhage
floor -rare but occurs most common in isthmic - intraligamentary hematoma
tubal perforation - secondary abdominal pregnancy (very rare)
floor - secondary intraligamnetray pregnancy (v rare)
what are the signs and symptoms for acute tubal pregnancy ?
traid
acute : tubular rupture and tubular abortion with
massive intraperitoneal hemorrhage :
1) 6-8 weeks of amenorrhea
then
2) severe abdominal pain - leading to fainting and fast pulse
there can also be shoulder tip pain - pan due to diaphragmatic irritation hemoperitoneum.
3) scanty and continious vaginal bleeding after the colicky pain pain
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vomitting and fainting attack - peritoneal irritation from hemoperitoneum
pallor and perspires
LOWER and usually UNILATERAL abdominal tenderness
dysuria
CULLEN SIGN - dark blue hemorrhagic discoloration of the umbilical area
what are the signs and symptoms of unruptured tubal pregnancy ?
presence of delayed period or spotting
uneasiness of one side of flank , which is colicky sometimes
where do most ectopic pregnancy occur ?
most common in the fallopian tube (ampulla most, isthmus , infundibulum, interstitial)
abdominal
cervical
what is the diagnosis of acute tubal pregnancy ?
laparotomy when hemodynamically unstable
in acute
pelvic examinations
vaginal mucosa blanched and white
extreme tenderness of the vaginal fornix or movement of the cervix
no mass felt but uterus floats as if in water
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culdocentesis not used as freq- spinal needle through the posterioir vaginal fornix into the peritoneal space of the pouch of Douglas
Fluid containing fragments of old clots, or bloody fluid that does not clot confirm diagnosis of hemoperitoneum
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Do a
high resolution transvaginal ultrasound -adnexal mass that moves separately from the ovary,showing a gestational sac with fetal heart beat
+
do beta HCG levels
Lower concentration of b-hCG compared to normal intrauterine pregnancy (2) Doubling time in plasma fails to occur in 2 day
The lowest level of serum b-hCG at which a gestational sac is visible using TVS (discriminatory zone) is 1,500 IU/L
6,000 IU/L for TAS
b-hCG value is greater than 1,500 IU/L and empty uterine cavity, ectopic pregnancy is likely.
Failure to double the value of b-hCG by 48 hours along with an empty uterus is very much likely
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laparoscopy only when hemodynamically stable
Confirmation of diagnosis
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Serum progesterone—greater than 25ng/mL suggestive of viable intrauterine pregnancy whereas level less than 5 ng/mL suggests an ectopic
what is the diagnosis of unruptured tubal ectopic pregnancy ?
ill defined and extremely tender ,pulsatile ,small , well circumscribes tender mass felt through ONE of the posterolateral fornix extending to the pouch of douglas.
this mass can push the uterus to opposite side
TVS
high sensitive radioimmunoassay of Bhcg
dd of acute etopic pregnancy
misscarriage appendicitis ruptured corpus luteum ruptured chocolate cysts perforated peptic ulcer
what is the treatment for acute tubal pregnancy?
Ringer’s solution
blood transfusion
laparotomy when Patient hemodynamically unstable.(Laparoscopy contraindicated)
Salpingectomy
ipsilateral ovary and its vascular supply is preserved. Oophorectomy is done only if the ovary is damaged beyond salvage
what is the treatment for unruptured tubal pregnancy /early detection ectopic pregnancy?
only observation for spontaneous resolution hcg <1,000iu/ml and falling
gestational sac <4cm
no fetal heart beat on TVS
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medical : systemic
or direct through us guided / laparoscopic
patient must be hemodynamically stable
tubal diametere <4cm with no fetal activity
- methotrexate IM injection / potassium chloride
measuring serum b-hCG on D4 and D7 should be declining
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conservative
laparoscopy :Salpingectomy
is done when
(i) whole of the affected tube is damaged,
(ii) contralateral tube is normal or
(iii) future fertility is not desired
what is the cause of persistent ectopic pregnancy ?
incomplete removal of trophoblast.
It is high after fimbrial expression and in cases where initial serum b-hCG level is greater than 3,000 IU/L
what other things do we ensure for ectopic pregnancy ?
rh negative women
anti-D gamma globulin IM
what is the management for abdominal pregnancy
MRI best for diagnosis more that US
early conceptus expelled into the peritoneal cavity, its placental attachment may persist
urgent laparotomy irrespective of period of gestation. The risks of continuation of pregnancy are:
(1) Catastrophic hemorrhage.
(2) Fetal death.
(3) Increased fetal malformation.
management for ovarian ectopic pregnancy ?
salpingo-oophorectomy is the definite
Ovarian resection could be done when the diagnosis is made early
what are other places of ectopic pregnancy ?
broad lig
cornual
heterotopic ectopic preg -uterine pregnancy coexising with a second pregnancy in an extrauterine location
