Bleeding Inearly Preg ( Ectopic )

Question 1

Def
Incidence
Sites

Answer 1

• implantation outside the uterus
• 1.5%
• •fallopian : the moct common especially
  amupllary then isthmus then interstiam
  •ovary
  • cervix
  • rudimentary horn
  • cs scar
  • advanced abdominal

Question 2

Recurrence
Causes
Fate

Answer 2

• reach 30%
• (6) 3/3
  • previous pid : gonoccal, chlamydial
  • previous pelvic or tubal surgeries: tubal sccaring , pelvic adhesions
  • endometriosis: pretubal adhesion

• iud: + outside implant
• prg only contraception: alter motiliy thus + implant in tube
• ICSI : due to multiple ovulation, prg support

• Preg may reach up til 8:10 w then this may occur

• tubal mole : attacks of slight bleeding surrounding the becoming dead ovum ~> mole
• tubal rupture : causing pelvic hematocele, intraperitoneal hge
• tubal abortion : passing through abdominal ostium incompletely or completely with persistent bleeding causing hematosalpinx, pelvic hematocele or diffuse intraperitoneal hge

Question 3

Cp

Answer 3

Disturbed preg , either stable or not
Sym (4)
• pain is the most prominent sym maybe aching, colicy , shoulder pain due to accumulation of blood under diaphragm irritating phrenic n
• nausea, vomiting : due to irritation of peritoneam by blood
• minimal vaginal bleeding due to shedding of decidua after death of embryo
• syncope ( fainting attacks) inproportional to external but internal bleeding

Signs
(4)
(3)
(3)

General
- pallor if long stand, syncope if sudden severe
- temp may be n or - or + due to absorption of blood ( inflammation)
- pulse : rapid
- bp : low proportion to internal bleeding

Abdominal
- lower abd pain , tenderness , rebound tenderness on MID INGINUAL LIGAMENT
- shifting dullness
- cullen sign : in long standing intraperitoneal hge

Vaginal
- jumping or frog sign : tenderness on moving cervix
- ut is slightly enlarged up to 8w , soft ( hormonal) decidua without villi ( arias stella reaction )

-adnexal mass may be felt

Undisturbed
No sym or signs , accidentally during antenatal follow up

Question 4

• dd
• inv

Answer 4

• Acute abdomen, bleeding in early preg , gynaecological causes ( excluded but bhcg )

-
•Bhcg with doubling : doubling after 48h
• if doubled at peast 60%: normal preg detected later by us
• if increased not doubled : diag for ectopic
• if decreased: abortion

•Bhcg with us above the discrimination zone
• tvs : at 1500 if ut is empty then its ectopic
• tas :at 3500
-
•laproscopy : to confirm ectopic
• bhcg before doubling: PUL

Question 5

Management

Answer 5

Medical
• mtx im 1mg / kg once a week
• indications :
* stable vitally
* undisturbed
* ectopic < 3cm
* bhcg < 6000
* no pulsations
* normal liver , kidney
( if one of them ~> surgical )

• follow up d4,d7 must decrease 15%
•If its still increased give other dose if still then surgical
•Pregnancy is delayed for 3m after use of mtx

Surgical
Laproscopy ( stable vitally )
Open Laprotomy ( unstable)

Salphingotomy :
•as it less invasive
• preserve especially if young patient
• recurrence is very high
• healed by 2ry intention

Or

Salpingectomy

Question 6

Ovarian
Abdominal

Answer 6

(4)
• as tubal but pain is less
• diagnosis is difficult without laproscopy
• ovary must be preserved so lazm ady rabna ino metx ynfaa
• oophrectomy may be done if severe bleeding

(4)
• disturbance is delayed til 2nd ir rarely 3rd tri
• laportomy is made for diagnosis
• placenta is attached to vital organs or even major vessels that may cause on removal internal hge
• its best to leave it attached until spontaneous autolysis happens

Question 7

Rudimentary
Cervical
Cs scar

Answer 7

• (3)
  •Rupture in 4or 5m ( delay due to myometrium but poorly developed)
  • diagnosis is difficult due to delayed
  • associated with internal hge

-(3)
• massive vaginal bleeding
• mtx if minal bleddig or small
• hysterectomy if massive bleeding

-(3)
• best diagnosed with tvs
• mtx and guided us feticide
• if deep invasion ~> hysterotomy