ectopic/ovarian torsion Flashcards
Ectopic Pregnancy
general
Implantationof a fertilized egg (embryo) outside the uterine cavity
Epidemiology
3rd-leading cause of maternalmortality
Occurs in 1%–2% of all first trimester pregnancies
Diagnosed in ~10% ofpatientspresenting with vaginal bleeding and abdominalpainin early pregnancy
Etiology
Can occur when the fertilized egg does not enter the uterine cavity by way of thefallopian tubeby the 5th to 6th day of gestation
Caused by:
Disorders of theovulationmechanism
Blockage of theembryo’s tubal passage…affected by congenital anomalies, acquired tubal obstructions, and disruption of ciliary activity or tubemotility
ectopic pregnancy
RF
Pelvic inflammatory disease(50% of cases, increases risk 3x)
Adhesionsafter tubal surgery (25% of cases)
Assisted reproduction (in vitro fertilization(IVF))
Prior ectopic pregnancy
Abnormal endometrium (endometriosisor fibroids)
Congenital malformation of theuterus(bicornuateuterus)
Smoking
Advanced age (> 35 years old)
Intrauterine device/oral contraceptives (if pregnancy occurs despite their use)
ectopic
Locations of Implantation
> 95% within thefallopian tube
3% in the ovary
1% in the peritoneal cavity (abdominal)
< 1% in thecervix
Combined intrauterine and extrauterine pregnancy may occur rarely
Ectopic pregnancy
clin man
General pregnancy symptoms
Breast enlargement and tenderness
Secondary amenorrhea
Morning sickness
May present as anacute abdomen
Sudden, severe, lower abdominal or pelvicpain
Pain may be more diffuse if there is blood in the abdominal cavity
If painradiates toward the shoulder → sign of tubular rupture
Rupture can cause significant internal bleeding → leading to hypovolemicshock
ectopic pregnancy
PE
History and clinical examination
Patients may report a missed or irregularlast menstrual period
Vital signs
Tachycardia and hypotension in the case of rupture
Abdomen
Abdominal rigidity
Rebound tenderness and/or guarding
Pelvis
Cervical motion tenderness (differentiate from pelvic inflammatory disease (PID))
Closedcervix
Adnexal tenderness
Palpable adnexalmass (10%–20% of cases)
ectopic
labs
Medical Commandment!
Thou shall perform a pregnancy test on all women of reproductive age who present with abdominal pain!
Urine or serum β-hCG (qualitative → quantitative)
Generally lower than expected
If followed over 2 days…plateau rather than doubling every 2 days
Type and screen
Blood type and Rh factor
Rh negative → RhoGAM is required
Complete blood count (CBC)
Anemia/evidence of hemorrhage
To evaluate for other causes of acute abdominal pain: liver function tests(LFTs), basic metabolic panel(BMP), urinalysis (UA)
ectopic preg
Diagnosis
US
Normal pregnancy
At 5–6 weeks gestation → a gestational sac and yolk sac are present within theuterus (intrauterine pregnancy)
+*Ectopic pregnancy findings
An empty uterine cavity without an amniotic sac **
β-hCG of 6,500 mIU/mL with an empty uterine cavity by transvaginal US is highly suspicious for ectopic pregnancy
Enlargement of thefallopian tubewith an amniotic sac
Case of tubal rupture, free fluid (blood) is present in thepouch of Douglas
Diagnosis can be further confirmed bylaparoscopy
ectopic pregnancy
differentials
Mnemonic “HAIKU POEM” can help you remember the differential diagnoses of an ectopic pregnancy
Non-gynecological causes: HAIKU
H:Hepatitis
A:Acute abdomen
I:Intestinal Inflammation (appendicitis, sigmoiddiverticulitis)
K:Kidney stone
U:Urinary tract infection
Gynecological causes:POEM
P:Pelvic inflammatory disease
O:Ovarian disease (cyst rupture, torsion, polycysticovaries)
E:Endometrial diseases (endometriosis,hyperplasia)
M:Miscarriage/spontaneous abortion
ectopic
Surgical management
Can be expectant, medical, or surgical depending on the patient’s condition, hCG trend, and maternal/fetal factors
Surgical (EMERGENCY) management
Assess and stabilize ABCs (airway, breathing, circulation)
Giveintravenous fluidsto compensate for blood loss
Transfusion if blood loss is significant
If the patient is Rh-negativeblood type
Administer RhoGAM to prevent Rh incompatibility in future pregnancies
Laparoscopy → salpingostomy or salpingectomy
Size of the ectopic pregnancy and whether or not it has ruptured
ecoptic
medical management
Indications
Administration of methotrexate 50 mg/m2IM to induce a medicalabortion
Must monitor the patient’s β-hCG levels to 0
Reserved for patients that meet the following:
Hemodynamically stable
Normal liver function
Normal renal function
Pregnancy sac < 3.5 cm and no fetal cardiac activity on ultrasound
**Use of methotrexate in an unstable patient is absolutely contraindicated!**
ectopic pregnancy
Expectant management
Reserved for patients who meet the following:
Asymptomatic
No evidence of extrauterine sac/masson ultrasound
Low and decreasing serum β-hCG (≤200 mIU/mL)
Agreeable to close follow-up
Steps include:
Monitoring the pattern of serial β-hCG levels → levels should decline
Giving strict return for follow-up instructions to ensure that β-hCG is monitored
Abandoning expectant management if significant abdominal pain develops or β-hCG increases or fails to decline
Ovarian Torsion/ Adnexal Torsion
general
SURGICAL EMERGENCY
Ovaries twist along their axis, with or without involvement of the fallopian tubes, leading to partial or complete obstruction of the arterial blood flow and causing ischemia
Epidemiology:
More common in women of reproductive age because of the regular formation of physiologiccysts
More commonly affects women withovaries> 5 cm
Ovarian cysts and tumors (found in > 85% of cases)
Women undergoing fertility treatments
Polycystic ovarian syndrome (PCOS)
Pregnancy
Right ovarian torsion > Left ovarian torsion (mobility of the left ovary is limited by the sigmoidcolon)
ovarian torsion
RF
Age
Reproductive age
Ovarian enlargement (particularly by a benign mass/tumor)
Benign tumors are more likely to cause torsion than malignant tumors
Severity of the torsion is determined by the size of the mass/tumor
Pregnancy
Highest risk during the 1st trimester
Congenital abnormalities (elongation offallopian tubes)
A history of pelvic surgery (adhesions)
ovarian torsion
patho
Ovarian or tubo-ovarian torsion involves the following sequence of events:
Twisting along the ovarian axis (suspensory ligament or utero-ovarian ligament)
Compression/blockage of the venous and lymphatic drainage from theovaries
Local edema of the ovary,fallopian tubes, and supportive ligaments
Compression/blockage of the arterial supply of theovaries
Ischemia, followed by necrosis of the ovarian tissue
Local hemorrhage from friable necrotic tissue
ovarian torsion
Clin man
Sudden, severe lower abdominal/pelvicpain
Nausea and vomiting
Common
May be continuous or appear in waves
Fever (late finding) → ovary is undergoing necrosis or rupture
Abnormal vaginal bleeding and discharge might be present if associated with rupture or an abscess
Physical examination looking for:
Abdominal guarding/rebound pain
Localizedpainupon palpation
Unilateral tender adnexalmass
ovarian torsion
imaging
Common findings
Imaging
Pelvic ultrasonography with Doppler
Transvaginal US is better than transabdominal US
Often nondiagnostic
NormalDopplerflowdoes not exclude torsion
Common findings:
Asymmetrical, enlarged ovary
Decreased/absent Doppler flow
Whirlpool sign – thickened vascular pedicle
Intraperitoneal fluid → leakage of interstitial fluid from the twisted ovary/fallopian tube
CT abdomen and pelvis is used to rule out other abdominal conditions (appendicitis, diverticulitis, etc.)
ovarian torsion
Laparoscopic oophoropexy
Fixate the detorted ovary +/- contralateral ovary to the pelvic side wall, back of uterus, or ipsilateral uterosacral ligament
