Ectopic pregnany pt.1

Question 1

What is the uterus?

Answer 1

Thick-walled, pear-shaped hollow sexual muscular organ

Question 2

What does the uterus consist of anatomically? Provide location and significance in size

Answer 2

Three parts:

• The body/corpus (Superior two thirds)
• The isthmus (1cm portion connecting the body to the cervix)
• The cervix (narrower cylindric inferior one third)

Question 3

Describe the shape of the body of the uterus

Answer 3

• The body of the uterus narrows from the fundus, the rounded superior part of the body, to the isthmus, the 1-cm-long constricted region between the body and cervix
• Constricted opening at each end The internal os (opening) of the cervix communicates with the cavity of the uterine body, and the external os communicates with the vagina

Question 4

What is the shape of the cervix?

Answer 4

Cylindrical

Question 5

What is the area within the uterus called?

Answer 5

Uterine cavity

Question 6

What is the lumen of the cervix known as?

Answer 6

Cervical canal

Question 7

Describe the relation of the cervical canal to the rest of the female reproductive system

Answer 7

• The lumen of the cervix, the cervical canal, has a constricted opening at each end
• The internal os (opening) of the cervix communicates with the cavity of the uterine body, and the external os communicates with the vagina
• In front of the upper part of the cervix lies the bladder, separated from it by cellular connective tissue known as parametrium, which also extends over the sides of the cervix
• To the rear, the supravaginal cervix is covered by peritoneum, which runs onto the back of the vaginal wall and then turns upwards and onto the rectum, forming the recto-uterine pouch.
• The cervix is more tightly connected to surrounding structures than the rest of the uterus

Question 8

What can the cervix be divided into anatomically?

Answer 8

Two portions:

• Vaginal portion of cervix (ectocervix)
• Supravaginal portion of cervix

Question 9

Describe the location of the vaginal portion of the cervix

Answer 9

• Lower end of the cervix which bulges through the anterior wall of the vagina projecting into the cervix between the anterior and posterior vaginal fornices

Question 10

Describe the location of the supravaginal portion of the cervix

Answer 10

The rest of the cervix above the vagina

Question 11

What is the mucosa lining the cervix known as?

Answer 11

The mucosa lining the cervical canal is known as the endocervix, and the mucosa covering the ectocervix is known as the exocervix

Question 12

What do the walls of the uterus consist of? Describe their thickness

Answer 12

The walls of the body of the uterus consist of three layers:
• Perimetrium, the thin external layer
• Myometrium, the thick smooth muscle layer
• Endometrium, the thin internal layer

Question 13

What is the uterine cavity?

Answer 13

A virtual space lined by the endometrium

Question 14

Where does the uterus extend from and to? What is it connected to basically

Answer 14

Extends from the fundus superiorly to the vaginal portion of cervix inferiorly (external os)

Question 15

What is another term for normal pregnancy?

Answer 15

Eutopic pregnancy

Question 16

What is an ectopic pregnancy?

Answer 16

Refers to the implantation of

the gestational sac (blastocyte) outside the uterine cavity

Question 17

Where do ectopic pregnancies occur?

Answer 17

• Most commonly (around 90%) in the fallopian tubes (most commonly in ampula but also common in isthmus)
• Nontubal EPs (less than 10%)

Question 18

What are possible locations for nontubal EPs?

Answer 18

The cervix, ovary, myometrium, abdominal cavity, interstitial (i.e.intramuscular/proximal) portion of the fallopian tube, cesarean scar

Question 19

What is an abdominal EP?

Answer 19

ECtopic pregnancy in which implantation occurs in the peritoneal cavity

Question 20

What can abdominal EP be divided into?

Answer 20

Primary or secondary

Question 21

What are primary abdominal EPs?

Answer 21

The original site of implantation is the peritoneal cavity.

Question 22

What are secondary abdominal EPs?

Answer 22

The result of tubal rupture or expulsion of pregnancy through the fimbrial end of the tube and its re-implantation into the abdominal cavity.

Question 23

What are the most common sites of abdominal EPs?

Answer 23

The most common sites for implantation are the broad ligament, pouch of Douglas,
uterovesical pouch and surface of the tubes and uterus.

Question 24

How hard is it to diagnose abdominal pregnancies?

Answer 24

Early abdominal pregnancies are often difficult to diagnose: there is usually an empty uterine cavity and no evidence of a dilated Fallopian tube or an adnexal mass

Question 25

What is a heterotopic pregnancy?

Answer 25

Refers to the coexistence of an intrauterine pregnancy with an EP

Question 26

What is the incidence rate of heterotopic pregnancies?

Answer 26

• Extremely rare (Less than 0.05%) in the general population

- About 1% following IVF

Question 27

What is the incidence rate of ectopic pregnancies?

Answer 27

• 1–2 % in the general population
• 2–5 % of pregnancies obtained by using
  assisted reproductive technology (ART)

Question 28

How much do ectopic pregnancies account for maternal mortality?

Answer 28

• Up to 6 % of all maternal deaths

- Despite advances in early diagnosis, ectopic pregnancy still accounts for 4% to 10% of pregnancy-related deaths

Question 29

How do Nontubal EPs vs Tubal EPs differ when it comes to maternal morbidity and mortality?

Answer 29

Nontubal EPs contribute disproportionately to maternal morbidity and mortality in comparison to tubal EPs.

Question 30

How much do interstitial pregnancies make up of all ectopic pregnancies?

Answer 30

4% of all EP

Question 31

Describe the effect of interstitial pregnancies on maternal morbidity

Answer 31

Associated morbidity much higher, with mortality rates of 2.5 % (7 times the mortality rate associated with other EP locations, largely due to hemorrhage)

Question 32

What are ultrasound diagnosis criteria for interstitial pregnancy?

Answer 32

Ultrasound criteria for diagnosis include a gestational sac at least 1 cm lateral to the edge of the uterine cavity, with a thin (5 mm or less) layer of overlying myometrium surrounding it.

Question 33

What is a cesarean scar EP?

Answer 33

The implantation of a pregnancy is on the scar of a

previous cesarean section (“scar pregnancy”)

Question 34

What is the incidence rate of cesarean scar EP?

Answer 34

Extremely rare (Less than 0.1%)

Question 35

What are risk factors of tubal ectopic pregnancies?

Answer 35

• Risk factors include smoking, infection, toxic, immunological, and hormonal factors
• Up to 50% of cases have no identifiable risk factors
• The most important predisposing condition, present in 35% to 50% of patients, is prior pelvic inflammatory disease resulting in intraluminal fallopian tube scarring (chronic salpingitis)
• The risk of ectopic pregnancy is also increased with peritubal scarring and adhesions, which may be caused by appendicitis, endometriosis, and previous surgery. In some cases, however, the fallopian tubes are apparently normal.
• Another risk factor is use of an intrauterine contraceptive device, which is associated with a twofold increase in ectopic pregnancy.
• Age (over the age of 35 in both spontaneous pregnancies and after ART)
• Smoking (causing tubal dysfunction, dysregulation of the paracrine signals
  needed for coordinated embryo transport and development)
• History of EP (strong risk factor: recurrence rate of 5–25%, or up to 10 times
  the risk in the general population)
• Tubal surgery or tubal damage: tubal reanastomosis, salpingostomy, tuboplasty
  and lysis of adhesions. Similarly, any causes of pelvic adhesions (including
  endometriosis, appendicitis, or other pelvic surgeries) may distort the anatomy of
  the fallopian tube
• Prior pelvic infection: Chlamydia trachomatous (the risk increasing with each successive infection), Neisseria gonorrhoeae, Mycoplasma and schistosomiasis.
• Pregnancy conceived by ART (2–5 % of pregnancies from ART are ectopic): the
  main risk factors are the specific type of procedure and the history of infertility.

Question 36

What do risk factors of tubal ectopic pregnancy cause to increase the likelihood of the event of a tubal ectopic pregnancy occurring

Answer 36

• They lead to tubal dysfunction or damage
• This can lead to abnormal embryo transport and alterations in the tubal environment, which enables abnormal implantation to occur
• This all leads to tubal ectopic pregnancy

Question 37

What is the incidence rate of intramural pregnancy?

Answer 37

Rare (Less than 2%)

Question 38

Where can intramural pregnancies be found?

Answer 38

It could be located anywhere within the uterine corpus

Question 39

Are intramural pregnancies easy to detect?

Answer 39

Can be hard to detect

Question 40

When do intramural pregnancies typically occur?

Answer 40

It typically occurs after previous myomectomy (surgical removal of uterine leiomyomas, also known as fibroids), uterine perforation (complication of
uterine curettage) or after classical (upper segment vertical) caesarean section or rarely in a focus of adenomyosis

Question 41

What is the defining feature of intramural pregnancies?

Answer 41

The defining feature is extension beyond the endometrial–myometrial junction above the level of the internal os (which differentiates them from cervical and caesarean section scar pregnancies)