L9: Ectopic Pregnancy Flashcards
1
Q
Def of Ectopic Pregnancy
A
Implantation of fertilized ovum outside normal uterine cavity.
2
Q
Incidence of Ectopic Pregnancy
A
3
Q
Why is incidence of Ectopic Pregnancy increasing?
A
↑↑ incidence of chronic PID & STDs.
↑↑ use of IUCD (specially progesterone releasing IUCD).
↑↑ rate of ART.
Better diagnostic tools.
4
Q
RF for Ectopic Pregnancy
A
5
Q
RF for Ectopic Pregnancy
- Contraceptive Failure
A
Failure è use of IUCD (specially progesterone releasing IUCD).
Failure è use of progesterone only contraceptives
(not conclusive).
Pregnancy after tubal sterilization.
6
Q
RF for Ectopic Pregnancy
- Previous Ectopic Pregnancy
A
Recurrence rate is 10%.
7
Q
RF for Ectopic Pregnancy
- Increased Maternal Age
A
Highest rate occurs in women aged 35-44 years.
8
Q
RF for Ectopic Pregnancy
- Smoking
A
Due to altered tubal motility, ciliary action & blastocyst implantation process
9
Q
RF for Ectopic Pregnancy
- Others
A
- Previous DES exposure
- previous abdominal surgery
- ruptured appendix
- uterine malformations
- salpingitis isthmica nodosa (microscopic presence of tubal epithelium in myosalpinx or beneath tubal mucosa).
10
Q
Types & Sites of RF for Ectopic Pregnancy
A
11
Q
Complications of Ectopic Pregnancy
A
12
Q
Complications of Ectopic Pregnancy
- Early Complications
A
13
Q
Complications of Ectopic Pregnancy
- Late Complications
A
14
Q
Def of Tubal Pregnancy
A
Implantation of fertilized ovum into tubal wall.
15
Q
Etiology of Tubal Pregnancy
A
- Tubal factors
- Factors in ovum
16
Q
Etiology of Tubal Pregnancy
- Tubal Factors
A
17
Q
Etiology of Tubal Pregnancy
- Mechanical Tubal factors
A
18
Q
Etiology of Tubal Pregnancy
- Mechanical Tubal factors (Congenital)
A
Long tortuous tube, diverticulum or accessory ostium.
19
Q
Etiology of Tubal Pregnancy
- Mechanical Tubal factors (Traumatic)
A
Microsurgery of tube or after tubal sterilization.
20
Q
Etiology of Tubal Pregnancy
- Mechanical Tubal factors (Inflammatory)
A
21
Q
Etiology of Tubal Pregnancy
- Mechanical Tubal factors (Neoplastic)
A
Tumors kinking the tube (as broad ligamentary swellings).
22
Q
Etiology of Tubal Pregnancy
- Functional Tubal factors
A
23
Q
Etiology of Tubal Pregnancy
- Functional Tubal factors (Tubal Spasm)
A
Due to parasympathetic overactivity
24
Q
Etiology of Tubal Pregnancy
- Functional Tubal factors (Abnormal Peristalisis)
A
As in IUCD & progesterone only contraceptives use.
25
Etiology of **Tubal Pregnancy**
- Ovum factors
26
Migration theory (wandering ovum)
27
Uterine Pathology in **Ectopic Pregnancy**
28
Uterine Pathology in **Ectopic Pregnancy**
- Cause
Due to effect of pregnancy hormones.
29
Uterine Pathology in **Ectopic Pregnancy**
- Size & Consistency of Uterus
- Enlarged (but not > size of 8 weeks).
- Soft.
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Uterine Pathology in **Ectopic Pregnancy**
- Areas-Stella Reaction
- Areas of hypersecretory endometrium characterized by nuclear pleomorphism & hyperchromatosis (present also in normal pregnancy, GTD & endometriosis).
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Uterine Pathology in **Ectopic Pregnancy**
- Most Importnat Pathology
Absence of chorionic villi.
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Tubal Pathology in **Ectopic Pregnancy**
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- Decidual Reaction
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Tubal Pathology in **Ectopic Pregnancy**
- Unditurbed Ectopic Pregnancy
- After implantation, there is picture of undisturbed ectopic pregnancy but pregnancy will not continue due to unfavorable environment (deficient decidual function & thin tubal wall which ruptures easily)
35
Tubal Pathology in **Ectopic Pregnancy**
- Disruption of ectopic Pregnancy
- disruption will occur (usually at 6-10 weeks) giving picture of disturbed ectopic pregnancy which have one of the following pathological types (fate) depending on whether disruption occurs towards lumen or towards outer surface:
36
Tubal Pathology in **Ectopic Pregnancy**
- If disruption occurs towards lumen, This may lead to:
- Tubal mole
- Tubal abortion
37
Pathogenesis of Tubal mole
- Repeated attacks of slight Hge → embryo dies but is still attached to tubal wall & becomes surrounded by clotted blood forming mole
37
Fate of **Tubal mole**
Shrinkage & absorption, hematosalpinx or pyosalpinx (if infected).
38
Pathogenesis of **Tubal Abortion**
- Separation of embryo from tubal wall followed by its expulsion into peritoneal cavity through abdominal ostium.
39
Incidence of **Tubal Abortion**
Most common in ampullary or fimbrial pregnancy.
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Fate (Types) of **Tubal Abortion**
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Fate (Types) of **Tubal Abortion**
- Complete Tubal Abortion
Beeding stops & products of conception are absorbed.
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Fate (Types) of **Tubal Abortion**
- Incomplete Tubal Abortion
43
Fate (Types) of **Tubal Abortion**
- Incomplete Tubal Abortion may lead to ....
- Hematosalpinx: Blood collects in tube when both tubal ends are closed.
- Peritubal hematocele: Blood collects around abdominal ostium.
- Pelvic hematocele: Blood collects in Douglas pouch.
- Diffuse intraperitoneal Hge.
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Hematosalpinx
- Blood collects in tube when both tubal ends are closed.
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Peritubal hematocele
- Blood collects around abdominal
ostium.
46
Pelvic hematocele
Blood collects in Douglas pouch
47
Tubal Pathology in **Ectopic Pregnancy**
- If disruption occurs towards Outer Surface, This may lead to:
...
48
Incidence of **Tubal rupture**
Occurs in 55% of cases & is more common in isthmic pregnancy.
49
fate of **Tubal rupture**
50
Tubal Pathology in **Ectopic Pregnancy**
- Tubal Erosion
51
Tubal Pathology in **Ectopic Pregnancy**
- Local Signs
1. Signs of early pregnancy (present in all clinical types).
2. Tender cervical motion (Dodd's sign): Pain on cervical mobility from side to side.
3. Tender adnexal swelling (50%).
52
CP of **Ectopic Pregnancy**
53
Clinical Types of **Ectopic Pregnancy**
- Subacute disturbed ectopic pregnancy
- Acute disturbed ectopic pregnancy
- Chronic disturbed ectopic pregnancy
- Advanced abdominal pregnancy
54
Clinical Types of **Ectopic Pregnancy**
- Subacute disturbed ectopic pregnancy is mostly associated with .....
Mostly è tubal abortion
55
CP of **Subacute disturbed ectopic pregnancy**
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CP of **Subacute disturbed ectopic pregnancy**
- Amenorrhea
- Short period of amenorrhea or no amenorrhea if pregnancy is disturbed before time of next menstruation (specially in isthmic pregnancy)
57
CP of **Subacute disturbed ectopic pregnancy**
- pain
58
CP of **Subacute disturbed ectopic pregnancy**
- Vaginal Bleeding
- Occurs in 70% of cases (due to shedding of decidua) & it follows pain.
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CP of **Subacute disturbed ectopic pregnancy**
- Fainting attacks
Due to repeated attacks of Hge & colicky pain.
60
CP of **Subacute disturbed ectopic pregnancy**
- Bathroom Sign
- Urge to have bowel action followed by sudden syncope while straining at defecation (it is due to vasomotor disturbance following peritoneal
irritation).
61
CP of **Subacute disturbed ectopic pregnancy**
- General Signs
Pallor, tachycardia & hypotension.
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CP of **Subacute disturbed ectopic pregnancy**
- Abdominal Signs
1. Lower abdominal tenderness & rigidity ± shifting dullness
2. Cullen's sign: Bluish discoloration around umbilicus (due to intraperitoneal Hge).
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CP of **Subacute disturbed ectopic pregnancy**
- Local Signs
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**Acute disturbed ectopic pregnancy** is mostly associated with ......
Mostly è tubal rupture.
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CP of **Acute disturbed ectopic pregnancy**
- Amenorrhea
Short period of amenorrhea followed by acute lower abdominal pain & sudden collapse
66
CP of **Acute disturbed ectopic pregnancy**
- Pain
Shoulder pain (due to accumulation of blood under diaphragm
67
CP of **Acute disturbed ectopic pregnancy**
- General Signs
Signs of shock (rapid weak pulse, low BP & subnormal temperature
68
CP of **Acute disturbed ectopic pregnancy**
- Abdominal Signs
Marked lower abdominal tenderness & rigidity + shifting dullness.
69
CP of **Acute disturbed ectopic pregnancy**
- Local Signs
- Doesn't give much information because of marked vaginal tenderness, however, there is severe tender cervical motion.
70
**Chronic disturbed ectopic pregnancy** is mostly associated with ......
- Pelvic hematocele
71
CP of **Chronic disturbed ectopic pregnancy**
72
CP of **Chronic disturbed ectopic pregnancy**
- Pain
73
CP of **Chronic disturbed ectopic pregnancy**
- Vaginal Bleeding
74
CP of **Chronic disturbed ectopic pregnancy**
- General Signs
Pallor
75
CP of **Chronic disturbed ectopic pregnancy**
- Abdominal Signs
- Pelviabdominal swelling + Cullen's sign may be present
76
CP of **Chronic disturbed ectopic pregnancy**
- Local Signs
77
INVx for **Ectopic Pregnancy**
78
INvx for **Ectopic Pregnancy**
- Labs
79
Lab INVx for **Ectopic Pregnancy**
..
80
Lab INVx for **Ectopic Pregnancy**
- Urine Pregnancy Test
May give false -ve results
81
Lab INVx for **Ectopic Pregnancy**
- Serum B-HCG
82
Lab INVx for **Ectopic Pregnancy**
- Serum B-HCG (Single Measurment)
83
Lab INVx for **Ectopic Pregnancy**
- Serum B-HCG (Serial Measurments)
84
Lab INVx for **Ectopic Pregnancy**
- Serum Progesterone
85
INVx for **Ectopic Pregnancy**
- US
86
US Signs of Ectopic Pregnancy
Signs of ectopic pregnancy:
- Empty uterine cavity
- Cystic adnexal mass
- Free fluid in Douglas pouch or pelvic hematocele
87
US Signs of Ectopic Pregnancy
- Empty Uterine Cavity
88
Visualization of true intrauterine GS mostly exclude ....... (however, heterotopic pregnancy is a very rare possibility)
ectopic pregnancy
89
- Presence of pseudo GS (collection of fluid in uterine cavity due to bleeding from decidualized endometrium) in uterus in cases of ectopic pregnancy
- May be confused è true GS (true GS is located eccentrically èin uterus beneath endometrial surface whereas pseudo GS fills the uterine cavity)
...
90
presence of decidual casts in uterus in cases of ectopic pregnancy may be confused è fetal shadows
..
91
US Signs of Ectopic Pregnancy
- Cystic adnexal Mass
92
Def of **Comination of ultrasound & serum β-HCG level (discriminatory Level)**
- Serm level of β-HCG above which true GS should be seen by ultrasound inside uterus in all cases of normal pregnancy
93
Levels of **Comination of ultrasound & serum β-HCG level (discriminatory Level)**
- Using TAS: 6000-6500 mIU/ml.
- Using TVS: 1000-2000 mIU/ml
94
Result of **Comination of ultrasound & serum β-HCG level (discriminatory Level)**
- Empty uterus + β-HCG > discriminatory level = ectopic pregnancy.
95
Def of **Culdocentesis**
- Aspiration of contents of Douglas pouch by needle inserted through posterior fornix.
96
Aim of **Culdocentesis**
Diagnose of hemoperitoneum.
97
Dx Criteria of **Culdocentesis**
- Aspiration of > 0.5 ml non clotted blood.
98
Indications of **Endometrial curettage**
Done only after documentation of non viable intrauterine pregnancy (serum progesterone level < 5 ng/ml).
99
Aim of **Endometrial curettage**
Differentiation ( ) non viable intrauterine pregnancy & ectopic pregnancy.
100
Results of **Endometrial curettage**
1) Presence of chorionic villi: Non viable intrauterine pregnancy (villi can be detected by floating in saline or histopathological examination).
2) No chorionic villi: Ectopic pregnancy
101
Indications of **Laparoscopy in ectopic Pregnancy**
Doubtful diagnosis or hemodynamically unstable patient.
102
Value of **Laparoscopy in ectopic Pregnancy**
103
DDx of **Ectopic Pregnancy**
104
TTT of **Ectopic Pregnancy**
SAM ”Surgically administered medical treatment” or no SAM “ conservative” or S “Surgical” or M “Medical”
105
TTT of **Ectopic Pregnancy**
- 1st Aid Measures
Treatment of shock if present & preparation of matched blood.
106
TTT of **Ectopic Pregnancy**
- Surgical TTT
Main line of treatment
107
Main Line of TTT of Ectopic Pregnancy
Surgical treatment
108
Approaches for Surgical TTT of Ectopic Pregnancy
- Laparoscopy
- Laparotomy
109
Indications of laparoscopy in TTT of Ectopic Pregnancy
Recommended approach in hemodynamically stable patients.
110
Indications of Laparotomy in TTT of Ectopic Pregnancy
111
**Surgical Techniques** used in TTT of Ectopic Pregnancy
112
**Surgical Techniques** used in TTT of Ectopic Pregnancy
- Conservative Methods
113
Salpingostomy
- Opening the tube & evacuation of its contents & leaving wound opened to heal by granulation
114
Salpingotomy
- Opening the tube & evacuation of its contents
methods: then closure of wound.
115
Segmental resection & end to end anastomosis
- Resection of part containing ectopic pregnancy followed by end to end anastomosis of tube.
116
**Surgical Techniques** used in TTT of Ectopic Pregnancy
- Non-Conservative Methods
Salpingectomy
117
Salpingectomy
Resection of tube (or part of it) containing ectopic pregnancy **(recommended line of TTT )**
118
Medical TTT of **Ectopic Pregnancy**
119
Medical TTT of **Ectopic Pregnancy**
- Indications
120
Medical TTT of **Ectopic Pregnancy**
- CI
opposite to Indications
121
Medical TTT of **Ectopic Pregnancy**
- Drugs Used
122
Dose of Methotrexate in Ectopic Pregnancy
123
SE of Methotrexate in Ectopic Pregnancy
124
Other Drugs in Ectopic Pregnancy
125
Principle of **Expectant TTT in Ectopic Pregnancy**
Some Cases show spontaneous resolution è death of trophoblasts → progressive ↓↓ in HCG level & absorption of products of conception è no squeals
126
Selection Criteria of Expectant TTT in Ectopic Pregnancy
127
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