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Ectopic pregnancy

Department of

gynaecology and

obstetrics

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ovary

Ampulla tubae uterinaeUterus

firtilizedegg

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Ectopic pregnancy

.In ectopic pregnancy ,a fertilized ovum

implants in an area other than the

endometrial lining of the uterus

Definition

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Classification and Incidence 1 tubal >95%

ampullary(55%),

isthmic 25%),

fimbrial(17%),

interstitial(2%) 2.other(

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TIME OF RUPTURE

Rupture is usually

spontaneous. .1.isthmic pregnancies

at 6 to 8 weeksgestation,

.2.ampullary pregnancies

ruptute- at 8to 12weeks.

.3.interstitial pregnancies are

the last - at 12-16wesks

.

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EtiologyPathology Clinical situation

Laboratory findings Special examinationsDiagnosis

Differental diagnosis Treatment

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Etiology .tubal factors

Chronic salpingitis

dysplastic or parafunctionalOviduct

.ovarian factors

Fertilized egg transmigration

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Etiology .other factors

Birth control failure

psychentonia

dyscrinism

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Pathology little or no decidual reaction

the trophoblast invades bloodvessels to cause local hemorrhage.

bleeding

ariasstrlla reaction--

no trophoblastic cells

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PathologyTubal abortion

Rupture of tubal pregnancy

Secondary abdominal pregnancy

Persistent ectopic pregnancy

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tubal abortion

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EtiologyPathology Clinical findings



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Clinical findings SYMPTOMS A pain

Pelvic or abdominalpainsubdiaphragmatic orshoulder pain

pain can be

unilateral orbilateral,localized orgeneralized

.

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B bleeding

--- Abnormal uterinebleeding,usually spotting

C amenorrhes

About half of women with ectopicpregnancies have some spotting

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D syncope

Dizziness, lightheadedness, and or syncope

E Decidual cast

mistaken for products of conception.

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2.signs

A tenderness

.Diffuse or localized

abdomimal tenderness

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.adnexal and /orcervical motiontenderness

B adnexal mass

Bimanual examination

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Laboratory findings 1.Hematocrit-the hematocrit will

vary depending on the patient

population and the degree,if any,of intraabdominal bleeding.

2.White blood count-the white

blood count is variable ,and it isnot uncommon to see aleukocytosis

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3.pregnancy test-the -HCG is positive invirtually 100%of ectopic pregnancies,

however ,a positive test only confirmspregnancy and does not indicate whether itis intrauterine orextrauterine.

-in normal pregnancy,HCG should doubleevery 2days. ectopic pregnancies have anormal serial

titers,

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Special examinations

1.Ultrasound

documenting the presence or absence of an

intrauterine pregnancy

The presence of an adnexal mass with an

empty uterus

.a tubal ring seen on ultrasound may

represent an unruptured extopic

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Sonography of gravid uterus

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Ectopic pregnancy

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.HCG titers and ultrasound complementone another

An intrauterine sac should be visible by

transvaginal ultrasound when the HCG Is

approximalely 1000mIU/mL, when an

empty uterine cavity is seen with a HCGtiter above this threshold, the patient is

likely to have an extopic pregnancy.

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an empty cavity is less of a concern when a

HCG below the threshold is obtained,as this

may be associated with an ectopicpregnancy, but may also be seen with an

early IUP.

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2.Laparoscopy

it is still usefull,however, in certain

situations when a definitive diagnosis is

difficult,especially in the case of a

desired,potentially viable intrauterine

pregnancy when a DandC iscontraindicated.

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3D and C

May confirm or exclude intrauterine

pregnancy in the case of an undesiredpregnancy.when chorionic villius arerecovered,the diagnosis of anintrauerine pregnancy is confirmed .

on the other hand Ifonly decidua isobtained on D and C,ectopic pregnancyis highly likely.

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5 culdocentesis

free blood is presentin the abdomen may

be useful in the

diagnosis of

intraperitomealbleeding

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Diagnosis

Clinical fingdings

Pain bleeding amenorrhea

Physical sign

Tenderness

adnexal/or cervix motion tenderness Adnexal mass

Uterus changes

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Sonography

we could not see the gestation sac

in the uterus cavity but it can befound outside the uteruscavityThere is fluidify in cul-de-

sac of douglas

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pregnancy test

HCG is positive in some ectopic

pregnancy case

This is a useful index

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Culdocentesis

non-clotting blood is meaningful

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Differental diagnosis

Abortion

Rupture of yellow body

Acute appendicitis

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Treatment

1.expectant management

because many ectopic pregnancy resolve

spontaneously, it may be reasonable tomanage an asymptomatic, compliant

patient expectantly if HCG titers are

low()

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2. surgical treatment

.conservative surgery

.A linear salpingostomy performed with a

small(

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3.emergency treatment immediate surgery is indicated when the

diagnosis of ectopic pregnancy withhemorrhage is made .

blood products should be available astransfusion is often necessary. There is noplace for co nservative therapy in ahemodynamically unstable patient.

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MTX(methotrexae has been shown to

destroy proliferatin trophoblast and may be

effective in the mediclal management ofsmall,unruptured ectopic pregnancies in

asymptomatic women

.relative contraindications include an adnexalmass >=3.5cm or an extrauterine gestation

with fetal heart motion

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