Transcript Ectopic pregnancy

Ectopic pregnancy:
Definition:
Any pregnancy accruing outside
the uterine cavity
incidence 1/100
one cause of maternal death.
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Pathology:Commonest site
uterine tube "ampulla".
ovary.
abdominal cavity.
cervical canal.
 Secretion of HCG –> maintain corpus luteum to
secrete estrogen and progesterone .
 endometrial changes.
 Trophoblastic cells  invade fallopian tube wall and
erode blood vessels in mesosalpinx thus result :
 rupture  "abd. Cavity, broad ligament.
 embryo dies .
 tubal mole then absorption it.
 Decrease progesterone hormone
 shedding of deciduas
vaginal bleeding
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predisposing factors :
no identifiable cause :
previous history of ectopic pregnancy.
infertility,subinfertility .
PID
IUCD
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clinical presentation:
Acute presentation: "classical" 25%
-Amenorrhea – vaginal bleeding.
one side of lower abdominal pain then become generalized – diarrhea
shoulder pain due to sub diaphragmatic irritation by blood "should tip
pain
discomfort –syncope - difficult breath.
On examination: hypotension – tachycardia
Signs of peritonism "abdominal distension, guarding, rebound
tenderness"
Cervix closed – cervical excitation tender when moving cervix.
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sub acute presentation:
bleeding –Amenorrhea – abnormal last light period –
irregular vaginal bleeding
– abdominal pain.
DX : mass on fornix of vagina ??
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outcomes of tubal pregnancy:
tubal abortion.
tubal mole
tubal rupture.
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Different diagnosis :
threatened or incomplete miscarriage.
ovarian cyst
acute salpingitis .
 HCG level :  1500 Iu/L raised.
 uls  empty uterus, no gestational sac ,TVS. Extra
ovarian tubal mass . free fluid peritoneal cavity.
 laparoscopy.
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Management:
I) surgical management :
- lapratomy :- indication
1. haemodynamic compromised.
2. obese patient .
3. extensive pelvic adhesion.
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Advantages of lapratomy:
less blood loos.
reduce need for post operative pain relief.
less time to return to normal activity.
less time for hospitalization.
 lapratomy or laparoscopy:
 partial salpingectomy : removing part of tube.
 salpingotomy "leaving the tube in place , remove the
ectopic through incision.
 Risk for recurrent ectopic pregnancy 15%
 Risk of salpingotomy:
 Some gestational tissue may be left in place and
continue to develop so follow up of HCG hormone
weekly up to 10 weeks.
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salpingectomy :
indication 1. uncontrolled bleeding.
2. ectopic pregnancy for the 2nd time in
the same tube.
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) Medical management :
Advantages of medical management :
avoid surgical intervention.
less coast.
less hospitalization.
Drug : Methotrexate :
Classification : anti metabolite.
Action : interfere with synthesis of DNA
Mode : IM single does 1 mg /kg body weight .
Side effect: abdominal pain after 6-7 days of administration.
-could be repeat the dose .
 Follow up HCG indicator of success, when there is
decrease of this hormone .
 indication of success of medical treatment
"methotrexate"
 decrease level of HCG, until disappear.
 size of ectopic diminish.
 no fetal cardiac activity.
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?? would choose medical or surgical intervention:
According to the following criteria:
serum HCG less than 2000iu/L
ectopic less than 2cm.
no fetal cardiac activity.