Transcript ectopic pregnancy

OB CASE
PRESENTATION
Zshari Zxilka T. Tanggol
Medical Intern
Department of Obstetrics and Gynecology
August 2010
Preceptor: Dr. Fernandez
GENERAL DATA
N.A.
 31 y/o G3P3 (3003)
 Married
 Islam
 Pasig City

PAST MEDICAL HISTORY

No hypertension, diabetes mellitus, bronchial
asthma, cancer, thyroid disease
Previous operation: s/p CS III x, Ix for CPD
(1997, 2008, 2005)
 No known allergies
 No history of blood transfusions

FAMILY HISTORY
(+) Hypertension – mother
 (+) Diabetes Mellitus – mother
 No bronchial asthma, heart disease, cancer,
thyroid abnormalities

PERSONAL AND SOCIAL HISTORY
Nonsmoker
 Non-alcoholic beverage drinker

MENSTRUAL HISTORY
Menarche: 12 y/o
 Regular
 5 days
 3 pads per day
 (-) pain

LMP: June (3rd or 4th week) 2010
 PMP: May 2010

OBSTETRIC HISTORY

G3P3 (3003)
Year
AOG
Type of Delivery
Place of Delivery
Fetomaternal
Complication
G1
(1997)
FT
Primary CS for
CPD
Zamboanga
None
G2
(1998)
FT
RCS
Zamboanga
None
G3
(2005)
FT
RCS
Zamboanga
None
GYNECOLOGIC
AND
SEXUAL HISTORY
Coitarche: 18 y/o
 Sexual Partner: 1
 Sexually active
 Family Planning Method: None
 (-) Pap smear
 (-) use of OCPs
 (-) abnormal vaginal discharge

HISTORY OF PRESENT ILLNESS
7 days PTA
3 days PTA
(+) Right lower quadrant pain, stabbing,
nonradiating, 7/10 intensity, intermittent
(-) fever, nausea, vomiting
(-) vaginal bleeding
(-) vaginal discharge
(+) Amenorrhea ~5 weeks
No consult done nor medications taken
(+) Recurrence of RLQ pain
(+) Associated with minimal vaginal
bleeding with passage of blood clots
HISTORY OF PRESENT ILLNESS
2 days PTA
Few hours
PTA
(+) Symptoms persisted
 Patient sought consult with AMD where
ultrasound was done (Zamboanga) which
showed, right ovary: 3.9 x 3.7 thin walled
anechoic mass
(+) Increase in RLQ pain
(+) Generalized weakness
Consult at SLMC where TVS done which
showed right adnexal mass highly suggestive of
an ectopic gestational sac probably tubal with
small leak or rupture
 stat gyne laparotomy: ADMISSION
REVIEW OF SYSTEMS
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General: no weight loss, anorexia, easy
fatigability
Eye: no visual dysfunction, itchiness,
lacrimation or redness
Ears: no dizziness, tinnitus, deafness, discharge
or vertigo
Nose: no congestion, no discharge, no hyperemia
Mouth: no lesions or discharges
Neck: no hoarseness or stiffness
REVIEW OF SYSTEMS
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Pulmonary: no dyspnea, no cough
Cardiac: no chest pains, no palpitations, no
PND
Vascular: no phlebitis, varicosities, cyanosis
Gastrointestinal: no change in bowel
movements, vomiting
Genitourinary: no frequency, urgency, flank
pains
Endocrine: no polyuria, polydipsia, polyphagia,
heat/cold intolerance
REVIEW OF SYSTEMS

Musculoskeletal: no joint stiffness, swelling or
numbness,

Hematopoietic: no pallor or easy bruisability

Neurologic: no headache, vertigo or seizures

Psychiatric: no anxiety, depression,
interpersonal relationship difficulties, illusion,
delusion
PHYSICAL EXAMINATION
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Awake, conscious, coherent, ambulatory
Not in cardiorespiratory distress
Vital Signs: 120/80 mmHg, 78 bpm regular,
20 cpm regular, 37.3° C
Weight: 65 kg
Height: 157.48 cms
BMI: 26.21 kg/m2 (Overweight)
PHYSICAL EXAMINATION
Skin: warm, smooth
 Head: normocephalic, normal pattern of distribution
 Face: no facial asymmetry
 Eyes: pink palpebral conjunctivae, anicteric sclerae,
pupils 2-3mm briskly reactive to light
 Ears: patent ear canal; tympanic membrane non
perforated, pearly white, with intact cone of light,
bilateral
 Nose: nasal septum midline, pink nasal mucosa, no
nasal congestion.
 Throat: non-hyperemic tonsillopharyngeal walls

PHYSICAL EXAMINATION
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Neck: supple neck, no masses, no lymphadenopathies
Chest/Lungs: symmetrical chest expansion, no rib
retractions, equal tactile and vocal fremitus; clear
breath sounds in all lung fields
Breast/Thorax: symmetrical, no palpable masses or
tenderness
Heart: adynamic precordium, normal rate and regular
rhythm, apex beat at 5th L ICS-MCL, no heaves, no
thrills, no murmurs.
PHYSICAL EXAMINATION
Abdomen: Flabby, normoactive bowel sounds,
tympanitic, soft, (+) direct tenderness on right lower
quadrant, no masses palpated
 External pelvic examination: No lesions, redness,
excoriations, hyper/hypopigmentations
 SE: cervix pink, smooth, (+) minimal to moderate
vaginal bleeding
 IE: Cervix is long, closed; uterus not enlarged, (+)
cervical motion tenderness, (+) right adnexal
tenderness and fullness, no left adnexal mass or
tenderness
 Full and equal pulses; No edema, no cyanosis
 Neurologic exam: Essentially normal

SUBJECTIVE SALIENT FEATURES
31 y/o G3P3 (3003)
 (+) severe stabbing right lower quadrant pain
 (+) amenorrhea
 (+) minimal vaginal bleeding
 (-) abnormal vaginal discharge, urinary or bowel
changes
 s/p CS III (Ix for CPD)
 Sexually active, (-) use of OCP

OBJECTIVE SALIENT FEATURES
Conscious, coherent, not in distress
 Stable vital signs
 Abdomen: Flabby, normoactive bowel sounds,
soft, (+) RLQ direct tenderness, no masses
palpated
 External pelvic examination: No lesions, redness,
excoriations, hyper/hypopigmentations
 SE: cervix pink, smooth, (+) minimal to moderate
vaginal bleeding
 IE: Cervix is long, closed; uterus not enlarged, (+)
cervical motion tenderness, (+) right adnexal
tenderness and fullness, no left adnexal mass or
tenderness

DIFFERENTIALS
Abortion
 Ovarian Cyst
 Pelvic Inflammatory Disease
 Subchorionic Hemorrhage
 Ectopic Pregnancy

CLINICAL IMPRESSION
31 y/o G4P3 (3013)
 Ovarian Cyst, Right
 Amenorrhea 5-6 weeks R/o Tubal Pregnancy,
right
 Previous Caesarian Section IIIx, Ix for
Cephalopelvic Disproportion (1997, 1998, 2005)

ECTOPIC PREGNANCY
ECTOPIC PREGNANCY
Ektopos: (Greek) out of place
 Implantation of a fertilized ovum outside the
endometrium lining the uterine cavity
 Implantation in any other site considered
ectopic
 Located mostly in the oviducts
 Other reported sites are the cervix, uterine
cornu, ovaries, abdomen broad ligament,
spleen, liver, retroperitoneum and diaphragm

RISK FACTORS: CLASSIFICATION
Mechanical
 Functional
 Assisted reproduction
 Failed contraception

MECHANICAL FACTORS
 Prevent
or retard passage of ovum to uterine cavity
 Tubal kinking and narrowing secondary to:
 Prior tubal surgery: highest risk (failed tubal
ligation, tubal fertility surgery, partial
salpingiectomy)
 Peritubal adhesions 2o to post-abortal/puerperal
infection, appendicitis, endometriosis
 Salpingitis (previous ectopic): narrowing/blind
pockets
 Myomas/adnexal masses
MECHANICAL FACTORS
 Reduced
ciliation 2o to infection: PID
(Chlamydia trachomatis), Salpingitis
 Developmental tubal abnormalities
(diverticula, accessory ostia, hypoplasia)
FUNCTIONAL FACTORS
 Altered
tubal motility 2o to changes in
serum levels of estrogen and progesterone
Progestin only contraceptives
 IUD devices with progesterone
 Post-ovulatory high dose estrogen
 Ovulation induction
 Luteal phase defects

 Cigarette
smoking: nicotine is known to alter
tubal motility, ciliary activity or blastocyst
implantation
 Increasing
age
ASSISTED REPRODUCTION
 Increased
incidence with gamete intra-fallopian
transfer (GIFT) and in-vitro fertilization (IVF)
techniques (atypical implantations more
common)
FAILED CONTRACEPTION
With any form of contraceptive, the absolute
number of ectopic pregnancies is decreased
because pregnancy occurs less often
 In some contraceptive failures, however, the
relative number of ectopic pregnancies is
increased.

RISK FACTORS
Multiple sexual partners
 Prior Caesarian section

EPIDEMIOLOGY
 Increasing
absolute number and rate of
ectopic pregnancy
 Non-Caucasians > Caucasians
 Increased age
 2% of all pregnancies
 10% of all pregnancy-related deaths
 Most common cause of maternal mortality
in the 1st trimester
PATHOPHYSIOLOGY
Fertilized ovum borrows through the epithelium
Zygote reaches the muscular wall
Trophoblastic cells at zygote periphery proliferate,
invade, and erode adjacent muscularis
Maternal blood vessels disrupted leading to
hemorrhage
Intratubal/intraperitoneal collection
Rupture
SITES OF ECTOPIC IMPLANTATION:
CLASSIFICATION
 Tubal
(95-96%)
Ampullary (70%)
 Isthmic (12%)
 Fimbrial (11%)
 Cornual and interstitial (2-3%)

 Abdominal
(1%)
 Cervical (<1%)
 CS scar (<1%)
 Ovarian (3%)
NORMAL ANATOMY OF FALLOPIAN TUBE
ECTOPIC PREGNANCY:
CLINICAL PRESENTATION
PAIN. Severe sharp/stabbing or tearing lower
pelvic and abdominal pain (95%)
 ABNORMAL BLEEDING. Amenorrhea with
some degree of vaginal spotting or bleeding (6080%)
 Abdominal and pelvic tenderness (75%) on
palpation with or without palpable pelvic mass
(20%)
 Vasomotor disturbance (vertigo/syncope) with
signs of hemodynamic compromise (20%)

CLINICAL PRESENTATION
 First
trimester uterine changes (25%)
 Cervical motion tenderness
 Bulging of posterior fornix
 CLASSIC
CLINICAL TRIAD: Pain,
amenorrhea, vaginal bleeding
ECTOPIC PREGNANCY: DIAGNOSIS


Complete history and physical examination
Urinary pregnancy tests: positive in 50% to 95%
ECTOPIC PREGNANCY: DIAGNOSIS
 Serum
B-hCG
serial values lower than in normal
pregnancy
 best correlated with ultrasound
 in first 6 weeks of normal gestation, serum
HCG rises exponentially: doubling time is
noted and is relatively constant
 doubling time does not occur in gestation
destined to abort or are ectopic

ECTOPIC PREGNANCY: DIAGNOSIS
 Serum
progesterone (inconclusive 5-25
ng/ml)
 A single progesterone measurement can be
used to establish with high reliability that
there is a normally developing pregnancy:
value exceeding 25 ng/mL excludes ectopic
pregnancy with 92.5 % sensitivity
 Values <5 ng/mL suggest either an
intrauterine pregnancy with a dead fetus or an
ectopic pregnancy
 Has limited clinical utility
ECTOPIC PREGNANCY: DIAGNOSIS
 Novel
serum markers under investigation:
vascular endothelial growth factor (VEGF),
cancer antigen 125 (CA125), creatine kinase,
fetal fibronectin, and mass spectrometrybased proteomics
DIAGNOSIS: ULTRASONOGRAPHY
 Abdominal
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
Identification of tubal pregnancy products is difficult
Uterine pregnancy usually is not recognized using
abdominal sonography until 5 to 6 menstrual weeks or
28 days after timed ovulation
 Vaginal


sonography
sonography
Uterine pregnancy 1 week after missed menses with BhCG >1500 mIU/ml
Identification of fetal pole within the uterus with FHT
PATIENT: TRANSVAGINAL USG
Normal sized AV uterus w/ no myometrial lesion
 Thin nonspecific endometrium (0.60)
 Normal right ovary
 Corpus luteum cyst (3.0x2.8x2.6cm), left ovary
 Inferomedial and adjacent to right ovary is a
complex mass with a 1.0cm gestational sac-like
structure within (~5weeks and 5days AOG).
 Slightly echogenic free fluid in the cul-de-sac
~5.2x1.8x3.5cm, volume 11cc with amorphous
echogenic structure suggestive of blood clot
 IMPRESSION: right adnexal mass highly
suggestive of an ectopic gestation, probably tubal
with small leak or rupture

VAGINAL COLOR AND PULSED DOPPLER
ULTRASOUND
 Uterine
or extrauterine site of vascular
color in characteristic placental shape
 Ring of fire pattern
 High-velocity low impedance flow pattern
compatible with placental perfusion
 Ectopic pregnancy: “cold” pattern outside
uterus
ECTOPIC PREGNANCY: DIAGNOSIS
 Culdocentesis
 Laparoscopy
MULTIMODALITY DIAGNOSIS:
5 COMPONENTS
Ectopic pregnancies are identified with the
combined use of clinical findings along with
serum analyte testing and transvaginal
sonography.
Transvaginal sonography
 Serum B-hCG level—both the initial level and
the pattern of subsequent rise or decline
 Serum progesterone level
 Uterine curettage
 Laparoscopy, laparotomy

ECTOPIC PREGNANCY: MANAGEMENT
Medical management
 Expectant management
 Surgical management
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MEDICAL MANAGAMENT
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Medical therapy (Methotrexate) for the patient who is
asympotomatic, motivated and compliant
The single best prognostic indicator of successful
treatment of single dose methotrexate is the initial
serum B-hCG level
Methotrexate: rapid absorption of placental tissue
EXPECTANT MANAGEMENT
Tubal ectopic pregnancies only
 Decreasing serial -hCG levels
 Diameter of the ectopic mass not >3.5 cm
 No evidence of intra-abdominal bleeding or
rupture by transvaginal sonography.

According to the American College of Obstetricians
and Gynecologists (2008), 88 percent of ectopic
pregnancies will resolve if the B-hCG is <200
mIU/mL.
SURGICAL MANAGEMENT
Laparoscopy - shorter operative time, less blood
loss, less analgesic requirement, and shorter
hospital stay
 Laparotomy
 Salpingectomy – may be used for both
ruptured or unruptured ectopic pregnancies
 Salpingostomy - used to remove a small
pregnancy that is usually less than 2 cm in
length and located in the distal third of the
fallopian tube
 Salpingotomy – same with salpingostomy but
incision is closed with delayed absorbable suture

SURGICAL MANAGEMENT
SOME PRACTICE GUIDELINES*
Less than half of the patients with ectopic
pregnancy present with the classic triad of a
history of amenorrhea, abdominal pain, and
irregular vaginal bleeding (C).
 Definite cervical motion tenderness and
peritoneal signs are the most sensitive and
specific examination findings for ectopic
pregnancy--91% and 95%, respectively (A).

*Ectopic pregnancy: forget the "classic presentation" if you want to catch it sooner: a
new algorithm to improve detection. Journal of Family Practice. May 2006.
Ramakrishnan, K., and Scheid, D.C.
SOME PRACTICE GUIDELINES
Beta-hCG levels can be used in combination with
ultrasound findings to improve the accuracy of
the diagnosis of ectopic pregnancy (A).
 Women with initial nondiagnostic transvaginal
ultrasound should be followed with serial betahCGs (B).

SOME PRACTICE GUIDELINES
Despite advanced detection methods, ectopic
pregnancy may be missed in 40% to 50% of
patients on an initial visit.
 Most women with ectopic pregnancy have no risk
factors and the classic triad of a history of
amenorrhea, abdominal pain, and irregular
vaginal bleeding is absent in more than half of
cases.
 Early diagnosis not only decreases maternal
mortality and morbidity; it also helps preserve
future reproductive capacity--only one third of
women with ectopic pregnancy have subsequent
live births. (2)

PATIENT: INTRAOP FINDINGS
Hemoperitoneum, approx. 50cc + blood clots
 The right fallopian tube was dilated to 4x3x3cms
from the cornual end to the infundibular area, with
no point of rupture noted
 Uterus is small with pink and smooth serosal
surface
 There was 3x2cm corpus luteum cyst in the right
ovary
 The left ovary and fallopian tube were grossly
normal


Procedure: Evacuation of Hemoperitoneum +
Right Salpingectomy + Left Fallopian Tube
Ligation
PATIENT:
LABORATORY/HISTOPATHOLOGY
 Urine
hCG (+) for pregnancy
 Serum total B-hCG: 1351 mIU/ml
 CBC, PT and PTT: Normal
Histopathology:
A. Tubal Pregnancy, right fallopian tube
B. Unremarkable segment of left fallopian tube
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