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8/17/2019 Ectopic Pregnancy5
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ECTOPICPREGNANCY
http://crisbertcualteros.page.tl
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Ectopic Pregnancy
Ectopic Pregnancy
The blastocyst normally implants in
the endometrial lining of the uterine
cavity
Implantation anywhere else is an
ectopic pregnancy
There is a 7-to 13-fold increase in
the risk for a subsequent ectopic
pregnancy
Intrauterine pregnancy: !" to #!"
Tubal pregnancy: $!" to %"
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Ectopic Pregnancy
Ris !actor Ris
High Risk
Tubal corrective surgery
Tubal sterili&ation
Previous EP
In utero 'E( e)posure
I*'
'ocumented tubal pathology
Moderate Risk
Infertility
Previous genital infection
+ultiple partners
Slight risk
Previous pelvic or abdominal surgery (moking
'ouching
Intercourse before $# weeks
%$.!
,.-
#.-
.
.%0
-.#0%$
%.0%$
%.0-.1
%.$
!.,-0-.#%.-0%.
$.$0-.$
$.
Table $. 2isk 3actors for Ectopic Pregnancy
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Ectopic Pregnancy
Increasing ectopic pregnancy
rates
$. Prevalence of se)ually transmitted tubal
infection and damage
%. 4scertainment through earlier diagnosis ofsome EP otherwise destined to resorb
spontaneously
-. Popularity of contraception that predisposesfailures to be ectopic
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Ectopic Pregnancy
Increasing ectopic pregnancy
rates
. *se of tubal sterili&ation techniques that
increase the likelihood of EP
. *se of assisted reproductive techniques. *se of tubal surgery5 including salpingotomy
for tubal pregnancy and tuboplasty for
infertility
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Ectopic Pregnancy
"istory
6lassic triad of symptoms
Pain# a$enorr%ea# &aginal 'leeding
(een in only about !" of patients +ost typical in patients in whom EP has ruptured
4bdominal pain 7 most frequent complaint
8ith rupture5 the patient may e)perience transient relief of
pain since stretching of the serosa ceases
Shoulder and back pain 7 hemoperitoneal irritation of the
diaphragm9 may indicate intraabdominal hemorrhage
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Ectopic Pregnancy
"istory
Passage of decidual
cast
ccurs in "0$!" ofwomen
Their passage may be
accompanied by cramps
similar to those occurringwith a spontaneous
abortion
'ecidual cast
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Ectopic Pregnancy
P%ysical E(a$ination +easurement of
vital signs
8ith rupture and
intraabdominalhemorrhage5 the
patient develops
tachycardia
followed by
hypotension
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Ectopic Pregnancy
P%ysical E(a$ination
E)amination of the abdomen and pelvis
4bdomen may be nontender or tender5 with orwithout rebound
*terus may be enlarged5 with findings similar toa normal pregnancy
6ervical motion tenderness may or may not be
present ;ulging of the posterior cul0de0sac
4dne)al mass palpable in up to !" of cases
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Ectopic Pregnancy
C)ldocentesis 4 simple technique to identify hemoperitoneum
The cervi) is pulled toward the symphysis pubis with atenaculum
4 long $0 or $#0gauge needle is inserted through the posteriorforni) into the culdesac
Non-clotting blood aspirated :compatible with the diagnosis ofhemoperitoneum resulting from an
EP
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Ectopic Pregnancy
*a'oratory tests
<emogram
Even after substantive hemorrhage5 hemoglobin
and hematocrit readings may at first show only a
slight reduction
<ence after an acute hemorrhage5 a decrease in
hemoglobin or hematocrit level over several hours is a
more valuable inde) of blood loss than the initial
reading
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Ectopic Pregnancy
*a'oratory tests
h6= assays
EP cannot be diagnosed by a positive pregnancy
test alone
h6= assays positive in over ,," of EPs
(ensitive to levels of chorionic gonadotropin of $!0
%! mI*/ml
The h6= pattern that is most predictive of EP is
one that has reached a plateau >doubling time of
more than 1 days?
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Ectopic Pregnancy
*a'oratory tests
(erum progesterone levels
4 single progesterone measurement can be used
to establish that there is a normally developing
pregnancy with high reliability
4 value e)ceeding % ng/m@ e)cludes EP with
,1." sensitivity
Aalues below ng/m@ occur only in !.-" ofnormal pregnancies 7 suggests a dead fetus or
EP
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Ectopic Pregnancy
+ltraso)nd i$aging
4bdominal sonography If a gestational sac is clearly
identified within the uterine
cavity5 EP rarely coe)ists
8ith sonographic absence
of a uterine pregnancy5 a
positive pregnancy test
result5 fluid in the cul0de0sac5and an abnormal pelvic
mass5 EP is alsmost certain
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Ectopic Pregnancy
+ltraso)nd i$aging
Aaginal sonography
The imaging of choice in early pregnancy
4 tubal pregnancy may be missed when the massis small or obscured by bowel
2eported sensitivity for diagnosing EP varies
widely from %!" to #!"
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Ectopic Pregnancy
,)rgical diagnosis
@aparoscopy ffers a reliable diagnosis in
most cases of suspected EP and
a ready transition to definitive
operative therapy
@aparotomy
pen abdominal surgery is
preferred when the woman is
hemodynamically unstable orwhen laparoscopy is not feasible
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Ectopic Pregnancy
"istologic c%aracteristics
Evidence of chronic salpingitis and salpingitis
isthmica nodosa >(IB?
4rias0(tella reaction
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Ectopic Pregnancy
Type of EP 'efinition
Tubal pregnancy 4 pregnancy occurring in the fallopian tube 7 most often theseare located in the ampullary portion of the fallopian tube
Interstitial pregnancy 4 pregnancy that implants within the interstitial portion of thefallopian tube
4bdominalpregnancy
Primary 7 the $st and only implantation occurs on a peritoneal
surface
(econdary 7 implantation originally in the tubal ostia5
subsequently aborted and then reimplanted into the
peritoneal surface
6ervical pregnancy Implantation of the developing conceptus in the cervical canal
@igamentouspregnancy
4 secondary form of EP in which a primary tubal pregnancyerodes into the mesosalpin) and is located between the leaves
of the broad ligament
<eterotopicpregnancy
4 condition in which ectopic and intrauterine pregnancies coe)ist
varian pregnancy 4 condition in which an EP implants within the ovarian corte)
Table %. 'efinitions of Types of Ectopic Pregnancies
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Ectopic Pregnancy
T)'al Pregnancy
The fertili&ed ovum may
lodge in any portion of the
oviduct5 giving rise to
ampullary5 isthmic5 andinterstitial tubal pregnancies
4mpulla is the most frequent site5 followed by
the isthmus
Interstitial pregnancy accounts for only -" ofall tubal gestations
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Ectopic Pregnancy
T)'al Pregnancy
Treatment 4nti0' immunoglobulin '0negative women with an ectopic pregnancy who
are not sensiti&ed to '0antigen should be given anti0' immunoglobulin
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Ectopic Pregnancy
T)'al Pregnancy
Treatment (urgical +anagement @aparoscopy is preferred over laparotomy unless the
patient is unstable Tubal surgery for EP is considered conservative
when there is tubal salvage >salpingostomy5
salpingotomy5 fimbrial e)pression of the EP?
2adical surgery is defined by salpingectomy
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Ectopic Pregnancy
T)'al Pregnancy
(alpingostomy *sed to remove a small pregnancy
that is usually less than % cm in length
and located in the distal third of the
fallopian tube
4 linear incision5 $!0$ mm in lengthor less5 is made on the antimesenteric
border5 immediately above the EP
P6 e)truded out9 small bleeding
sites controlled with needlepoint
electrocautery or laser Incision is left unsutured and to heal
by secondary intention
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Ectopic Pregnancy
T)'al Pregnancy
(alpingotomy Essentially the same as salpingostomy e)cept
that the incision is closed with 10! Aicryl or
similar suture
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Ectopic Pregnancy
T)'al Pregnancy
(alpingectomy +ay be performed through an operative
laparoscope and may be used for both ruptured
and unruptured EP 8hen removing the oviduct5 it is advisable to
e)cise a wedge of the outer third >or less? of the
interstitial portion of the tube >cornual resection? To minimi&e the rare recurrence of pregnancy in the
tubal stump
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Ectopic Pregnancy
T)'al Pregnancy
(egmental resection and anastomosis 2esection of the ectopic mass and tubal
reanastomosis is sometimes used for an
unruptured isthmic pregnancy becausesalpingostomy may cause scarring and
subsequent narrowing of the small isthmic lumen
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Ectopic Pregnancy
T)'al Pregnancy
+edical +anagement (ystemic +TC +TC acts as a folic acid antagonist and is highly
effective against rapidly proliferating trophoblasts 4ctive intraabdominal bleeding is contraindicated
+ay not be used if the EP is D cm
(uccess is greatest if the 4= is weeks5 the tubal
mass is not D -. cm in diameter5 the fetus is dead5and the ;0h6= $5!!! mI*/m@
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Ectopic Pregnancy
Cer&ical Pregnancy
$ in %5!! to $ in !5!!! pregnancies >*(?
6onditions that predispose:
Previous therapeutic abortion 4shermanFs syndrome
Previous 6(
'E( e)posure
@eiomyomas
IA3
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Ectopic Pregnancy
Cer&ical Pregnancy
'iagnostic 6riteria
$. The uterus is smaller than the surrounding
distended cervi)
%. The internal os is not dilated
-. 6urettage of the endometrial cavity is non0
productive of placental tissue
. The e)ternal os opens earlier than in
spontaneous abortion
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Ectopic Pregnancy
Cer&ical Pregnancy
Preoperative preparation should include
blood typing and cross0matching5 IA access5
and detailed informed consent which
include the possibility of hysterectomy in theevent of hemorrhage
Bon0surgical management: intraamniotic
and systemic +TC administration
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Ectopic Pregnancy
O&arian Pregnancy
6riteria for diagnosis >(piegelbergFs 6riteria?
$. The fallopian tube on the affected side must be
intact
%. The fetal sac must occupy the position of the
ovary
-. The ovary must be connected to the uterus by the
ovarian ligament
. varian tissue must be located in the sac wall
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Ectopic Pregnancy
O&arian Pregnancy
!." to $" of all ectopic pregnancies
+ost common type of non0tubal pregnancy
+isdiagnosis common because it is confused with a
ruptured corpus luteum in up to 1" of cases
varian cystectomy is the preferred treatment
Treatment with +TC and prostaglandin inGection has
also been reported
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Ectopic Pregnancy
A'do$inal pregnancy
6lassified as primary and secondary
(econdary abdominal pregnancies are by farthe most common and result from tubal
abortion or rupture or5 less often5 fromsubsequent implantation within the abdomenafter uterine rupture
$ in -1% to $ in ,51$ live births Incidence of congenital anomalies: %!"0
!"
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Ectopic Pregnancy
A'do$inal pregnancy
6linical presentation
In the $st and early second trimester5 thesymptoms may be the same as a tubal EP
In advanced pregnancy: Painful fetal movement
3etal movements high in the abdomen or suddencessation of movements
Persistent abnormal fetal lies5 abdominal tenderness5displaced cervi)5 fetal superficiality
Bo uterine contractions after o)ytocin infusion
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Ectopic Pregnancy
A'do$inal pregnancy
6riteria for diagnosis 7 (tuddifordFs 6riteria
$. Presence of normal tubes and ovaries with no
evidence of recent or past pregnancy
%. Bo evidence of uteroplacental fistula
-. The presence of a pregnancy related e)clusively
to the peritoneal surface and early enough to
eliminate the possibility of secondary implantationafter primary tubal abortion
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Ectopic Pregnancy
A'do$inal pregnancy
(urgical intervention
Placenta can be removed if its vascular
supply can be identified and ligated9
otherwise it is left behind5 packing is done
which is removed after % to # hours
+TC treatment appears to be
contraindicated because of the high rate of
complications due to rapid tissue necrosis
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Ectopic Pregnancy
Interstitial pregnancy
2epresent about $" of EPs
Patients tend to present later in gestation
than those with tubal pregnancies
ften associated with uterine rupture 7
represent a large proportion of fatalities from
EP
Treatment: cornual resection by laparotomy
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Ectopic Pregnancy
Interliga$ento)s pregnancy
2are form of EP9 $ in -!! EPs
*sually results from trophoblastic penetrationof a tubal pregnancy through the serosa and
into the mesosalpin)5 with secondaryimplantation between the leaves of the broadligament
6an also occur if a uterine fistula developsbetween the endometrial cavity andretroperitoneal space
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Ectopic Pregnancy
"eterotopic pregnancy
ccurs when there are coe)isting
intrauterine and ectopic pregnancies
$ in $!! to $ in -!5!!! pregnancies
<igher in patients who undergo ovulation
induction
Treatment is operative
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E t i P
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