Lecture 8Lecture 8

ECTOPIC PREGNANCY.ECTOPIC PREGNANCY.

ABORTION ABORTION

Prof. Vlad TICA, MD, PhDProf. Vlad TICA, MD, PhD

ECTOPIC PREGNANCY

DEFINITIONImplantation outside of the uterine cavity

It is a condition that significantly jeopardizes the mother → catastrophic bleeding may occur when the implanting pregnancy erodes blood vessels / ruptures of the tubal wall

IMPLANT LOCATIONS

Tubal: 95% (80% ampullary portion)

Ovarian: < 1%

Abdominal: 1-2%

Cervical: 0.15%

Cornual: 2%

ETIOLOGY

Salpingitis - 6x increase the risk of ectopic pregnancy

Operation of fallopian tubes

IUD (intrauterine device)

Dysfunction of fallopian tubes

Other: endometriosis

OUTCOMES OF ECTOPIC PREGNANCYTubal abortion

8-12 weeks ampullary portion

Rupture of tubal pregnancy 5 weeks isthmic portion

Tubal abortion with subsequent implantation on an intraperitoneal structure, for example

liver pregnancy

CLINICAL MANIFESTATIONSAmenorrhea - 70-80% (6-8 weeks)

Abdominal and pelvic pain - the most common symptom, which is present in nealy all patients Pain is a result of distented of fallopian tube

and irritation of peritoneum by blood

Irregular vaginal bleeding - results from the sloughing of the decidua

Shock - result from amount of blood loss

Abdominal mass

PHYSICAL FINDINGS IN TUBAL PREGNANCY

Anemic / pale face

Pulse ↑↓

BP ↓

T < 38 ºC

ABDOMINAL EXAMINATION

Distention and tenderness with or without rebound

Decreased bowel sound

Shifting dullness positive

Mass

PELVIC EXAMINATION

Slightly open cervix with bleeding

Cervical motion tenderness

Adnexal tenderness

Adnexal mass

The uterus size may be normal / enlarged

DIAGNOSTIC PROCEDURES

Typical cases can be determined easy

Early ectopic pregnancy / unruptured type - difficult

It is necessary to need assistant examination

DIAGNOSTIC PROCEDURES

Typical cases can be determined easy

Early ectopic pregnancy / unruptured type - difficult

It is necessary to need assistant examination

DIAGNOSTIC PROCEDURES

A. hCG TEST

80-100% positive

Urinary hCG level

Blood hCG level

If hCG negative, ectopic pregnancy does not be rule out

B. TYPE B ULTRASOUND

DIAGNOSTIC PROCEDURES

C. CULDOCENTESIS

Aid in the identification of peritoneum bleeding

Positive (noncloting blood)

Ectopic pregnancy may be confirmed

Negative ectopic pregnancy does not be depletion

DIAGNOSTIC PROCEDURES

D. LAPAROSCOPY

It is a direct visualization and accurate method to diagnosis ectopic pregnancy

Even laparoscopy - 2-5% misdiagnosis rate

an extremely early tubal pregnancy gestation may not be identified

PATHOLOGY OF ENDOMETRIUM

Curettage of the uterine cavity can also help rule out ectopic pregnancy

Identification of chorionic villi in curetting may identify an intrauterine pregnancy

DIFFERENTIAL DIAGNOSIS

Abortion

Acute salpingitis

Acute appendicitis

Rupture of corpus luteum

Torsion of ovarian cyst

TREATMENT

SURGICAL TREATMENT

Salpingectomy

Conservative operation

Salpingostomy

Segmental resection and tubal reanastomosis

TREATMENT

CHEMICAL THERAPY

Drug: MTXMTX

Indications:

The diameter of the mass < 3cm

Unrupture

Not significantly bleeding

hCG level < 2000 UI/L

ABORTION

DEFINITION

The termination of a pregnancy before 26 weeks from the first day of the last menstrual period

CLASSIFICATION

Early abortion: < 12 wks

Late abortion: 12-28 wks

Spontaneous abortion

Artificial abortion

ETIOLOGYGenetic factors

Maternal factors

Infection

Systemic factors, heart disease, sever anemia, endocrine

Reproductive tract abnormality

Immunologic factors

Enviromental factors - Toxin, Radiation, smoking, alcohol

PATHOLOGY

1. Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation

PATHOLOGY

2. The ovum, partly or wholly detached, acts as a foreign body and irritates uterine contractions. The cervix begins to dilate.

PATHOLOGY

3. Expulsion complete. The decidua is shed during the next few days in the lochial flow

CLINICAL MANIFESTATIONS

Haemorrhage

usually the first sign

may be significantly if placental separation is incomplete

Pain

usually intermittent, ‘like a small labrur’

it ceases when the abortion is complete

THREATENED ABORTION

Low abdominal pain Vaginal bleeding

Cervix is closed

Unruptured membranes

Embryo survive

INEVITABLE ABORTION Bleeding increased

Pain development

Rupture of membranes

Cervix dilation

Embryo tissue incarcerated in the cervix

COMPLETE ABORTION Uterine contractions are felt,

the cervix dilates and blood loss continues

The fetus and placenta are expelled complete, the uterus contracts and bleeding stops

No further treatment is needed

INCOMPLETE ABORTION In spite of uterine contractions

and cervical dilatation, only the fetus and some membranes are expelled

The placenta remains partly

attached and bleeding continues

This abortion must be completed by surgical methods

MISSED ABORTIONMISSED ABORTION

Is the retention of a failed intrauterine Is the retention of a failed intrauterine pregnancy for a extended period, usually pregnancy for a extended period, usually defined as > 2 menstrual cyclesdefined as > 2 menstrual cycles

RECURRENT ABORTIONRECURRENT ABORTION

The patient has had two / more consecutive spontaneous abortions

SEPTIC ABORTIONSEPTIC ABORTION

TREATMENTINCOMPLETE ABORTION

Remove the embryo and placenta as soon as possible

Negative pressure suction

Embryulcia

MISSED ABORTION Notice blood clot function prevent DIC

SEPTIC ABORTION

Broad-spectrum antibiotics

REMOVAL OF PLACENTAL TISSUE WITH OVUM FORCEPS

REMOVAL OF PLACENTAL TISSUE WITH CURETTE