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Ectopic Pregnancy PowerPoint Presentation

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Description : An ectopic pregnancy occurs when the conceptus implants either outside the uterus (Fallopian tube, ovary or abdominal cavity) or in an abnormal position within the uterus (cornua, cervix).

Tags : ectopic pregnancy,pregnancy,pregnancy test,cervix,cornua,heterotopic

Published on : Aug 07, 2024 | Views : 4456 | Downloads : 22

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ECTOPIC PREGNANCY
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Human chorionic gonadotrophin has a half-life of 6-24 hours and rises to a peak in pregnancy at 9-11 weeks' gestation. Pregnancy tests The first test to confirm the existence of pregnancy is for the detection of human chorionic gonadotrophin (hCG) in the patient's urine or plasma
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Early pregnancy disorders currently account for approximately three-quarters of emergency gynaecological admissions and are an important cause of maternal morbidity and mortality throughout the world. Disorders of early pregnancy:
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The three main categories of early pregnancy disorders are: 1. spontaneous miscarriages 2. ectopic pregnancies 3. gestational trophoblastic disorders (GTDs). Introduction
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An ectopic pregnancy occurs when the conceptus implants either outside the uterus (Fallopian tube, ovary or abdominal cavity) or in an abnormal position within the uterus (cornua, cervix). Combined tubal and uterine (heterotopic) pregnancies are uncommon. Definition:
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The incidence of ectopic pregnancy is about 11 in 1000 pregnancies Between 95 and 98 percent of ectopic pregnancies occur in the Fallopian tube. Epidemiology and risk factors
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Site of tubal ectopic pregnancy are: 1.More than 50 % of tubal pregnancies are situated in the ampulla. 2. approximately 20 % occur in the isthmus. 3. around 12 % are fimbrial . 4.approximately 10 % are interstitial Sites of ectopic pregnancy:
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Sites of Implantation Fallopian tube – most common site (ampulla) – 95% Ovary Uterine cornu Cervix Broad ligament Spleen 5% Liver Retroperitoneum Diaphragm Cesarean scar Pathogenesis
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The risk of recurrence is around 10 per cent and is increased in those who have had a previous miscarriage or who have suffered tubal damage. Recurrence rate:
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pathophysiology -It is believed that the main cause for a tubal implantation of the gestational sac is a low-grade infection, as approximately 50 % of women operated on for an ectopic pregnancy have evidence of chronic pelvic inflammatory disease.
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ACUTE ECTOPIC PREGNANCY
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Signs & Symptoms Often subtle, or even absent 1.Pain :Pelvic and abdominal pain – sharp, stabbing or tearing in character, rectal pain. Pleuritic chest pain – from diaphragmatic irritation caused by the hemorrhage 2.Abnormal Menstruation Amenorrhea Vaginal bleeding – may be scanty, dark brown, intermittent or continuous 3.Abdominal and pelvic Tenderness Tenderness on abdominal and vaginal examination especially on motion of the cervix – ruptured or rupturing tubal pregnancies
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Signs & Symptoms 4. Uterine changes In 25% of women, the uterus enlarges due to hormonal stimulation of pregnancy. 5. Blood pressure and pulse Before rupture vital signs are generally normal. Hypotension and tachycardia – if bleeding continues and hypovolemia becomes significant 6. Pelvic Mass Almost always either posterior or lateral to the uterus, and typically soft and elastic The mass may be firm with extensive infiltration of blood into the tubal wall.
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This must include a record of pulse rate and blood pressure. Shoulder pain, which may occur secondary to blood irritating the diaphragm . vascular instability characterized by low blood pressure, fainting, dizziness and rapid heart rate may be noted. These symptoms are present in more than 50 % of patients and are most typical of patients whose ectopic pregnancy has ruptured (intra-abdominal bleeding). General examination
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Speculum or bimanual examination must be performed in an environment where facilities for resuscitation are available, as this examination may provoke the rupture of the tube. Gynaecological examination:
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plasma hCG and transvaginal sonography have allowed for a less invasive evaluation of the patient with a suspected ectopic pregnancy. The hCG levels and ultrasound findings must be interpreted together. One of the most important parameters is the discriminatory hCG level above which the gestational sac of an intrauterine pregnancy should be detectable by ultrasonography (usually l000 -1500 IU/L). Human chorionic gonadotrophin andtransvaginal ultrasound:
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Serum Progesterone Levels: Serum Progesterone Levels: A value exceeding 25ng/mL excludes ectopic pregnancy. -Values below 5ng/mL suggest either an intrauterine pregnancy with a dead fetus or an ectopic pregnancy.
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The presence or absence of an intrauterine gestational sac is the principal point of distinction between intrauterine and tubal pregnancy. The sonographic finding of an extrauterine sac with an embryo or embryonic remnants is the most reliable diagnosis of ectopic pregnancy. An empty ectopic sac or a heterogeneous adnexal mass is a more common ultrasound feature. ultrasound
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The presence of fluid in the pouch of Douglas is a non-specific sign of ectopic pregnancy. In 10-20 % of ectopic pregnancies, a pseudogestational sac is seen as a small, centrally located endometrial fluid collection surrounded by a single echogenic rim of endometrial tissue undergoing decidual reaction. ultrasound
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Laparoscopy Laparoscopy should be considered in women with hCG above the discriminatory level and absence of an intrauterine gestational sac on ultrasound
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Ectopic pregnancy can be treated : 1. conservative (expectant ). 2. medical. 3. surgical . According to: Clinical presentation. Ultrasound finding. Serum B-HCG titer. Management
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Anti-D Immunoglobulin Rhesus Negative women with an ectopic pregnancy who are not sensitized to D-antigen should be given anti-D immunoglobulin
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Expectant Management Criteria: 1.Decreasing serial β-hCG levels. 2.Tubal pregnancies only . 3.No evidence of intra-abdominal bleeding or rupture as assessed by vaginal sonography 4.Diameter of the ectopic mass not greater than 3.5 cm
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The classical approach to the treatment of ectopic pregnancy has always been surgical: (salpingectomy or salpingotomy), either by laparotomy or laparoscopy. the wider use of ultrasound, an early diagnosis is now possible in many cases before the onset of symptoms. Management
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Medical Management: METHOTREXATE An anti-neoplastic drug that acts as a folic acid antagonist, and is highly effective against rapidly proliferating trophoblasts. Success is greatest if The gestation is <6 weeks The tubal mass should be <3.5 cm in diameter The fetus is dead Β-hCG is <15,000 mIU/mL
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Summary
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1. Positive pregnancy test Lowe abdominal pain + Minimal Vaginal bleeding Asymptomatic with factors for ectopic pregnancy Risk factors Previous ectopic pregnancy Previous PID Tubal surgery Tubal Surgery Tubal pathology (PID, endometriosis Infertility, ovarian stimulation IUCD failure Sterilization failure Previous abdominal surgery Multiple sexual partners 2. History + clinical examination MANAGEMENT OF ECTOPIC PREGNANCY
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If sure of date of LMP and /or Regular cycle, i.e. >6 wks. gestation, Arrange TV ultrasound If unsure of date of LMP and /or irregular cycle, Measure serum hCG If hCG <1000 (?early Intrauterine/ ? Ectopic pregnancy If Hcg >1000, use protocol for suspected Ectopic pregnancy 3. Empty uterus + free fluid in POD + adnexal + FH serum hCG > 1000 Meet criteria for Methorexate treatment Does not meet criteria for methotrexate treatment Use methotrexate protocol Laproscopic /salpingotomy/ Salpingectomy ?Proceed to laparotomy OR Laparotomy if haemodynamically unstable
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Thank you