ECTOPIC PREGNANCY

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ECTOPIC PREGNANCY:

ECTOPIC PREGNANCY  An ectopic pregnancy aka extrauterine pregnancy is the one in which the fertilized ovum gets implanted anywhere other than the endometrial lining.

Location:

Location  Nearly all the ectopic pregnancies (97%) are implanted within the fallopian tubes.  Nevertheless, implantation can occur in the cervix, abdomen, ovary and uterine cornua .

Risk Factors:

Risk Factors  Most common cause for the tubal ectopic pregnancy is a pathologic fallopian tube.  This also means that if you have a inflammatory process such as salpingitis and salpingitis isthmica nodosa , you will be at an increased risk for developing an ectopic pregancy .  A previous history of ectopic pregnancy can also predispose you to an increased risk of developing another one.  Infections such as Chlamydia trachomatis and endotoxin producing Neisseria gonorrhea causes virulent pelvic inflammation and acute cases of the same can also predispose you to develop and ectopic pregnacy .  Maternal use of DES has also been implicated for the development of ectopic pregancy to the daughters born to such mothers.

Symptoms:

Symptoms The classic symptoms associated with ectopic pregnancy are Amenorrhea followed by vaginal bleeding and abdominal pain on the affected side. However, there are no symptoms or any group of the same that are diagnostic.  normal pregnancy findings like breast tenderness, nausea and urinary frequency are also found. In any patient with a positive pregnancy test whenever the tissue evaluation obtained spontaneously or by curettage does not demonstrate villi , an ectopic pregnancy should be assumed to be present until proven otherwise

DDX:

DDX Abortion: Threatened, incomplete or missed abortion. Placental polyp. Hemorrhagic corpus luteal cyst. Appendicitis. Renal calculi. In order to decrease mortality any sexually active woman in the reproductive age group who presents with pain, irregular bleeding and/or amenorrhea should have ectopic pregnancy as a part of the initial ddx .

Diagnostic Procedures:

Diagnostic Procedures TVS and serial β - hCG measurements are the most valuable diagnostic aids to confirm the clinical suspicion of an ectopic pregnancy. Serum progesterone concentration has also been used as a screening test for ectopic pregnancy. Curettage of uterine cavity.  Culdocentesis . Direct visualization via laparascopy .

β-hCG levels:

β - hCG levels Each institution must define a β - hCG discriminatory value, that is the lower limit of hCG at which the examiner can reliably vixualize pregnancy on ultrasound.  TVS can visualize a pregnancy at hCG levels as little as 1000-2000 IU/L  Transabdominal ultrasonography can visualize a pregnancy when β - hCG reaches 5000-6000 IU/L  The absence of uterine pregnancy with β - hCG levels above the discriminatory value signifies an abnormal pregnancy---ectopic, incomplete abortion, or resolving completed abortion.

Serum Pregesterone:

Serum Pregesterone  A serum progesterone level of <5ng/ml has been used to identify a nonviable pregnancy.  Conversely, a serum progesterone level of >20 ng /ml is used to identify a healthy pregnancy.  Most ectopic pregnancies are associated with serum progesterone levels between 10ng/ml and 20ng/ml…this limits the clinical utility of this diagnostic procedure.  Serum progesterone values cannot differentiate between an ectopic and intrauterine pregnancy; it can only tell whether the patient is pregnant or not and whether the pregnancy is viable or healthy.

Curettage:

Curettage Curettage of uterine cavity can also help rule out ectopic pregnancy…however care should be taken because there is a possibility of interrupting a normal intrauterine pregnancy. Heterotopic pregnancy : Intrauterine and ectopic pregnancy existing simultaneously.

Culdocentesis:

Culdocentesis  Culdocentesis can identify hemoperitoneum which may indicate a ruptured ectopic pregnancy. This can also be consistent with a ruptured corpus luteum cyst. This process when used only tells the examiner that when blood is aspirated – positive culdocentesis (blood in cul-de-sac i.e. in peritoneal cavity), further workup is required to identify the source of bleeding.

Laparoscopy:

Laparoscopy  The most accurate technique of identifying an ectopic pregnancy is by direct visualization which is done most commonly via laparoscopy.  This process is considered best because the is a s little as 2% chance of misdiagnosis—lowest of any of the above listed procedures.  A false positive diagnosis can result from a hematosalpinx being misinterpreted as an unruptured ectopic pregnancy or tubal abortion.

Management and Treatment:

Management and Treatment  METHOTREXATE MTX therapy can be considered for those women with a comfirmed , or a high suspicion of ectopic pregnancy who are hemodynamically stable with an unruptured mass. MTX affects all of the rapidly dividing cells by binding to the catalytic site of DHF reductase interrupting the synthesis of purine nucleotides thus inhibting DNA synthesis and repair and cell replication. It is inevitable for the patients taking MTX regimen to follow up due to the antimetabolite mechanism of the drug that can affect all the rapidly dividing cells in the body.

MTX Treatment Protocol:

MTX Treatment Protocol Single dose Regimen Single dose MTX 50mg/ m 2 IM day 1 Measure hCG levels on days 4 and 7. Check for 15% decrease between day 4 and 7. Then measure hCG level weekly until reaching non pregnant level. If during a follow up the hCG level plateau or increase, consider repeating MTX. Two dose Regimen Administer 50 mg/m 2 IM on day 0. Repeat 50mg/m2 IM on day 4. Check for 15% decrease between day 4 and 7. If the decrease is greater than 15% measure hCG levels weekly until reaching non pregnant level. If less than 15% decrease in hCG levels re administer MTX 50 mg/m2 on days 7 and 11, measuring hCG levels.

MTX Containdications:

MTX Containdications ABSOLUTE Breast feeding. Immunodeficiency Alcoholism or related Hepatic Cirrhosis. Blood dyscrasias . MTX sensitivity. Active pulmonary disease. Peptic Ulcer disease. Hepatic, Renal or Hematologic dysfunction. RELATIVE Gestational Age >3.5 cm, Embryonic HR present.

Surgical Management:

Surgical Management Women who are hemodynamically stable and in whom there is a small tubal diameter, no feta cardiac activity and serum β - hCG concentration <5000 IU/L. Linear salpingostomy : The surgeon makes a linear incision on the fallopian tube over the site of implantation, removes the pregnancy, and allows the incision to heal bt secondary intention. Segmental resection : Removal of the portion of the affected tube.  Salpingectomy : The removal of entire tube.

References:

References http://en.wikipedia.org/wiki/Ectopic_pregnancy http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/ http://www.google.com/imgres?q=ectopic+pregnancy American College of Obstetricians and Gynecologists. Management of recurrent and early pregnancy loss. ACOG Practice Bulletin No. 24. Obstet Gynecol . 2001; 97 (2). American College of Obstetricians and Gynecologists. Medical management of abortion. ACOG Practice Bulletin No. 67. Obstet Gynecol . 2005;106 (4):871-882. American College of Obstetricians and Gynecologists. Medical Management of tubal pregnancy. ACOG Practice Bulletin No. 3. Obstet Gynecol . 1998;92(6):1-7.

Salpingitis Isthmica Nodosa:

Salpingitis Isthmica Nodosa

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