ECTOPIC PREGNANCY
Definition,
classification, incidence, etiology /risk factor, natural HX, pathology
clinical features, investigation, treatment, preventioo
DEFINITION: Ectopic
pregnancy is a gestation in which implantation occurs at a site other than the uterine
cavity. It is not to be seen as extra unterne pregnancy b/c some
ectopic pregnancies can take place in the uterus (e.g. cervix interstitial part
of e fallopian tube.)
CLASSIFICATION: this
is bascal an e site of unplantatri
1. Tubal
ectopic pregnancy: this is e most common (95%)
2. cervical
etopic pregnancy
3. ovaran
etopic pregnancy
4. Abdominal
ectopic pregnancy.
The
conimonest tubal partri include is the ampullany, part of the tube (abt 55%),
followed by is thunic end (25%), firubrial end (17% ), with only 2% ocaining at
the interstitial end. Other forms of ectopic pregnancy make up only 5%
HETEROTOPIC
PREGNANCY: this is when ectopic pregnancy is co-existing e an intra-uteune
pregnancy. This condition is very rare (1 in 15000-40000 specutaneous pregnancies),
but with e induct of IVF, it has become more common (abt 1% of all women
including NFX ET-EU BJO transfer )
BILATERAL
ECTOPIC PREGNANCY: here, there is ectopic pregnancy in both tubes.
INEIDENCE:
this depends on e population under study. It tends to be higher development ceuntries than in
developed countries this is b/c STLS are more common in developing than in
developed countries .the ectopic tends to very b/w 0.25 and 1% of all pregnancy
AETIOLOGY
AND RISK FACTORES
RISK
FACTERS: sexually transmitted infection (STLS)
The
risk factors can be divided in to high, maderate and nuldnsk factors
High
risk factors: STI/PID (infection
RISK FACTOR: sexually
transmitted infection (STLS)
The risk factor can
be divided in to high, made rate and muildnsk factors
High risk factors:
STI/PID (infection of upper genital tract due to STLS)
Tubal suragenes
Previcus ectopic pregnancy (abt
10% changes )
Stenlization
Use of intra-utenine
contraceptive daivce (IUCD)
Moderate risk
factors: infertility
History of muilliple
sexual patners.
Slight /mild risk
factors: cigarette smoking
Early age at ist
intercourse (>18yrs )
NATURAL HISTORY
Ectopic pregnancy can
progress in 3possible ways
1. spontaneans
res or ptri
2. tubal
abortion (pashed out via e fimbrial end )
3. tubal
rupture
4. abdominal
pregnancy (bldy. So give cortimous iv antibiotics and cytotoxic drugs. If
placenta attaches to essential organs, separation may be that )
PATHOLOGY
In
tubal ectopic pregnancy, unplantation takes place in e connective tissue
beneath e serosa. There is usually little or no decided response /defence
against e muading trophoblast in the fallopian tube. The trohablast, thus
uivades bld used to cause local haemorhege, the intent the sub-savesel space
predisposing to tubal rupture. The result in fnital death. But sometimes, the
fetus bld supply to uiable and continue as a secondary abd pregnancy. Veginal
bleding of utaine ongin is caused by slouglig fronectopic pregnancy (is heavy
and Brigitred )
CLUCAL
FEATURES:
Abdominal
pain and uregular vaginal bleding are the commoest symptones of ectopic
pregnancy. The abdomical pain occurs in abt 100% of cases, while the irregular
vaginal bleeding occurs in about 75% of
cases.
Secondary
arnemorrhea,: This is variable. About 50% of women in ectopic pregnancy have
some spotting spurting at the time of their menstrual period and so do not
realize that they are pregnant. However, there is almost always an alteration
in hermo menstrual cycle.
Syncopy
( fainting attack) : This is usually associated it rupture. The initial shock
is usually neurologic, while haemorrhagic shock takes place afterwards.
Syncopy is dizziness and rapid pulse, due to
severe hemoperitoneum, occur in about 25-20% of cases.
Presentations
Haemorrhagic shock/ Emergency – present ti
syncope ( those is previous HX of the patient are asked to present once they
miss their period)
Asymptomatic
group- discovered via USS
Sub
acute presentation group- seening those it tubal abortion or those it
incompletely ruptured tube. May present the diarrhea. (this is the
Commonest
ep. Presentation. In this group the symptoms are less dramatic due to tubal
rupture or abortion occurring gradually and often the doze of Ep. Is missed.
They often present the amenorrhea or altered menstrual cycle; abdominal pain;
or irregular vaginal bleeding.
Investigations
Combination of trans vaginal scan (TV) and
measurement of serum B- hcc level has reuolutrialized Ep management.
-USS
-B-HCG
titers
Their complementary use of B-HCG liters
TVs has brought early diagnosis of Ep,
it subsequent in adverse outcome. This revolution was brought about by Kader
Etol. This is done by comelating B- Hcg litres it ultrasound scan finding an
epically can often be differential from an intra-uterine pregnancy.
If
B-HCg level is < 1000ml. u/ml, but the TVS is enable to pick up an
intra-uterine pregnancy, the dose is epically. An intrauterine pregnancy should
be visible TVs when the B-HCG level is up to/ approbatory 1000mlu /ml(1000l.u/l) and by trans-abdominal
USS, approximately 1 week later, when B-hcg level is up to 1800- 3600 ml.u/ml.
thus , when an empty uterine cavity is seen with B-HCG to titre above theser
thes hold level, the patient is likely to have an epically. Sonographic finding
of an extra-uterine pregnancy sac, it an embryo or embryo remnants is the most
reliable diagnosis of ectopic pregnancy laparoscopy is also a diagnostic tread
its use in dose of epicotyls has declined because of the advent of ultrasound
scanning and B-HCG litre usage. It still hasplace, however, when the definitive
diagnosis is difficult to make it is an endoscope procedure to directly
visualize the abdominal cavity laparatomy (opening the abdominal cavity) this
is indicated when presumptive does
of Ep in an unable partient necessitake unmediated
surgecy .culdoceutasis :this procedure will reval non-clothing bld, if
intrabdominal bleeding has occurred. If culdcentesis is positive, laparoscopy
or laporotomy should be done unmediately. The finding of bld is not specific,
and the presence of bond adhesions may predispose to iatragevic bowel
ruptuning.
TREATMENT
Divided in to
:expectant management
Surgical treatment
Medical treatment
EXPECTANT MANAGEMENT
:can be done in asgmptomatic cases blc many epe resolve spontaneasly an
asymptomatic complaint patient may be managed expectanthy if B-HCG titres are
low or decreasing.
SURGICAL TREATMENT :
cervical ep: most cases may require a hysterectomy.
Tubal EP: TX varies
for total salpingectomy, partial saplingsctomy,
segnantal salpingectomy (e
tubo-tubal anastomos is done later ) to corneal resection. Hysterectomy is
rarely done. Used for cases dat have nerther nuphued nos aborted <
Conservative
surgenies
1. linea
salpingostomy (bring out gestatrialsac and leaves open )close by itself.
2. salpingetomy
(bring out gestatrial sac and suture it).
Sabsequesnt
pregnancy rates is abt 40-90% e other of them. But recurrent atapic rate is abt
16% these surgeries are better done in unruptived (50% of woman e gonorrhea
will have symptoms 25% of woman e chlanydeial infection will have symptoms )
more men have symptomy small (<3cm )
tubal pregnancies. After this, the b-HCG lencls should be monitored weekly to
ensure complete clearing, and to prevent pesient trophoblastic tissue.
3. plugging
out e product of conception via e ostium.
4. milking
out product of conception via e ostium. This is no longer done b/c of e
association of persistent trophoblatic tissue, TD risk of EP, e need for
re-exploration. Medical treatment :done in unniptured cases. Very inpt duged
methotrexate (for small unruptured ectopic pregnancies ) can be given either
paraenterally (systemically-IM ), or directly njected in to e following B-HCG
level along e FBC, SEUCr and LFT are abtained
for comparison e baseding levels.
PREVENTION
Abstinence
safe
sex practice
Early
d3 of unruptured tubal pregnancy. Early
and appropriate tx of STI.
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July 08, 2015
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