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PREGNANCY
ECTOPIC PREGNANCY
In ectopic pregnancy, a fertilized ovum implants
in an area other-than the endometrial lining of
the uterus
More than 95o/o of extrauterine Pregnanciesoccuri n the fallopian tube.
Interstitial
and
cornual 23%
Isthmic
12%
Ovarian 3%
Cesarean
scar <1
Abdominal
1%
Cervical <1%
Ampullary
70%
Fimbrial
11%
incidence
The incidence in the United Kingdom has
Mortality
According to the World Health Organization (2007),
TUBAL PREGNANCY
The fertilized ovum may lodge in any portion of the
Ectopic pregnancy
Clinical presentation
1-subacute clinical picture of
A. abdominal pain &vaginal bleeding in early pregnancy.
Vaginal bleeding is usually dark red, indicative old blood
B- abdominal/ pelvic pain may be localized to the iliac fossa.
C- sholder tip pain indicative of free blood in the abdominal cavity
D- dizzeness (anaemia)
Bimanual examination can reveal tenderness in the fornices and
there may be cervical excitation
2- Acute clinical presentation due to rupture ectopic pregnancy with
massive intraperitoneal bleeding. They can present with signs of
hypovolaemic shock & acute abdomen
Investigation
The following are useful investigation for the diagnosis of
ectopic pregnancy
1- observations :Bp, pulse ,temperatuer
2- laboratory investigations:
Haemoglobin. blood group(prepare blood forr cross match) &
B-HCG
A B-HCG level of less than 5mIU/ml, is considered negative for
pregnancy& any thing above 25 mIU/ml is considered positive
for pregnancy
In 85% of pregnancy the B-HCG levels almost double every 48
hours in normally developing intrautrine pregnancy
Culdocentesis
This simple technique was used commonly in the
past to identify hemoperitoneum. The cervix is
pulled toward the symphysis with a tenaculum, and
a long 16- or 18-gauge needle is inserted through
the posterior vaginal fornix into the cul-de-sac. If
present, fluid can be aspirated, however, failure to
do so is interpreted only as unsatisfactory entry into
the cul-de-sac and does not exclude an ectopic
pregnancy, either ruptured or unruptured. Fluid
containing fragments of old clots, or bloody fluid
that does not clot, is compatible with the diagnosis
of hemoperitoneum resulting from an ectopic
pregnancy. If the blood subsequently clots, it may
have been obtained from an adjacent blood vessel
rather than from a bleeding ectopic pregnancy.
Ultrasound
With the advent of diagnostic ultrasound and
Gestational sac
with a live
embryo
and a
yolk sac
Uterus
Differential diagnosis
Manageme
nt
Expectant management
Expectant management has important advantages over
medical treatment as it follows the natural history of the
disease and is free from serious side effects of methotrexate.
Expectant management requires prolonged follow-up and it
may cause anxiety to both women and their carers.
However, the main limiting factor in the use of expectant
management is the relatively high failure rate and
the inability to identify with accuracy the cases that are
likely to fail expectant management. To minimize the
risk of failure many authors have used very strict selection
criteria for expectant management such as the initial
hCG <250 IU
Surgery
Surgery has been traditionally used both for the
diagnosis and treatment of ectopic pregnancy.
With recent advances in operative laparoscopy,
the minimally invasive approach has also
become accepted as the method of choice to
treat most tubal ectopic pregnancies.
There are important advantages of laparoscopic
over open surgery which include less postoperative pain, shorter hospital stay and
faster resumption of social activity
Laporatomy
In a case of severe haemorrhage in ruptured
ectopic pregnancy , the patient must be taken
immediately to the operating theatre. Little
time should be wasted in attempting
resuscitation which can prove useless and
may only increase bleeding. An intravenous
drip should be set up and a blood transfusion
given as soon as possible.
Surgical Management
methotrexate use
1-cornual pregnancy
2-Prsistant trophoblastic disorders
3- patient with one fallopian tubeand fertility
desired .
4-patient who refuse surgery or whome
surgery is risky
5-treatment of ectopic pregnancy where
trophoblast is adherent to bowel or blood
vessel
Contrindications of medical
treatment
1- chronic liver, renal or haematological disordes
2- active infection
3-immunodeficency
4- breast feeding
Non-tubal ectopics
Interstitial ectopics
The implantation of the conceptus in the proximal portion
of the Fallopian tube, which is within the muscularwall
of the uterus, is called an interstitial pregnancy. The
incidence of interstitial ectopic is 1 in 25005000 live
births and it accounts for26% of all ectopic pregnancies
section
pregnancy is likely to cause severe vaginal
bleeding and
hysterectomy rates of 40% have been
described when
a D&C was attempted without pre-operative
diagnosis
of cervical pregnancy
Ovarian pregnancy
Ovarian
pregnancy
is
defined
as
the
implantation of the
conceptus on the surface of the ovary or inside
the ovary,
away from the fallopian tubes
. The diagnosis of ovarian pregnancy is rarely
achieved
pre-operatively; hence most women are treated
surgically as the diagnosis is reached only at
operation
Abdominal pregnancy
Abdominal pregnancy is a rarity that only a few
gynaecologists will encounter during their professional
career. Most abdominal pregnancies are the result of
reimplantation of ruptured undiagnosed tubal ectopic
pregnancies.
With the increasing accuracy of first-trimester
transvaginal scanning it is likely the prevalence of
advanced abdominal pregnancy will decrease even
further
in the future.