1 / 46

Ch.10 ECTOPIC PREGNANCY

Ch.10 ECTOPIC PREGNANCY. 부산백병원 산부인과 R2 서영진. Implantation anywhere (normally, endometrial lining of the uterine cavity) 2% in U.S.A >95% : involve oviduct Risk of death ↑, subsequent successful pregnancy↓  but, with earlier diagnosis,

hye
Télécharger la présentation

Ch.10 ECTOPIC PREGNANCY

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Ch.10 ECTOPIC PREGNANCY 부산백병원 산부인과 R2 서영진

  2. Implantation anywhere (normally, endometrial lining of the uterine cavity) • 2% in U.S.A >95% : involve oviduct • Risk of death ↑, subsequent successful pregnancy↓  but, with earlier diagnosis, maternal survival ↓, reproductive capacity ↓

  3. GENERAL CONSIDERATIONS • Risk factors - prev. tubal surgery - prev. ectopic pregnancy - PID, endometriosis - prev. c/sec - assisted reproduction: GIFT, IVF - failed contraception

  4. EPIDEMIOLOGY - increase fourfold in the U.S.A from 1970 to 1992 - nonwhite, older age - increasing causes 1. Increase STD 2. Earlier diagnosis (before resorb spontaneously) 3. Contraception (failed) 4. Tubal sterilization techniques 5. Assisted reproductive techniques 6. Tubal surgery

  5. Mortality - markly decreased - improved diagnosis & management - but, most common cause of the maternal death in first trimester of the U.S.A

  6. PATHOGENESIS OF ECTOPIC PREGNANCIES • Tubal pregnancy - ampullary > isthmic > interstitial - secondary, tubo-ovarian, tubo-abdiminal, broad-ligament pregnancies develop - fertilized ovum burrows through the epithelium (because, tube lacks a submocosal layer)  zygote comes to lie within the muscular wall  rapidly proliferating trophoblast invades the subjacent muscuralis  maternal blood vessels are opened

  7. Tubal abortion - common in ampulla but rupture is usual in isthmus - if placetal separated completely, all tissues extruded into the pelvic cavity  disappear hemorrhage and symptoms - some bleeding: remain the oviduct & PCDS or forming a hematosalpinx

  8. Tubal rupture - the invading, expanding products of conception may rupture the oviduct at any sites - occur in the first few weeks in first trimester (but, interstitial pregnancy usually occur later) - usually, spontaneously rupture (sometimes coitus or bimanual examination) - rarely, undamaged conceptus into the peritoneal cavity  lithopedion

  9. # abdominal pregnancy - if the greater portion of the placenta retains its tubal attachment, further development is possible # broad-ligament pregnancy - into a space formed between the folds of the broad ligament # interstitial pregnancy (cornual pregnancy) - 3% of all tubal pregnancy - rupture may not occur until up to 16 weeks - severe hemorrhage (because the inplantation site is located between the ovarian & uterine arteries)

  10. Multifetal ectopic pregnancy # heterotypic ectopic pregnancy - tubal pregnancy + uterine pregnancy - 1/30,000  1/7,000 (assisted reproduction)  1/900 (ovulation induction) - after assisted reproductive technique persistent gonadotropin level after D&C or abortion fundus is larger than menstrual dates more than one corpus luteum ectopic pregnancy without vaginal bleeding USG evidence of intra- and extrauterine pregnancy

  11. # Multifetal tubal pregnancy - same tube or in each tube

  12. CLINICAL FEATURES OF ECTOPIC PREGNANCY - depend on whether rupture has occurred - usually, not suspect pregnancy thinks that she has a normal pregnancy - in contemporary prectice, symptoms and signs of the ectopic pregnancy are often subtle or even absent

  13. Symptoms and signs - pain : most frequently abdominal and pelvic pain (95%) G-I symptom (80%) dizziness or headache (58%) - abnormal menstruation : amenorrhea (most common) bleeding (true menstruation vs. abnormal) if profused, incomplete abortion > ectopic preg

  14. - abdominal and pelvic tenderness - uterine change : be pushed to one side due to ectopic mass : enlarged uterus (hormonal stimulation) : endometrium is converted to decidua (the decidua without trophoblast suggests ectopic pregnancy but not absolutely) - blood pressure and pulse : early – no change or slightly BP↓ , pulse↓ late – hypovolemic shock (BP↓, pulse ↑)

  15. - pelvic mass : 5-15cm, 20% (bimanual examination) posterior or lateral of uterus soft and elastic : iatrogenic rupture - culdocentesis : identify hemoperitoneum simply : cervix is pulled toward the symphysis pubis 16- or 18- gauze needle through the posterior fornix into the cul-de-sac

  16. Laboratory tests - hemogram : Hb↓,Hct↓.WBC↑ (>30,000㎕) - chorionic gonadotropin assays : ELISA are sensitive to levels of chorionic gonadotropin of 10 to 20 mIU/mL - serum progesterone level : >25㎍/mL – normal pregnancy (97.5% sensitivity) but, inconclusive

  17. Ultrasound imaging - abdominal sonography : if tubal pregnancy, difficult…. : using abdominal ultrasound until 5 to 6 menstrual weeks or 28 day after timed ovulation - vaginal sonography : earlier and more specific : as early as a week after missed menses : when hCG > 1000 , G-sac is seen half the time : detect adnexal mass, fluid collection of PCDS

  18. DIAGNOSIS OF ECTOPIC PREGNANCY • Multi-modality diagnosis 1. Vaginal sonography 2. Serum -hCG: intiallavel and subsequent level 3. Serum progesterone 4. Uterine curettage 5. Laparoscopy and, less frequently, laparotomy  only hemodynamically stable women, with rupture should undergo prompt surgery

  19. # discriminatory -hCG level - failure to visualize a uterine pregnancy by transvaginal ultrasound - empty uterus + >1500 mIU/mL 100% excluding a live uterine pregnancy - mean doubling time for -hCG : 48 hours - if the -hCG level rises inappropriately, plateaus, or exceeds the discriminatory level without evidence of a uterine pregnancy, a live uterine pregnancy can be excluded - biopsy < curettage (sensitivity)

  20. # serum progesterone - its accuracy is crude - if < 5 ng/mL or > 25 ng/mL, neither absolutely refute nor confirm a living uterine pregnancy

  21. Surgical diagnosis - laparoscopy :direct visualization of the fallopian tube, pelvis - laparotomy :hemodynamically unstable

  22. TREATMENT AND PROGNOSIS - importantly, early diagnosis→early medical Tx (more cost-effective than surgical therapy) • Anti-D immunoglobulin - D-negative women who are not sensitized D- antigen should be given anti-D immunoglibulin

  23. Surgical management - laparoscopy > laparotomy (if stable) - salpingostomy : < 2cm incision, distal third of tube small bleeding – electrocautery incision is left unsutured - salpingotomy : incision is closed with Vicryl 7-0 - salpingectomy : tubal resection (wedge of the outer third of the interstitial portion)

  24. - segmental resection and anastomosis : an unruptured isthmic pregnancy : prevent scarring and narrowing of the small isthmic lumen - persistent trophoblast : increase the risk 1. small preg < 2 cm 2. early preg < 42 menstrual days 3. β-hCG > 3000 mIU/mL 4. implantation medial to the salpingostomy site

  25. : incomplete remove of trophoblast 5~10% of salpigostomies : post op #1 → β-hCG value is less than 50% of preop. value

  26. Medical management # systemic methotrexate - folic acid antagonist effective against rapidly proliferating trophoblast - contraindication : active bleeding, >4cm, breast feeding, alcoholic, immunodeficiency, lever or renal ds, peptic ulcer - success rate ↑ : < GA 6 weeks, <3.5cm, -hCG<15,000 mIU/mL fetus is dead

  27. <patient selection> - must be hemodymamically stable - fails 5~10% ( higher : > 6weeks, >4cm) require treatment : other medical or surgical if outpatient, rapid transportation signs of rupture must be reported promptly until resolved, sexual intercourse(X), alcohol(X) folic acid, vitamins (X)

  28. table 10-3

  29. <monitoring toxicity> - liver involve, stomatitis, gastroenteritis BM depression, pneumonitis, alopecia - resolved by 3~4 days after methotrexate was stop <monitoring efficacy of therapy>

  30. <persistent ectopic pregnancy> - requires additional methotrexate or surgery - separation pain : mild and relieved by nonnarcotic analgesics but, worrisome pain : Hb, β-hCG follow up, USG

  31. Other treatment - direct injection : various cytotoxic drugs laparoscopy or transvaginally by culdocentesis - oral methotrexate therapy : two devided doses 2 hours apart for total dose of 60 mg/㎡ : lower success rate

  32. - expectant management : spontaneous resolution : 1. Decreasing serial -hCG levels 2. Tubal pregnancies only 3. No evidence of bleeding or rupture 4. Ectopic mass < 3.5cm : more likely if initial -hCG < 1000mlU/mL

  33. ABDOMINAL PREGNANCY - follow early rupture or abortion of a tubal pregnancy into the peritoneal cavity - placenta : after penetrating the oviduct and maintains its tubal attachment, gradually encroaches upon and implants in neigh- boring serosa fetus : continues to growth within peritoneal cavity

  34. Diagnosis - difficult , because early rupture or abortion of a tibal pregnancy is the usual antecedent - nausea, vomiting, flatulence, constipation, diarrhea, abdominal pain - palpable fetal position : close to the examining fingers (thin, multiparous) - cervix : usually displaced - fetal head : vaginal fornix

  35. # laboratory tests : unexplained transient anemia after initial tubal rupture or abortion : unexplained increase AFP value # sonography : oligohydramnios is common but nonspecific : fetal head lie adjacent to maternal bladder with no interposed uterine tissue # MRI, CT

  36. Fetal outcome - surviving fetuses may be abnormal - fetal deformation : cranial asymmetry various joint abnormalities fetal malformation: limb deficiency CNS anomalies

  37. Management - risk for sudden and life-threatening bleeding : in-hospital management generally, termination - suppuration, mummification, calcification adipocere : yellowish, greasy mass - surgery : bleeding due to the lack of constriction of vessels after placental separation (adequate blood supply, monitoring) laparotomy : vertical midline incision

  38. # management of the placenta - avoid unnecessary exploration of other organ must be safety removed - if possible, blood vessel supplying the placenta should be ligated first - if leaving placenta : long-term sequelae (infection) resorption (>5years) - methotrexate use is controversal

  39. # arterial catheterization and embolization - preoperatively - lifesaving in massive pelvic hemorrhage # maternal prognosis - higher than normal pregnancy - reduced by preoperative planning

  40. OVARIAN PREGNANCY - rare - IUD user - similar to tubal pregnancy - rupture at early period • Diagnosis - serious bleeding : 1/3 - vaginal ultrasound • Treatment - surgical : wedge resection, cystectomy, ovariectomy - methotrexate in unruptured state

  41. CERVICAL PREGNANCY - rare form (1 in 18,000 pregnancies) - increasing : assisted reproduction (in vitro fertilization, embryo transfer) - typically, trophoblast erodes endocervix - 90% : painless bleeding 1/3 : massive bleeding 1/4 : abdominal pain - identification : clinical suspicion + sonography

  42. Surgical management - in past : hysterectomy (but, urinary tract injury↑, because the enlarged barrel-shaped cervix) - Cerclage : similar to a McDonald cerclage Shirodkar cerclage - Curettage and Tamponade : hemostatic cervical suture at 3 and 9 o’ clock suction curettage, then foley catheter(30cc) vaginal packing tightly

  43. - Arterial embolization : preoperative arterial embolization : laparoscopic uterine artery ligation + hysteroscopic endocervical resection

  44. Medical management - to avoid the risk of uncontrolled hemorrhage - chemotherapy is the first choice in stable women (methotrexate and other drug) - other method (not systemically) : directly into the gestational sac intra-amnionically

  45. OTHER SITES OF ECTOPIC PREGNANCY - Splenic pregnancy - hepatic pregnancy - retroperitoneal pregnancy - diaphragmatic pregnancy - cesarean scar pregnancy

More Related