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Lecture 8 ECTOPIC PREGNANCY. ABORTION

Lecture 8 ECTOPIC PREGNANCY. ABORTION. Prof. Vlad TICA, MD, PhD. ECTOPIC PREGNANCY. DEFINITION Implantation outside of the uterine cavity

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Lecture 8 ECTOPIC PREGNANCY. ABORTION

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  1. Lecture 8ECTOPIC PREGNANCY. ABORTION Prof. Vlad TICA, MD, PhD

  2. ECTOPIC PREGNANCY DEFINITION • Implantation outside of the uterine cavity • It is a condition that significantly jeopardizes the mother → catastrophic bleeding may occur when the implanting pregnancy erodes blood vessels / ruptures of the tubal wall

  3. IMPLANT LOCATIONS • Tubal: 95% (80% ampullary portion) • Ovarian: < 1% • Abdominal: 1-2% • Cervical: 0.15% • Cornual: 2%

  4. ETIOLOGY • Salpingitis - 6x increase the risk of ectopic pregnancy • Operation of fallopian tubes • IUD (intrauterine device) • Dysfunction of fallopian tubes • Other: endometriosis

  5. OUTCOMES OF ECTOPIC PREGNANCY • Tubal abortion • 8-12 weeks ampullary portion • Rupture of tubal pregnancy • 5 weeks isthmic portion • Tubal abortion with subsequent implantation • on an intraperitoneal structure, for example liver pregnancy

  6. CLINICAL MANIFESTATIONS • Amenorrhea - 70-80% (6-8 weeks) • Abdominal and pelvic pain - the most common symptom, which is present in nealy all patients • Pain is a result of distented of fallopian tube and irritation of peritoneum by blood • Irregular vaginal bleeding - results from the sloughing of the decidua • Shock - result from amount of blood loss • Abdominal mass

  7. PHYSICAL FINDINGS IN TUBAL PREGNANCY • Anemic / pale face • Pulse ↑↓ • BP ↓ • T < 38 ºC

  8. ABDOMINAL EXAMINATION • Distention and tenderness with or without rebound • Decreased bowel sound • Shifting dullness positive • Mass

  9. PELVIC EXAMINATION • Slightly open cervix with bleeding • Cervical motion tenderness • Adnexal tenderness • Adnexal mass • The uterus size may be normal / enlarged

  10. DIAGNOSTIC PROCEDURES • Typical cases can be determined easy • Early ectopic pregnancy / unruptured type - difficult • It is necessary to need assistant examination

  11. DIAGNOSTIC PROCEDURES • Typical cases can be determined easy • Early ectopic pregnancy / unruptured type - difficult • It is necessary to need assistant examination

  12. DIAGNOSTIC PROCEDURES A. hCG TEST • 80-100% positive • Urinary hCG level • Blood hCG level • If hCG negative, ectopic pregnancy does not be rule out B. TYPE B ULTRASOUND

  13. DIAGNOSTIC PROCEDURES C. CULDOCENTESIS • Aid in the identification of peritoneum bleeding • Positive (noncloting blood) • Ectopic pregnancy may be confirmed • Negative ectopic pregnancy does not be depletion

  14. DIAGNOSTIC PROCEDURES D. LAPAROSCOPY • It is a direct visualization and accurate method to diagnosis ectopic pregnancy • Even laparoscopy - 2-5% misdiagnosis rate • an extremely early tubal pregnancy gestation may not be identified

  15. PATHOLOGY OF ENDOMETRIUM • Curettage of the uterine cavity can also help rule out ectopic pregnancy • Identification of chorionic villi in curetting may identify an intrauterine pregnancy

  16. DIFFERENTIAL DIAGNOSIS • Abortion • Acute salpingitis • Acute appendicitis • Rupture of corpus luteum • Torsion of ovarian cyst

  17. TREATMENT SURGICAL TREATMENT • Salpingectomy • Conservative operation • Salpingostomy • Segmental resection and tubal reanastomosis

  18. TREATMENT CHEMICAL THERAPY • Drug: MTX • Indications: • The diameter of the mass < 3cm • Unrupture • Not significantly bleeding • hCG level < 2000 UI/L

  19. ABORTION DEFINITION • The termination of a pregnancy before 26 weeks from the first day of the last menstrual period

  20. CLASSIFICATION • Early abortion: < 12 wks • Late abortion: 12-28 wks • Spontaneous abortion • Artificial abortion

  21. ETIOLOGY • Genetic factors • Maternal factors • Infection • Systemic factors, heart disease, sever anemia, endocrine • Reproductive tract abnormality • Immunologic factors • Enviromental factors - Toxin, Radiation, smoking, alcohol

  22. PATHOLOGY • Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation

  23. PATHOLOGY • The ovum, partly or wholly detached, acts as a foreign body and irritates uterine contractions. The cervix begins to dilate.

  24. PATHOLOGY • Expulsion complete. The decidua is shed during the next few days in the lochial flow

  25. CLINICAL MANIFESTATIONS • Haemorrhage • usually the first sign • may be significantly if placental separation is incomplete • Pain • usually intermittent, ‘like a small labrur’ • it ceases when the abortion is complete

  26. THREATENED ABORTION • Low abdominal pain • Vaginal bleeding • Cervix is closed • Unruptured membranes • Embryo survive

  27. INEVITABLE ABORTION • Bleeding increased • Pain development • Rupture of membranes • Cervix dilation • Embryo tissue incarcerated in the cervix

  28. COMPLETE ABORTION • Uterine contractions are felt, the cervix dilates and blood loss continues • The fetus and placenta are expelled complete, the uterus contracts and bleeding stops • No further treatment is needed

  29. INCOMPLETE ABORTION • In spite of uterine contractions and cervical dilatation, only the fetus and some membranes are expelled • The placenta remains partly attached and bleeding continues • This abortion must be completed by surgical methods

  30. MISSED ABORTION • Is the retention of a failed intrauterine pregnancy for a extended period, usually defined as > 2 menstrual cycles RECURRENT ABORTION • The patient has had two / more consecutive spontaneous abortions SEPTIC ABORTION

  31. TREATMENT INCOMPLETE ABORTION • Remove the embryo and placenta as soon as possible • Negative pressure suction • Embryulcia MISSED ABORTION • Notice blood clot function prevent DIC SEPTIC ABORTION • Broad-spectrum antibiotics

  32. REMOVAL OF PLACENTAL TISSUE WITH OVUM FORCEPS

  33. REMOVAL OF PLACENTAL TISSUE WITH CURETTE

  34. THANK YOU !

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