Ectopic Pregnancy7

8/17/2019 Ectopic Pregnancy7

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Ectopic Pregnancy

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Denition

• It is the implantation of the fertilisedovum outside the normal uterinecavity.

* Common site (9!"# the tu$es.

* %are sites (!"# &he ovaries' arudimentary horn of a $icornuateuterus' $road ligaments' peritoneumand cervi.



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&)+,P%E-+C/0+etiology

• &he following ris1 factors have $eenimplicated#

2.3echanical factors

4.Premature implantation



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2.3echanical factors

* Previous in5ammatory disease#* Previous pelvic surgery#

* Developmental a$normalities#

* Previous ectopic pregnancy#* Intrauterine contraceptive device#



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4.Premature implantation#

a. Premature shedding of the 6onapellucida

$.&ransperitoneal migration of thefertilised ovum to the contralateraltu$e

c.Presence of ectopic endometriumin the tu$e.www.freelivedoctor.com


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&)+,P%E-+C/0Pathogenesis

* &he tropho$last develops in the fertilisedovum and invades deeply into the tu$al wall.

* 7ollowing implantation' the tropho$last

produces hC- which maintains the corpusluteum.

* &he corpus luteum produces oestrogen andprogesterone which change the secretory

endometrium into decidua. &he uterusenlarges up to 8 wee1s si6e and $ecomessoft.



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• &he tu$al pregnancy does not usuallyproceed $eyond 82:wee1s due to#

0 lac1 of decidual reaction in the

tu$e'

0 the thin wall of the tu$e'

0 the inade;uacy of tu$al lumen'

0 $leeding in the site ofimplantation as tropho$last invades.



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•


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7ate of tu$al pregnancy

• &u$al mole#

• &u$al a$ortion#

•

&u$al rupture#



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• &u$al mole#

o &he gestational sac issurrounded $y a $lood clot andretained in the tu$e.



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&u$al a$ortion#

&his occurs more if ovum had $een implanted in theampullary portion of the tu$e.


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&u$al rupture#

3ore common if implantation occurs in thenarrower portion of the tu$e which is the

isthmus.%upture may occur in the antimesenteric

$order of the tu$e. )sually profuse $leedingoccurs = intraperitoneal haemorrhage.

If rupture occurs in the mesenteric $order ofthe tu$ea $road ligament haematoma willoccur.



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Clinical Picture0tu$alpregnancy

-eneral symptoms

aginal $leeding#



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Clinical Picture0tu$alpregnancy

• -eneral signs

0 -eneral eamination#

o reast signs of pregnancy.

o +$dominal eamination#

o ,ower a$dominal tenderness and rigidity especially on oneside may $e present.

0 >aginal eamination#

o luish vagina and $luish soft cervi.

o )terus is slightly enlarged and soft.

o 3ar1ed pain in one iliac fossa on moving the cervi fromside to side.

o Ill dened tender mass may $e detected in one adnea inwhich arterial pulsation may $e felt.



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Clinical Picture0&u$al+$ortion


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0


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+$dominal eamination#

o Cullen@s sign# a perium$ilical$luish discoloration may $e presentdue to a$sorption of the $lood in theperitoneal cavity $y lymphatics. It isa late sign.



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,ocal eamination#

oggy swelling in the culdesacif pelvic haematocele is present.



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Clinical Picture0&u$al%upture

• &he most dramatic although not themost common.

•


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-eneral eamination#

* %apidly developed shoc1' with pallor'sweating' air hunger' rapid threadypulse and hypotension.

*


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+$dominal eamination#

•

&he a$domen is distended' rigid withgeneralised tenderness.

•


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,ocal eamination#

•

&he same as in general signs ofectopic' although it is undesira$le asit may induce more disruption and$leeding.



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Investigations of Ectopic

Pregnancy



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)ltrasonography

• In general' a positive BhC- test with emptyuterus $y sonar indicates ectopic pregnancy.

• Discriminatory hC- 6ones#

0 Diagnosis of ectopic pregnancy is made if thereis#

2. +n empty uterine cavity $y a$dominalsonography with $ hC- value a$ove A:::

mI)ml.4. +n empty uterine cavity $y vaginal sonography

with $ hC- value a$ove 4::: mI)ml.



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• Progesterone in ectopic pregnancy

•


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Culdocentesis

• If nonclotting $lood is aspirated fromthe Douglas pouch througha widepored needle' intraperitoneal

haemorrhage is diagnosed. ut if not'ectopic pregnancy cannot $eecluded.



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)ncommon


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Cornual angular pregnancy

• It is implantation in the interstitialportion of the tu$e.

• It is uncommon $ut dangerous

$ecause when rupture occurs$leeding is severe and disruption isetensive that it needs hysterectomy.

• In some cases' the pregnancy isepelled into the uterus and rupturedoes not occur.



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Pregnancy in a rudimentaryhorn

* Pregnancy occurs in the $lindrudimentary horn of a $icornuateuterus.

* +s such a horn is capa$le of somehypertrophy and distension' rupture

usually does not occur $efore 2A4:wee1s.



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Pregnancy in a rudimentaryhorn

• &reatment#

• Ecision of the horn. Duringoperation' pregnancy in a

rudimentary horn can $edierentiated from interstitial cornualtu$al pregnancy $y nding the

attachment of the round ligamentlateral to the rst and medial to thelater.



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Cervical pregnancy

• Implantation in the su$stance of thecervi $elow the level of uterine vessels.

• 3ay cause severe vaginal $leeding.

• &reatment#

0 Evacuation and cervical pac1ing withhaemostatic agentas $rin glue and

gau6e.0If $leeding continues or etensive

rupture occurs hysterectomy is needed.



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varian pregnancy

+etiology#

* Pelvic adhesions.

* 7avoura$le ovarian surface for implantation

as in ovarian endometriosis.

Pathogenesis#

* 7ertilisation of the ovum inside the ovary or'

* implantation of the fertilised ovum in theovary.



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varian pregnancy


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varian pregnancy

&reatment#

•

,aparotomy and inoculation of theectopic pregnancy andreconstruction of the ovary ifpossi$le. therwise' removal of the

aected ovary is indicated.



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+$dominal (peritoneal"pregnancy

&ypes#

* Primary# implantation occurs in the peritonealcavity from the

start.

*


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• Diagnosis#

* Fistory# of amenorrhoea followed$y an attac1 of lower a$dominal painand slight vaginal $leeding whichsu$sided spontaneously.



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0+$dominal eamination#

o )nusual transverse or o$li;ue lie.

o 7oetal parts are felt very

supercial with no uterine muscle wallaround.

0>aginal eamination#

o &he uterus is soft' a$out 8 wee1sand separate from the foetus.

• o o presenting part in the pelvis.


$d i l ( i l"


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•


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• &reatment#

• &he condition should $e terminatedsurgically through laparotomy oncediagnosed

f li d t

Ectopic Pregnancy7

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