Ectopic Pregnancy PDF

ECTOPIC PREGNANCY Ectopic pregnancy is defined as any pregnancy occurring outside the uterine cavity. It can result from a fertilized ovum implanted in the abdomen, fallopian tube, cervix, ovary or peritoneal surface. The clinical presentation of ectopic pregnancy is variable. The most common symp...

ECTOPIC PREGNANCY Ectopic pregnancy is defined as any pregnancy occurring outside the uterine cavity. It can result from a fertilized ovum implanted in the abdomen, fallopian tube, cervix, ovary or peritoneal surface. The clinical presentation of ectopic pregnancy is variable. The most common symptom associated with ectopic pregnancy is abdominal pain, followed by amenorrhea and vaginal bleeding. Women rarely present with dizziness and syncope. Clinical signs include abdominal and adnexal tenderness, adnexal mass, and varying uterine size. Over 70% of the time the uterus is normal size Classical presentation of combined gestation is abdominal pain, adnexal mass, peritoneal irritation, and enlarged uterus. Differential diagnosis of a single ectopic gestation includes : acute salpingitis, torsion, gastroenteritis, threatened or incomplete abortion endometriosis. PID is the most common condition confused with ectopic pregnancy. Up to 20% of patients with ectopic pregnancy may have temperatures up to 38°C (100.4°F). PID is, however, rare in pregnancy, occurring less than 1% of the time. Human Chorionic Gonadropin (hCG) In a normal intrauterine gestation, the hCG level increases by 66% every 2 days. A patient in whom hCG levels fall, plateau, or fail to reach a predicted slope has an abnormal pregnancy. Serial hCG levels help to assess the viability of pregnancy and can be used to signal the optimal time for ultrasonography. In addition, after medical treatment with either an abortifacient or systemic methotrexate falling hCG levels help determine the effectiveness of treatment. Ultrasound Further localization of the pregnancy can then be attempted with a real-time ultrasound examination of the pelvis, the findings on which will be greatly dependent on the gestational age and the type of sonographic approach used. In general, real-time sonography using an abdominal transducer can find an interuterine gestational sac by the fifth week, a sac with an embryonic or fetal pole by the sixth week, and an embryonic mass with cardiac motion by the seventh week. The recent use of high resolution transvaginal US has improved the accuracy of diagnosis and decreased the gestational age at which an ectopic pregnancy can be diagnosed. Culdocentesis Whenever ectopic pregnancy is suspected culdocentesis may be used to determine whether intraperitoneal hemorrhage is present. If a significant hemorrhage has occurred, cervical motion tenderness may be present accompanied by cul-de-sac fullness or bulging. Treatment Management of the unstable patient with ectopic pregnancy is aimed toward hemodynamic support. Oxygen should be administered and volume resuscitation started immediately. The patient should be given type-specific blood as indicated. Immediate gynecologic consult for surgical management is the obvious next step. With the increased use of tubal conservation procedures the risk of repetitive ectopic pregnancy is increased. Management of the stable patient varies depending on the degree of suspicion and the possible gestational age. Surgical Treatment Operative laparoscopy has virtually replaced laparotomy for the first-time treatment of ectopic pregnancy. This has occurred not only to reduce morbidity but also to preserve fertility and reduce cost. Tubal conservation procedures, linear salpingectomy or segmental resection are an attempt to preserve fertility. Unfortunately, these conservative treatments have led to the occurrence of repetitive ectopic gestations. In addition, persistent ectopic pregnancy or the continued growth of the trophoblast after incomplete removal by conservative surgery complicates 5 to 20% of tubal operations. Occasionally this persistent tissue grows and tubal rupture occurs requiring salpingectomy for hematasis. More recently, systemic methotrexate, discussed below, has been used to treat this condition. Medical Treatment Systemic Methotrexate Methotrexate has been used for years in the treatment of gestational trophoblastic disease. Its mechanism of action is through inhibition of spontaneous synthesis of purines and pyrimidines, thus interfering with DNA synthesis and the multiplication of cells. Stable patients with unruptured ectopic gestation of less than 4 cm in diameter by ultrasound are eligible for treatment. OVARIAN TORSION Clinical Features Ovarian torsion is an uncommon event and will not occur unless limited enlargement has developed. In such a circumstance the enlarging ovarian mass may stretch the mesovarium to the point where the ovary effectively becomes a pedunculated structure that may acutely twist on its pedicle. When torsion occurs, the ovarian blood supply is compromised, causing painful progressive anoxic degeneration of the ovary and eventual gangrenous necrosis. Torsion of tubal masses (hydrosalpinx, pyosalpinx) and pedunculated uterine leiomyomata (fibroids) may also cause acute pelvic pain. Diagnosis Patients with this condition usually describe sudden onset of acute, severe, unilateral, lower abdominal and pelvic pain. Up to two thirds of patients describe associated nausea and vomiting often leading to a missed diagnosis of appendicitis. In addition, many patients will recount previous intermittent episodes of similar pain. Pelvic exam reveals a unilateral tender adnexal mass. Treatment Laparoscopic treatment by adnexal conservation or removal is the treatment of choice. MITTELSCHMERZ Clinical Features Adnexal pain in the reproductive-age patient may be due to mittelschmerz (middle pain) which is unique to ovulatory cycles. The key to the diagnosis of mittelschmerz is the relationship of the timing of the pain to the menstrual cycle. In a woman with typically regular 28- to 33-day cycles, the pain associated with ovulation will usually occur between cycle days 14 to 16, be unilateral in location, be mild to moderate in severity, and often last less than a day. The pain may also be accompanied by light midcycle endometrial spotting. Although the source of the pain has not exactly been determined, it is thought to be due to follicular fluid irritation of the periovarian visceral peritoneum at the time of ovulation. Diagnosis and Treatment No diagnostic studies are helpful in evaluating the possibility of mittelschmerz, and treatment is symptomatic, with analgesics or non-steroidal antiinflammatory agents. Patient Disposition Patients should be told the pain will resolve spontaneously and instructed to keep a menstrual calendar noting the timing of the pain to confirm the diagnosis. ABNORMAL GENITAL BLEEDING (NONPREGNANCY) it is then necessary to systematically consider pathologic and traumatic causes of lower genital tract and uterine bleeding. Except for trauma, the bleeding is usually painless. Trauma to the vulva and vagina from a variety of causes may result in profuse bleeding and hypotension. Patient stabilization with intravenous fluids is the first priority, and a thorough pelvic examination will easily indicate the bleeding source. In most cases, hemostasis and other indicated surgical procedures will require an anesthetic and the assistance of a gynecologist. If the bleeding is determined not to be of vulvar, vaginal, rectal, or bladder origin, attention must then be given to the following pathologic causes of uterine cervix or corpus bleeding: erosion of the cervical vasculature by an invasive cervical carcinoma, HEMORRHAGIC CORPUS LUTEUM The corpus luteum of pregnancy usually persists until the 8th week or so of gestation and frequently is palpable as a 3- to 4-cm adnexal-ovarian mass associated with a normal intrauterine pregnancy. Rupture of the luteal cyst or hemorrhage into the corpus luteum may occur in early pregnancy and cause a clinical picture indistinguishable from that of a ruptured ectopic pregnancy, in terms of the patient's menstrual history and physical examination. An ultrasound examination demonstrating an intrauterine pregnancy will clearly distinguish between the two entities. More common than a ruptured corpus luteum of pregnancy, however, is the rupture of a persistent corpus luteum in a nonception menstrual cycle. If the corpus luteum persists and the cyst ruptures, the clinical presentation again could be very similar to that of an ectopic pregnancy or spontaneous abortion. HCG determinations and ultrasonography will be required for differentiation between the possible diagnoses. Acute rupture of a corpus luteum cyst with consequent hemoperitoneum, in either a pregnant or nonpregnant state, usually requires surgical intervention and ovarian cystectomy. Outpatient management in suspected cases is contraindicated, although expectant management on an inpatient basis may be feasible if, in the judgement of the consultant gynecologist, the clinical picture warrants close observation only.