Ectopic Pregnancy
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| Ectopic Pregnancy |
Is any gestation located outside the uterine cavity? when a fertilized ovum implants any place other than the endometrium of the uterus, the pregnancy called ectopic or extrauterine.
Most common cause of maternal death in the first half of pregnancy but, mortality is decreasing.
Factors responsible for increasing incidence ( diagnosis ) of ectopic pregnancy:
- Pelvic inflammatory disease.- Improved diagnostic method.
- Sensitivity and specific hCG assays.
- High-resolution ultrasound.
- Diagnostic lumbar scoby.
- Increase awareness.
Aetiology:
Ectopic implantation may be fortuitous or result of tubal abnormality, which obstructs or delays the passage of the fertilized ovum as :- Previous tubal surgery.
- Preceding pelvic inflammatory disease.
- IUD.
- Salpingitis.
- Congenital anomalies of the tube.
- Migration of the ovum across the pelvic cavity to the fallopian tube on the opposite side.
Frequency and implantation site:
1- tubal pregnancy: most frequent location, 86% in the distal half.- Ampullary: the most common.
- Isthmus: early rupture.
- Interstitial: rare but very dangerous because it ends in rupture uterus and haemorrhage.
- Infundibular.
2- Abdominal pregnancy: mortality rate much higher.
3- Ovarian pregnancy: pregnancy attached to the uterus by utero-ovarian vasculature. Oophorectomy may be indicated.
4- Cervical pregnancy: implantation within the endocervical canal, very rare.
Clinical manifestation:
Very with the site of implantation and usually occur after tubal rupture.Early signs and symptoms:
- Menstrual irregularities ( irregular vaginal bleeding).- Symptoms of early pregnancy.
- Dull pain on the affected side.
Signs and symptoms of the tubal rupture:
- Pain: sudden, severe, and unilateral, generalized and radiated to the shoulder and neck due to phrenic nerve stimulation.- Vaginal bleeding: dark brown and scanty, about 25 % of cases without vaginal bleeding.
Nausea, vomiting, fainting ( signs of internal blood loss ).
- Signs of shock.
- Normal or low temperature.
- Ruptured tubal pregnancy from salpingitis.
- Tenderness over abdomen upon palpation .
- Pelvic mass posterior or lateral to uterus .
- Cervical pain during vaginal examination .
- Distension of posterior fornix with blood in the cul-de-sac.
Diagnostic evaluation:
- Medical history.- Physical examination.
- HCG assay: serum hCG usually lower than normal.
- Laparoscopy: often the diagnosis made by direct visualization can be performed too early.
Culdocentesis:
1- Needle puncture into posterior cul-de-sac.2- Negative culdocentesis doesn't exclude a nonbleeding ectopic pregnancy.
ultrasound: to exclude intrauterine pregnancy and helpful in abdominal pregnancy.
Treatment:
- Surgical management: salpingostomy has replaced salpingectomy except in case of irreparable tubal rupture, tumour or haemorrhage.- Medical management: Methotrexate (inexpensive, easy to obtain and well tolerated ).
- Inclusion criteria : ( hemodynamically stable, unruptured tube, no fetal cardiac activity, the hCG level is less than 15000 IU/L ).
- Blood transfusion for haemorrhage.
- Fluid correction to treat or prevent shock.
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