Ectopic Pregnancy Clinical Manifestation,Treatment

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Ectopic Pregnancy

Ectopic Pregnancy

Ectopic Pregnancy: the most common cause of maternal death in the first half of pregnancy but, mortality is decreasing. 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.

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.

Etiology:

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 hemorrhage.

– 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, tumor or hemorrhage.

– 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 hemorrhage.

– Fluid correction to treat or prevent shock.

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