Ectopic Pregnancy Clinical Manifestation,Treatment
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.
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.
– 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.
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.
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.
– 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.
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.
– 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.