Lecture 8 ECTOPIC PREGNANCY. ABORTION Prof. Vlad TICA, MD, PhD

ECTOPIC PREGNANCY DEFINITION Implantation outside of the uterine cavity It is a condition that significantly jeopardizes the mother → catastrophic bleeding may occur when the implanting pregnancy erodes blood vessels / ruptures of the tubal wall

IMPLANT LOCATIONS Tubal: 95% (80% ampullary portion) Ovarian: < 1% Abdominal: 1-2% Cervical: 0.15% Cornual: 2%

ETIOLOGY Salpingitis - 6x increase the risk of ectopic pregnancy Operation of fallopian tubes IUD (intrauterine device) Dysfunction of fallopian tubes Other: endometriosis

OUTCOMES OF ECTOPIC PREGNANCY Tubal abortion 8-12 weeks ampullary portion Rupture of tubal pregnancy 5 weeks isthmic portion Tubal abortion with subsequent implantation on an intraperitoneal structure, for example liver pregnancy

CLINICAL MANIFESTATIONS Amenorrhea % (6-8 weeks) Abdominal and pelvic pain - the most common symptom, which is present in nealy all patients Pain is a result of distented of fallopian tube and irritation of peritoneum by blood Irregular vaginal bleeding - results from the sloughing of the decidua Shock - result from amount of blood loss Abdominal mass

PHYSICAL FINDINGS IN TUBAL PREGNANCY Anemic / pale face Pulse ↑↓ BP ↓ T < 38 º C

ABDOMINAL EXAMINATION Distention and tenderness with or without rebound Decreased bowel sound Shifting dullness positive Mass

PELVIC EXAMINATION Slightly open cervix with bleeding Cervical motion tenderness Adnexal tenderness Adnexal mass The uterus size may be normal / enlarged

DIAGNOSTIC PROCEDURES Typical cases can be determined easy Early ectopic pregnancy / unruptured type - difficult It is necessary to need assistant examination

DIAGNOSTIC PROCEDURES Typical cases can be determined easy Early ectopic pregnancy / unruptured type - difficult It is necessary to need assistant examination

DIAGNOSTIC PROCEDURES A. hCG TEST % positive Urinary hCG level Blood hCG level If hCG negative, ectopic pregnancy does not be rule out B. TYPE B ULTRASOUND

DIAGNOSTIC PROCEDURES C. CULDOCENTESIS Aid in the identification of peritoneum bleeding Positive (noncloting blood) Ectopic pregnancy may be confirmed Negative ectopic pregnancy does not be depletion

DIAGNOSTIC PROCEDURES D. LAPAROSCOPY It is a direct visualization and accurate method to diagnosis ectopic pregnancy Even laparoscopy - 2-5% misdiagnosis rate an extremely early tubal pregnancy gestation may not be identified

PATHOLOGY OF ENDOMETRIUM Curettage of the uterine cavity can also help rule out ectopic pregnancy Identification of chorionic villi in curetting may identify an intrauterine pregnancy

DIFFERENTIAL DIAGNOSIS Abortion Acute salpingitis Acute appendicitis Rupture of corpus luteum Torsion of ovarian cyst

TREATMENT SURGICAL TREATMENT Salpingectomy Conservative operation Salpingostomy Segmental resection and tubal reanastomosis

TREATMENT CHEMICAL THERAPY MTX Drug: MTX Indications: The diameter of the mass < 3cm Unrupture Not significantly bleeding hCG level < 2000 UI/L

ABORTION DEFINITION The termination of a pregnancy before 26 weeks from the first day of the last menstrual period

CLASSIFICATION Early abortion: < 12 wks Late abortion: wks Spontaneous abortion Artificial abortion

ETIOLOGY Genetic factors Maternal factors Infection Systemic factors, heart disease, sever anemia, endocrine Reproductive tract abnormality Immunologic factors Enviromental factors - Toxin, Radiation, smoking, alcohol

PATHOLOGY 1. Haemorrhage occurs in the decidua basalis leading to local necrosis and inflammation

PATHOLOGY 2. The ovum, partly or wholly detached, acts as a foreign body and irritates uterine contractions. The cervix begins to dilate.

PATHOLOGY 3. Expulsion complete. The decidua is shed during the next few days in the lochial flow

CLINICAL MANIFESTATIONS Haemorrhage usually the first sign may be significantly if placental separation is incomplete Pain usually intermittent, ‘ like a small labrur ’ it ceases when the abortion is complete

THREATENED ABORTION Low abdominal pain Vaginal bleeding Cervix is closed Unruptured membranes Embryo survive

INEVITABLE ABORTION Bleeding increased Pain development Rupture of membranes Cervix dilation Embryo tissue incarcerated in the cervix

COMPLETE ABORTION Uterine contractions are felt, the cervix dilates and blood loss continues The fetus and placenta are expelled complete, the uterus contracts and bleeding stops No further treatment is needed

INCOMPLETE ABORTION In spite of uterine contractions and cervical dilatation, only the fetus and some membranes are expelled The placenta remains partly attached and bleeding continues This abortion must be completed by surgical methods

MISSED ABORTION Is the retention of a failed intrauterine pregnancy for a extended period, usually defined as > 2 menstrual cycles Is the retention of a failed intrauterine pregnancy for a extended period, usually defined as > 2 menstrual cycles RECURRENT ABORTION The patient has had two / more consecutive spontaneous abortions SEPTIC ABORTION

TREATMENT INCOMPLETE ABORTION Remove the embryo and placenta as soon as possible Negative pressure suction Embryulcia MISSED ABORTION Notice blood clot function prevent DIC SEPTIC ABORTION Broad-spectrum antibiotics

REMOVAL OF PLACENTAL TISSUE WITH OVUM FORCEPS

REMOVAL OF PLACENTAL TISSUE WITH CURETTE