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

2. 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

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

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

5. 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

6. CLINICAL MANIFESTATIONS Amenorrhea - 70-80% (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

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

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

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

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

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

12. DIAGNOSTIC PROCEDURES A. hCG TEST 80-100% positive Urinary hCG level Blood hCG level If hCG negative, ectopic pregnancy does not be rule out B. TYPE B ULTRASOUND

13. 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

14. 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

15. 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

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

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

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

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

20. CLASSIFICATION Early abortion: < 12 wks Late abortion: 12-28 wks Spontaneous abortion Artificial abortion

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

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

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

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

25. 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

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

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

28. 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

29. 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

30. 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

31. 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

32. REMOVAL OF PLACENTAL TISSUE WITH OVUM FORCEPS

33. REMOVAL OF PLACENTAL TISSUE WITH CURETTE