CHAPTER II

LITERATURE REVIEW
2. 1 Definition
Endometrial hyperplasia is overgrowth of the lining of the womb (uterus),
beyond the normal 5 milimeters in the thickness. It is also called endometrial
hyperthrophy.hyperplasia can occur throughout the entire uterine lining or may
only affect isolated area. Endometrial hyperplasia is not cancer but it can cause
cellular changes that predispose an affected women to developing cancer later.
Most endometrial hyperplasia develops from a hormonal imbalance, where there
is a dominance estrogen and a deficiency of progesterone.
2. 2 Incidence
Endometrial hyperplasia peak incidence was simple, !"# per !$$,$$$
woman%years, comple&, #!' per !$$,$$$ woman%years, both in the early 5$s( and
atypical, 5) per !$$,$$$ woman%years in the early )$s. *ge%ad+usted incidence
decreased over the study period, especially for atypical hyperplasia.
2. 3 Risk Factors
*dvancing age is the one of the most important risk factor for development
endometrial hyperplasia
2. C!inica! Presentation
2
3
,eterotopic pregnancy may or may not have symptoms. *bout 5$- are
diagnosed only when the fallopian tube ruptures, at which point emergency
surgery is needed. If symptoms are present prior to a ruptured tube, the symptoms
are the same as those of ectopic pregnancy.
!,',"
,eterotopic pregnancy can have various presentations and should be
considered more likely (a) after assisted reproduction techni.ues, (b) with
persistent or rising chorionic gonadotropin levels after dilatation and curettage for
an induced/spontaneous abortion, (c) when the uterine fundus is larger than for
menstrual dates, (d) when more than one corpus luteum is present in a natural
conception, and (e) when vaginal bleeding is absent in the presence of signs and
symptoms of ectopic gestation.
!,',"

0sually, signs of the e&trauterine pregnancy predominate. 1our common
presenting signs and symptoms are abdominal pain, adne&al mass, peritoneal
irritation and an enlarged uterus. *bdominal pain was reported in 2'-, and
hypovolemic shock with abdominal tenderness reported in !'- of heterotopic
pregnancies. In addition, half of the patients did not complain of vaginal bleeding
in another publication, but it can be the vaginal bleeding does occur( however, it
may be retrograde from the ectopic pregnancy due to the intact endometrium of
the I0 pregnancy.
",5
* heterotopic gestation can also present as hematometra and lower .uadrant
pain in early pregnancy.
5
Most commonly, the location of ectopic gestation in a heterotopic
pregnancy is the fallopian tube of which 9597%. The most common site is the
4
ampullary portion of the tube (80%), followed by the isthmic sement of the
tube (!$-), the fimbria (5-) and the cornual and interstitial regions. ,owever,
cervical and ovarian heterotopic pregnancies have also been reported.
",)
1igure #.! 3ossible location of e&trauterine pregnancy
2. " Dia#nosis
,eterotopic pregnancies are usually diagnosed from 5 to '" weeks of
gestation. 4al et al reported that 5$- of the heterotopic pregnancies were
diagnosed between 5 and 2 weeks of gestation, #$- between 6 and !$ weeks and
only !$- after the !!th week. 4he early diagnosis of heterotopic pregnancy is
often difficult because the clinical symptoms are lacking.
#,5,5
,eterotopic pregnancies can pose a diagnostic dilemma because an early
transvaginal ultrasound may not diagnose an e&%utero gestation in all cases. *
diagnosis of a pseudosac should be made with caution, as even in the presence of
a pseudo sac there can be a high false positive diagnosis of an ectopic pregnancy.
5
7ometimes the presence of a hemorrhagic corpus luteum can confuse and delay
the diagnosis of a heterotopic pregnancy.
',5,)
4he detection rate of heterotopic pregnancy can vary from "! to 2"- with
transvaginal ultrasound scans. It is influenced by factors like routine and easy
access to transvaginal ultrasound scans for high risk patients with a history of
previous ectopic pregnancy and those who received fertility treatment.
!
8ith an increase in assisted conception the likelihood of detecting
heterotopic pregnancy will increase but missed or delayed diagnosis of
spontaneous heterotopic pregnancy remains a diagnostic dilemma and a challenge
for gynaecologists. In a case series 9ouis%7ylvestre et al, mentioned !' cases of
heterotopic pregnancy out of which only one case was a spontaneous heterotopic
pregnancy, ) with ovulation induction and ) with I:1. 4he mean gestational age
at the time of the diagnosis was 2 weeks and 5"- heterotopic pregnancies were
detected by transvaginal ultrasound. *ll the patients underwent surgical treatment
out of which !$ had a laparoscopy and ' had a laparotomy mainly for significant
hemoperitoneum. 4hey found laparoscopy to be useful for the early diagnosis of
heterotopic pregnancy and resulted in good surgical outcomes.
5,)
6
1igure #.! 4ransvaginal ultrasonography demonstrating a small gestational sac
$%& and hematic fluid $E& within the markedly dilated endometrial cavity of the
uterus. 7ome fluid is present in the cul%de%sac $F&.
1igure #.# 4ransvaginal ultrasound showing left adne&al mass containing
gestational sac with fetal pole.
7
1igure #.' 7agittal view of a heterotopic pregnancy at the age of 2 weeks ' days;
note the intracervical gestational sac along with an intrauterine sac containing a
viable embryo and a yolk sac.
1igure #." 0ltrasound image showing the right tubal gestational sac separated
from intrauterine gestational sac
4he .uestion however arises in women with spontaneous gestations who
do not necessarily have early ultrasound scans. 8omen with previous ectopic
pregnancy, tubal surgery or previous pelvic inflammatory disease may be at a
higher risk and should be scanned at an early gestation to confirm the location of
the pregnancy. *lso a high inde& of suspicion is necessary in the low risk
8
symptomatic patient with abdominal or pelvic pain in which ultrasound findings
are consistent with intrauterine gestation sac while free fluid is noted in the pelvis
with or without an adne&al mass.
5,2
4he diagnostic role of serum beta h<= levels in heterotopic pregnancy is
debatable. 4he normal algorithm for the rapid rise in the serum beta h<= in early
pregnancy cannot be used due to the presence of the intrauterine gestation which
could lead to false assurances.
6
2. ' Treat(ent
>nce a heterotopic pregnancy is diagnosed, the ne&t dilemma that arises is
how to manage it without harming the intrauterine pregnancy. *fter diagnosis, the
ectopic component in case of rupture is always treated surgically and the
intrauterine pregnancy is e&pected to continue normally. 4he follow up of
surviving intrauterine pregnancies has been reported to be normal after that with a
rate of successful pregnancy and delivery of "'-.
",5,2
In case the ectopic pregnancy was detected early and was unruptured,
treatment options include e&pectant management with aspiration and installation
of potassium chloride or prostaglandin into the gestational sac.
",5,2

If both intrauterine pregnancy and e&trauterine pregnancies were not viable
and without rupture, we could treat her with methotre!ate (M4?). 4o initiate
M4? therapy, the patient must be hemodynamically stable, with no signs or
symptoms of active bleeding or hemoperitoneum. Moreover, she must be reliable,
compliant and able to return for regular follow%up. 4he other factors to be
9
considered are si@e of the gestation, which should not e&ceed '.5 cm at its greatest
dimension on 07, absence of cardiac activity, absence of free fluid in 3>A and
beta h<=, which should not be more than 5$$$ mI0/ml. *lso, the patient must
not have any contraindications to medical therapy with M4?.
6

4he laparoscopic approach is technically feasible for both cases without
disrupting the course of an intrauterine pregnancy.
5
1igure #.' 9aparoscopic findings of left tubal ectopic pregnancy in the isthmic
area of the left fallopian tube with hemoperitoneum.