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Ectopic Pregnancy

Pembimbing
Coass

dr. Deny kushen

berth, Dessy, suciyanti, Yoseph

The fertilized ovum (blastocyst) normally implants in the endometrial lining


of the uterine cavity.
Implantation anywhere else is an ectopic pregnancy.
Almost 2 in every 100 pregnancies in the United States are ectopic, and
more than
95 percent of ectopic pregnancies involve the fallopian tube.

Sites of implantation of 1800 ectopic pregnancies from a 10-year populationbased study. (Reproduced,
with permission, from Cunningham FG, Leveno KJ, Bloom SL,
et al (eds). Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill; 2010. Data from
Callen PW (ed). Ultrasonography in Obstetrics and Gynecology. 4th ed. Philadelphia,
PA: WB Saunders, 2000; p. 919. Bouyer J, Coste J, Shojaei T, et al: Risk factors for ectopic pregnancy: A
comprehensive analysis based on a large case-control, populationbased study in France. Am J
Epidemiol 157:185, 2003.)

There has been a marked increase in both the absolute number and rate of ectopic
pregnancies in the United States in the past two decades.
Reasons for Increased Ectopic Pregnancy Rate in the United States
1. Increased prevalence of sexually transmitted tubal infection and damage.
2. Earlier diagnosis of some ectopic pregnancies otherwise destined to resorb
spontaneously.
3. Popularity contraception predisposes failures to be ectopic.
4. Use of tubal sterilization techniques that increase the likelihood of ectopic
pregnancy.
5. Use of assisted reproductive techniques.
6. Use of tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty
for infertility

classification
95 percent tuba;

fimbrial
ampullary,
isthmic, or
interstitial tubal pregnancies

ampulla is the most frequent site, followed


by the isthmus. The remaining 5 percent of
nontubal ectopic pregnancies implant in the
ovary, peritoneal cavity, cervix, or prior
cesarean scar.

TubaL Pregnancy
Fertilized ova may develop in any portion of the oviduct,
giving rise to ampullary, isthmic, or interstitial (cornual)
tubal pregnancies. Te ampulla is the most frequent site
of tubal ectopic pregnancies, with interstitial pregnancy
accounting for only about 2 percent of all tubal
gestations.

Sign and Symtoms


Pain
Rupture EP symtoms pelvic and abdominal pain
Gastrointestinal symptoms, dizziness/ lightheadedness
Pleuritic chest pain diaphragmatic irritation hemorrhage.

D-negative women with an ectopic pregnancy who are


not sensitized to Dantigen should be given IgG anti-D
immunoglobulin
in first-trimester pregnancies, a 50-g or a 300-g dose
is appropriate, whereas a standard 300-g dose is used
for later gestations.

Risk
Abnormal fallopian.
previous ectopic pregnancy10%
tubal infection Salpingitis
Congenital fallopian tube anomalies.
use of ART (assisted reproductive technologies)
Smoking
contraceptive method failures

Evolution and Potential


Outcomes
With tubal pregnancy, because the fallopian tube lacks
a submucosal layer, the fertilized ovum promptly
burrows through the epithelium. The zygote comes to lie
near or within the muscularis, which is invaded in most
cases by rapidly proliferating trophoblast. The embryo
or fetus in an ectopic pregnancy is often absent or
stunted.
tubal rupture,
tubal abortion,
or pregnancy failure

Alternatively, the pregnancy may abort out the distal fallopian


tube, and the frequency of this depends in part on the initial
implantation site.
With tubal abortion, hemorrhage disrupts the connection
between the placenta and membranes and the tubal wall.
if placental separation is complete, the entire conceptus may be
extruded through the fimbriated end
into the peritoneal cavity.

Some bleeding usually persists as long as products


remain in the tube.
Blood slowly trickles from the tubal fimbria into the
peritoneal cavity and typically pools in the rectouterine
cul-de-sac.
If the fimbriated extremity is occluded, the fallopian
tube may gradually become distended by blood
hematosalpinx.

Clinical Manifestations
delayed menstruation, pain, and vaginal bleeding or spotting.
tubal rupture lower abdominal and pelvic pain that is frequently described as sharp, stabbing, or tearing.
Abdominal palpation Tenderness
uterus may be pushed to one side by an ectopic mass
Symptoms of diaphragmatic irritation
pain in the neck or shoulder,

vaginal spotting or bleeding


decidual cast

Multimodality Diagnosis
miscarriage, infection, degenerating or enlarging leiomyomas, molar
pregnancy, or round-ligament pain.
Adnexal disease may include ectopic pregnancy; hemorrhagic,
ruptured, or torsed ovarian masses; salpingitis; or tuboovarian abscess.
physical findings, transvaginal sonography (TVS), serum -hCG level
measuremen

Beta Human Chorionic Gonadotropin


Current serum and urine pregnancy tests that use
enzyme-linked immunosorbent assays (ELISAs) for hCG are sensitive to levels of 10 to 20 mIU/mL and are
positive in > 99 percent of ectopic pregnancies
(Kalinski, 2002).

Levels above the Discriminatory Zone.


A number ofinvestigators have described discriminatory -hCG levels above which
failure to visualize an intrauterine pregnancy (IUP) indicates that the pregnancy
either is not alive or is ectopic.
an empty uterus with a serum -hCG concentration 1500 mIU/mL was 100percent accurate in excluding alive uterine pregnancy. (Barnhart and colleagues).
If the initial -hCG level exceeds the set discriminatory level and no evidence for a
uterine pregnancy is seen with TVS, then the diagnosis is narrowed in most cases
to a failed uterine pregnancy, completed abortion, or an ectopic pregnancy.

Levels below the Discriminatory Zone.


If the initial -hCG level is below the set discriminatory value,
pregnancy location is often not technically discernible with TVS.
With these PULs, serial -hCG level assays are done to identify
patterns that indicate either a growing or failing uterine
pregnancy. Levels that rise or fall outside these expected
parameters increase the concern for ectopicpregnancy.
no single pattern characterizes ectopic pregnancy and that
approximately halfofectopic pregnancies will show decreasing hCG levels, whereas the other halfwill have increasing levels.

In pregnancies without these expected rises or falls in hCG levels, distinction between a nonliving intrauterine
and an ectopic pregnancy may be aided by repeat hCG level evaluation (Zee,2013).

Serum Progesterone
A single serum progesterone measurement may clarify the
diagnosis in a few cases (Stovall, 1989, 1992b).
A value exceeding 25 ng/mL excludes ectopic pregnancy with
92.5-percent sensitivity (Lipscomb, 1999a; Pisarska, 1998).
Conversely, values below 5 ng/mL are found in only 0.3 percent
of normal pregnancies (Mol, 1998).
Thus, values < 5 ng/mL suggest either a nonliving uterine
pregnancy or an ectopic pregnancy.

Because in most ectopic pregnancies, progesterone


levels range between 10 and 25 ng/mL, the clinical
utility is limited

Transvaginal Sonography
Endometrial Findings.
During endometrial cavity evaluation, an intrauterine
gestational sac is usually visible between 4 and 5 weeks.
The yolk sac appears between 5 and 6 weeks, and a fetal pole
with cardiac activity is first detected at 5 to 6 weeks.
In contrast, with ectopic pregnancy, a trilaminar endometrial
pattern can be diagnostic

Its specificity is 94 percent, but with a sensitivity of only


38 percent (Hammoud, 2005).
In addition, Moschos and Twickler (2008b) determined
that in women with PUL at presentation, no normal
pregnancies had a stripe thickness < 8 mm.

Anechoic fluid collections, which might normally suggest an early intrauterine gestational
sac, may also be seen with ectopic pregnancy. These include pseudogestational sac and
decidual cyst.
First, a pseudosac is a fluid collection between the endometrial layers and conforms to the
cavity shape. If a pseudosac is noted, the risk of ectopic pregnancy is increased.
Second, a decidual cyst is identified as an anechoic area lying within the endometrium but
remote from the canal and often at the endometrial-myometrial border.
These two findings contrast with the intradecidual sign seen with intrauterine pregnancy.
This is an
early gestational sac and is eccentrically located within one of the endometrial stripe
layer

Adnexal Findings.
The sonographic diagnosis ofectopic pregnancy rests on visualization of an adnexal
mass separate from the ovary.
If fallopian tubes and ovaries are visualized and an
extrauterine yolk sac, embryo, or fetus is identified, then an ectopic pregnancy is
clearly confirmed.
hyperechoic halo or tubal ring surrounding an anechoic sac can be seen.
Alternatively,
an inhomogeneous complex adnexal mass is usually caused by hemorrhage within
the ectopic sac or by an ectopic pregnancy that has ruptured into the tube.

Overall, approximately 60 percent of ectopic


pregnancies are seen as an inhomogeneous mass
adjacent to the ovary; 20 percent appear as a
hyperechoic ring; and 13 percent have an obvious
gestational sac with a fetal pole.

Various transvaginal sonographic findings with ectopic tubal


pregnancies. For
sonographic diagnosis, an ectopic mass should be seen in the
adnexa separate from the ovary and may be seen as: (A) a
yolk sac (shown here) and/or fetal pole with or without cardiac
activity within an extrauterine sac, (B) an empty extrauterine
sac with a hyperechoic ring, or (C) an inhomogeneous adnexal
mass. In this last image, color Doppler shows a classic ring
offire, which reflects increased vascularity typical ofectopic
pregnancies. LT OV = left ovary; SAG LT AD = sagittal left
adnexal; UT = uterus.
Placental blood flow within the periphery of the
complex adnexal massthe ring of firecan be
seen with transvaginal color Doppler imaging

Hemoperitoneum
In women with suspected ectopic pregnancy, evaluation
for hemoperitoneum can add valuable clinical
information. More commonly, this is completed using
sonography, but assessment can also be made by
culdocentesis. Sonographically, hemoperitoneum is
anechoic or hypoechoic fluid. Blood initially collects in
the dependent retrouterine cul-de-sac, and then
additionally surrounds the uterus as it fills the pelvis.

As little as 50 mL can be seen in the cul-de-sac using TVS, and


transabdominal imaging helps to assess the hemoperitoneum extent.
For example, with significant intraabdominal hemorrhage, blood will
track up the pericolic gutters to fill Morison pouch near the liver.
Free fluid in this pouch typically is not seen until accumulated blood
reaches 400 to 700 mL
Diagnostically, peritoneal fluid in conjunction with an adnexal mass is
highly predictive ofectopic pregnancy.

Culdocentesis is a simple technique used commonly in the past to identify


hemoperitoneum. The cervix is pulled outward and upward toward the symphysis
with a tenaculum, and a long 18-gauge needle is inserted through the posterior
vaginal fornix into the retrouterine cul-de-sac. Ifpresent, fluid can be aspirated.
Fluid containing fragments of old clots or bloody fluid that does not clot is
compatible with the diagnosis of hemoperitoneum. In contrast, if the blood
sample clots, it may have been obtained from an adjacent blood vessel or from a
briskly bleeding ectopic pregnancy.
culdocentesis has been largely replaced by TVS.

Laparoscopy
Direct visualization of the fallopian tubes and pelvis by
laparoscopy offers a reliable diagnosis in most cases of
suspected ectopic pregnancy.
There is also a ready transition to definitive operative
therapy, which is discussed subsequently.

Treatment Options
options for ectopic tubal pregnancy treatment include
medical and surgical approaches.
Medical therapy traditionally involves the antimetabolite
methotrexate. Surgical choices include mainly
salpingostomy or salpingectomy.

Medical Management
Regimen Options

Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic
pregnancy unless a woman is hemodynamically unstable.
ruptured tubal pregnancies or interstitial pregnanciescan
safely be managed laparoscopically by those with suitable
expertise.
Before surgery, future fertility desires of the patient should
be discusse.

Salpingostomy
This procedure is typically used to remove a small
unruptured pregnancy that is usually < 2 cm in length
and located in the distal third of the fallopian tube.
Natale and associates (2003) reported that serum -hCG
levels > 6000 mIU/mL are associated with a higher risk of
implantation into the muscularis and thus with more tubal
damage.

INTERSTITIAL PREGNANCY
These pregnancies implant within the proximal tubal
segment that lies within the muscular uterine wall.
Risk factors are similar to others discussed for tubal
ectopic pregnancy, although previous ipsilateral
salpingectomy is a specific risk factor for interstitial
pregnancy.

Undiagnosed interstitial pregnancies usually rupture following


8 to 16 weeks of amenorrhea, which is later than for
moredistal tubal ectopic pregnancies.
This is due to greater distensibility of the myometrium
covering the
interstitial fallopian tube segment.
Because of the proximity of these pregnancies to the uterine
and ovarian arteries, there is a risk of severe hemorrhage,
which is associated with mortality rates as hig has 2.5 percent