General Data: G.

C, 22 years old, single, Catholic, born October 21, 1993 and currently
residing in Amadeo, Cavite was admitted for the 1' time at DLSUMC on April 10, 2019 at
around 4:00 pm.
Chief Complaint: Abdominal pain
Past Medical History: Patient underwent Tonsillectomy in 2010 due to recurrent
Tonsillitis. No known history of other diseases such as asthma, diabetes mellitus,
hypertension, heart disease, kidney disease or any infectious diseases. No history of trauma,
accidents and surgeries other than Tonsillectomy.
Family Medical History: Patient has a history of hypertension, diabetes mellitus, heart
disease, lung disease and asthma on her maternal side and colon cancer on her paternal side.
No known family history of infectious disease, congenital anomalies, or any gynecologic
pathology
Personal Social History: The patient is currently a 3"d year college student. She is a smoker
and she is an alcohol-beverage drinker. Her current boyfriend who is the 2nd and present
sexual partner is in 2nd year college and is a smoker and an alcohol-beverage drinker. The
patient lives in a house with 7 household members; she and her boyfriend do not live
together.
Menstrual History: She had menarche at 12 years old, subsequent menses occurred 28-30
days cycle, lasting for 3-4 days, using 2-3 moderately soaked pads per day with no associated
dysmenorrhea. No medications taken
Sexual History: The patient had her first sexual contact when she was 18 years old. She has
2 lifetime sexual partners. No history of post-coital bleeding nor dyspareunia. Her last sexual
contact was last febuay IS, 201q
Obstetrical History: G1PO
Gynecological History: The patient had yellowish foul smelling vaginal discharge 6 months
prior, for which no consultation was done nor medications taken. She never had any Pap
smear done. No history of diagnosed diseases or surgeries pertaining to the female
reproductive tract.
Contraceptive History: No history of use of any forms of contraceptive methods.
History of Present Pregnancy:
LNMP: February 7, 2019
EDC: November 14, 2019
AOG: 8-9 weeks AOG by LNMP
Two weeks prior to admission (6 weeks AOG), the patient experienced vaginal
spotting using 2 minimally soaked panty liners lasting for 3 days. There was associated right
lower quadrant pain with VAS of 4/10 but not associated with nausea, vomiting, dizziness
dysuria, urinary frequency, fever and abnormal vaginal discharge. No medications were taken
and no consultation was done.
One week prior to admission (7 weeks AOG), she experienced recurrence of the
vaginal spotting using 2 minimally soaked panty liners per day associated with intermittent

right lower quadrant pain with VAS of 5/10. She consulted at a private clinic a
nd pregnancv
patient did
Four hours prior to admission (8 weeks AOG), she experienced progression of the
test done had positive result. She was requested transvaginal ultrasound but the
not undergo the procedure and did not come back to the clinic.
right lower quadrant pain radiating to the hypogastrium with a VAS of 8/10 and persisten
of the vaginal spotting. She consulted at DLSUMC OPD
ultrasound (TVS). She returned 3 hours later with the result of the TVS:
and was requested a transvaginal
Uterine corpus measures 5.6 x 4.7 x 4.9 cm
Cervix measures 3.5 x 2.9 x 3.2 cm
Endometrium is hyperechoic measuring 1.8 cm
Right ovary measures 3.3 x 2.7 x 3.2 cm with follicles measuring 0.6 cm
Left ovary measures 3.4 x 2.8 x 2.9 cm with corpus luteum measuring 1.5 cm
Complex mass on the right adnexal area measuring 6.5 x 7.0 x 7.0 cm in the center of
which is a highly echogenic cystic structure containing a smaller cystic structure
within. On color mapping, there is a ring of fire seen in the periphery of the
echogenic cystic structure.
There is moderate free fluid in the right posterior cul de sac.
She was then in severe pain; hence she was advised admission.
Review of Systems:
A. General:
Θ low grade fever
(-) loss of appetite
Θ weight loss
weakness
(-) easy fatigability
B. Integument:
Θ hair loss
(-) clubbing of nails
(-) breast discharge
C. Head and Neck:
(-) rashes
( stiffness
(-) limitation of ROM
() dizziness
Θ distention of veins
yes
erythema
blurring of vision
(-) use of corrective lenses
ain
(-) anicteric sclera
Θ0talgia-, Θtinnitus Θvertigo Θdifficulty in hearing
F. Nose and Sinuses:
G. Mouth and Throat:
(-) tongue fasciculation
Θ discharge
Θ obstruction
epistaxis
hoarseness
sore
toothache
H. Respiratory:
(-) hemoptysis
cough
pleuritic chest pain
I. Cardiovascular:
orthopnea
palpitations
chest pain
J. Gastrointestinal:
Θ hematemesis
diarrhea
(-) hematochezia
(-) flank pains
constipation
+)abdominal pain
K. Genitourinary:
) dysuria
L. Hematologic:
() easy bruising
Θfrequency
(- easy bleeding
(-) diaphoresis
(-) muscle weakness
M. Endocrine:
) polyuria
N. Musculoskeletal:
Θ joint pains
(+) right shoulder pain
O. Nervous System:
(-) polydipsia
tractures
) redness
edema

(-) one-sided weakness

headache
(-) difficulty on concentration (- tremors
P. Autonomic:
(-) fecal and urinary incontinence
() syncope
Θconvulsions
Θ
() slight poor memory
PHYSICAL EXAMINATION
General Survey:
The patient is well-developed, well-nourished, ambulatory, awake, conscious
coherent, orientated to time, place and person, in severe pain and appears her stated
chronological age of 22 years old.
Vital Signs:
BP
HR
PR
RR20
O2sat
Temp.:
90/60
110
110
mmlg
beats/min.
beats/min.
cycles/min
98
36.8
Weight: 54
Height 159
BMI
cm
21.39
Regional Examination:
Skin
(+) pallor, (+) cold and clamnny, (+) diaphoretic, Θ cyanosis, () lesions
.
HEENT
A. Head and Neck
Hair: normal texture and equally distributed
Facial expression is symmetrical, Θ weakness of the face
Θ tenderness,(-) mass
Θ Cervical lymph nodes tenderness or enlargement
.
·
B. Eyes
Eyes are symmetrical
Pale palpebral conjunctiva
Pupils are equal and reactive to light
e
C. Nose
Symmetrical external nose
(-) masses, tenderness, lesions
Θ nasal discharge
Nasal septum is midline
·
D. Ears
Mobile pinna.(-) masses
( discharges, swelling, tenderness
.
E. Oral Cavity
* Lips are symmetrical, pale
() lesions and masses
Chest and Lungs
A. Inspection
Symmetrical chest
.No accessory muscle use
( Abnormal bulging /masses
(Prominent veins in anterior chest wall
.

B. Palpation
Equal thoracic expansion
C. Auscultation
Equal and normal breath sounds
Heart
A. Inspection
Θ precordial bulging
(-) heaves and trills
Regular Heart Rhythm
.
B. Palpation
C. Auscultation
() Extra heart sounds and murmurs
Abdomen
hypogastric fullness, (-) visible peristalsis,
(+)
.
(+) direct and rebound tenderness on the hypogastrium, LLQ, and RLQ
㈩ guarding, Θ rigidity, (+) norm oactive bowel sounds
Genitalia
External.(-) scars.(-) lesions, Θ ulcers, Θ varicosities, Θ discharge
Speculum Exam: cervix smooth with brownish red blood coming out of the internal
os, no lesions
Internal Exam: vagina admits 2 fingers with ease; cervix closed and smooth, (+)
cervical motion tenderness; corpus midline, small and
mass firm, movable, tender measuring 6.0 x 6.0 x 6.0 cm; () left adnexal mass
.
non tender; (+) right adnexal
; (+) fullness of the posterior cul de sac; (+) brownish red blood per
nderness
examining finger.
Extremities
Θ masses, Θ deformities.(-) edema.(-) atrophy.(-) wound
.

Primary impression: 22 years old G1P0, 12 6/7 weeks AOG, Ectopic Pregnancy, Ruptured
Basis:
History
·​ ​Persistent Vaginal spotting
·​ ​Intermittent Right lower quadrant pain
·​ ​No nausea, vomiting, dizziness, dysuria, urinary frequency, fever and abnormal vaginal
discharge
·​ ​Positive pregnancy test
·​ ​Progression of right lower quadrant pain radiating to the hypogastrium
·​ ​Pallor
·​ ​Right shoulder pain
Physical examination
·​ ​Pallor, Diaphoresis
·​ ​Pale palpebral conjunctiva
·​ ​Lips are pale
·​ ​Hypogastric fullness, direct and rebound tenderness on the hypogastrium, LLQ and RLQ,
guarding
·​ ​Cervix smooth with brownish red blood coming out of the internal os
·​ ​Cervical motion tenderness
·​ ​Right adnexal mass firm, movable , tender measuring 6.0x 6.0x6.0cm
·​ ​No left adnexal mass or tenderness
·​ ​Posterior cul de sac fullness
·​ ​Brownish red blood per examining finger

Differential diagnosis

Rule In Rule out

Threatened abortion ·​ ​Positive pregnancy test ·​ ​Progression of right

·​ ​Vaginal spotting in the
first trimester
·​ ​Intermittent Right lower
quadrant pain
·​ ​Pallor, Diaphoresis
·​ ​Pale palpebral
conjunctiva
·​ ​Lips are pale
·​ ​Hypogastric fullness,
LLQ and RLQ, guarding
·​ ​Cervix closed smooth
with brownish red blood
coming out of the internal
os
·​ ​Brownish red blood per
examining finger
lower quadrant pain
radiating to the
hypogastrium
·​ ​Cervical motion
tenderness
·​ ​Right adnexal mass
firm, movable , tender
measuring 6.0x 6.0x6.0cm
·​ ​Posterior cul de sac
fullness
·​ ​Right shoulder pain
·​ ​direct and rebound
tenderness on the
hypogastrium,
 Hydatidiform mole ·​ ​Positive pregnancy test
·​ ​Vaginal spotting
·​ ​Pallor, Diaphoresis
·​ ​Pale palpebral
conjunctiva
·​ ​Lips are pale
·​ ​Cervix closed smooth
with brownish red blood
coming out of the internal
os
·​ ​Brownish red blood per
examining finger
·​ ​Intermittent Right lower
quadrant pain
·​ ​Progression of right
lower quadrant pain
radiating to the
hypogastrium
·​ ​Cervical motion
tenderness
·​ ​Hypogastric fullness,
LLQ and RLQ, guarding
·​ ​Right adnexal mass
firm, movable , tender
measuring 6.0x 6.0x6.0cm
·​ ​Posterior cul de sac
fullness
·​ ​Right shoulder pain
·​ ​direct and rebound
tenderness on the
hypogastrium,
·​ ​Lower uterine segment
or posterior fornix is not full
or boggy on internal
examination

Discussion:
Location of implantation of ectopic pregnancy:
● 95% of ectopic pregnancy is implanted in the fallopian tube
● Most common site: Ampullary portion
● Ovary, uterus, peritoneal cavity, cervix, vagina abdomen and a prior caesarian section
scar
Risk factors:
● Factors that delay the passage of the conceptus along the tubes
○ Prior to tubal surgery, either to restore patency or to perform sterilization confers
the highest risk
○ Previous ectopic pregnancy
○ Chronic salpingitis (gonococcus and chlamydia): agglutination of mucosal folds
and reduced ciliation
○ Peritubal Adhesions i(appendicitis, endometriosis, puerperal infection): cause
tubal kinking and narrowing of the lumen
● Factors that increase tubal receptivity (tubal endometriosis or deciduosis)
 ● Factors that derive from the conceptus itself: abnormally immature or overly mature at
the time of passage down the tube
● Use of IUD: 5% incidence of ectopic pregnancy, Contraceptive method failures
● In utero exposure to diethylstilbestrol cause Congenital fallopian tube anomalies
● Assisted Reproductive Techniques (ART)
● Functional disturbance – normal tubes

Clinical Manifestation:
● Delayed menses or Amenorrhea
● Pain
○ Unruptured: stretching of the fallopian tube lumen may result in a dull abdominal
pain
○ Ruptured:
■ severe sharp stabbing or tearing lower abdominal and pelvic pain,
tenderness upon palpation,
■ cervical motion tenderness
■ neck or shoulder pain: due to diaphragmatic irritation via Vagus nerve
caused by hemoperitoneum
● Vaginal bleeding: levels of progesterone decrease resulting in withdrawal and sloughing
off of the endometrium

Outcomes of ectopic pregnancy

● Tubal rupture:
○ Fertilized ovum burrows through the tubal epithelium → trophoblast invades and
erodes the subjacent muscularis → maternal blood vessels open → blood pours
into the spaces between trophoblasts and adjacent tissue
○ Rupture in the first few weeks: isthmus (least muscular, easily rupture)
○ Rupture in the later weeks: interstitial (more muscular, more resistance)
● Tubal abortion
○ Hemorrhage disrupts the connection between the placenta, membranes, and
tubal wall → complete placental separation → entire conceptus is extruded
through the fimbriated end → to the peritoneal cavity

Management
Diagnostics:
● Serum B-HCG:
○ absence of B-HCG doubling every hour
○ >1500 mIU/mL with an empty uterus on sonogram
● Transvaginal songraphy
○ Trilaminar endometrial pattern
○ Presence of pseudosac
○ Visualization of adnexal mass which is separate from the ovary
○ Peritoneal fluid (hemoperitoneum) together with adnexal mass
**** UTZ picture
● Laparoscopy
○ definitive diagnosis
○ Direct visualization of the ectopic pregnancy in the fallopian tube, ovary,
peritoneal cavity, and pelvis
○ a route to remove the ectopic mass
○ Can do salpingostomy or salpingectomy by means of an operating laparoscope,
without having to do laparotomy
 ○ offers an avenue to inject chemotherapeutic drugs into the ectopic mass
○ often preferred over laparotomy unless the patient is unstable
● Laparotomy
○ If the patient has obvious case of ruptured ectopic pregnancy and has unstable
vital signs, laparotomy is life saving
○ It is conservative if the aim is to do tubal salvage (i.e. when you do
Salpingostomy)
○ It is radical when the aim is to do Salpingectomy
●

Management:
Surgical:
● Salpingostomy
○ Conservative surgical treatment of ectopic pregnancy
○ It is making an incision in the antimesenteric border of the mesosalpinx and the
incision is left ​unsutured ​and left to heal by secondary intention
○ This procedure is used to remove an unruptured ectopic pregnancy that is <2
cms in size and preferably located in the distal third of the fallopian tube
● Salpingotomy
○ Conservative surgical treatment of ectopic pregnancy
○ Entails the same procedure as salpingostomy but the incision is ​sutured
● Salpingectomy
○ Radical surgical treatment
○ Complete excision of the fallopian tube
■ Whole fallopian tube from the fimbriated portion up to the interstitial
portion removed
■ To prevent recurrent ectopic pregnancy which may occur in the stump of
the fallopian tube that will be left behind if partial salpingectomy is done
○ Indicated when the tube is extensively diseased or damage

Medical:
Methotrexate
● Folic acid antagonist
● When used in selected patients, the end result is rest of RNA, DNA, and protein
synthesis in fast replicating cells, specifically the trophoblast of an ectopic pregnancy
● 90% resolution rate
● Administered IM
● Single and multiple dose protocol
● The response to therapy using methotrexate as medical treatment for unruptured ectopic
pregnancy is measured by serial serum beta hCG determination
● Has many side effects
○ Liver involvement
○ Stomatitis (buccal and rectal area)
○ Gastroenteririts
○ Bone marrow depression (myelotoxic)
○ In patients with heterotopic pregnancies there can be craniofacial skeletal
abnormalities in the surviving fetus together with fetal growth restriction

Medical and surgical management of ectopic pregnancy has similar outcomes provided that:
● Patient is hemodynamically stable
● Diameter of ectopic pregnancy should be small (< 3.5 cm)
● No fetal cardiac activity
 ● Serum Beta HCG level should be less than 5000 mIU/mL

PREDICTORS OF SUCCESSFUL TREATMENT

● If the tubal mass is less than 3.5 cm in diameter
● Fetus is already dead
● Presence of low serum beta-hCG
○ Single best prognostic indicator