RUPTURED ECTOPIC

PREGNANCY
By
Lingga Lilianie Nur Safqi
Guidance
dr. Reno Yovial
CASE PRESENTATION
PATIENT IDENTITY
Name : Mrs. SM
Age : 35 years old
Place and Date of birth : Depok, 12 April 1981
Education : High School
Occupation : Baby Sitter
Marital status : Married
Religion : Islam
Med record number : 00-95-53-50
Entry date : 09-12-2016
ANAMNESIS
Abdomin
al pain
severely In
In
in the period
period
last 7 hr day
day 9th
9th

weak,
dizzy,
pale

Chief
Complaint
HISTORY OF THE PRESENT ILLNESS

Abdominal pain, start from 9 days ago and become heavy 7 hrs. BETH. The
pain spread to whole part of the abdomen also to anus. The spread of pain to
shoulder and neck is denied. The pain scale 9.

Patient feel her face

Patient in her 9th day of period. She change softex
getting pale day by
thrice a day with low-mild blood. The color of the
day. She never looks
blood is dark red to brown.
like this before
Patient also feel weak, lazy
Defecate and urinate feels
to do her usual activities, Patient also feels nausea
normal. Last urinate about
anorexia. She feels dizzy and vomiting twice.
3 hours ago.
like her head floating.
PAST MEDICAL HISTORY

Patient ever felt

Patient had some
similar pain when
abdominal Appendectomy
she diagnosed with
discomfort when history denied
ectopic pregnancy
eating late
6 years ago
OBSTETRIC AND GYNECOLOGICAL HISTORY
Patient had been
amenorrhea for 1st
st pregnancy was 2nd
nd pregnancy was

app 2 months. miscarriage caesarean section,

Usually she gets because of ectopic baby girl, 3 years
period regularly 5 pregnancy old, 2,7kg.
days.
Patient has
Patient use 3 experience in Cyst or other tumor
months injectable whitish vaginal are unknown.
birth control. Using discharge. Pelvic pain before
IUD before is Sometimes itchy allowed.
denied. and has fishy odor.
SOCIAL HISTORY

She was pregnant

Smoking habit Certain drug use
3 years after
denied denied
marriage
PHYSICAL EXAMINATION

Awareness : compos mentis Neck : lymph nodes enlargement not found

General conditions : very sick looking Thorax : Anterior lateral comparison 2:1, lesion . Protrude
GCS : 13 montgomery tubercle +/+ darkened areola +/+

Vital sign : Cardio : HS 1,2 regular pure. No extra sound

Blood pressure : 110/70 mmHg Lungs : vesicular breath sound. Rhonchi -/- Wheezing -/-

Heart rate : 74 x/m, regular, mild pulsation Abdomen : - Inspection : linea nigra +. Stretch mark +.
Mass -
Respiration rate : 20 x/m
- Auscultation : Bowel sound + normal.
Temperature : 36.0C
- Percussion :

Head : Normocephaly
Eye : Anemic conjunctiva +/+ Icterus sclera -/-
Nose : No epistaxis
Mouth : mouth mucosa dry
LABORATORY EXAMINATION

09 - 12 - 2016
Hemoglobin (L) 7.0 g/dl 11,7 15,5
Leucocyte (H) 17.04 10/L 3.60
11.00
Hematocrit (L) 22 % 35 47
Platelet 339 10/L 150 440
Erythrocytes (L) 3.35 104/
L
WORKING DIAGNOSE

Abdominal Pain e.c Suspect Ruptured Ectopic

Pregnancy
Anemia
Metrorraghia
Dyspepsia
DIFFERENTIAL DIAGNOSE

Abortus
Salpingitis
Bleeding because ruptured follicular cyst or luteal corpus
TREATMENT

IVFD RL
IV Ketorolac 30 mg
IV Ondansetron
FURTHER EXAMINATION SUGGESTIONS

Lab findings - 9/10/16 USG 10/12/16

Bleeding 2.30 Meni 1.00 3.00
time t
Clotting 4.00 Meni 4.00 6.00
time t

B-HCG +
test

HBsAg -
Uterus measurements : 7 x 5 x 4 cm
Outward retrouterina mass
Conclusion : hematocele retrouterina
FOLLOW UP
THEORY & CASE ANALYSIS
 DEFINITION
Ectopic pregnancy is the result of a flaw in human reproductive physiology that
allows the conceptus to implant and mature outside the endometrial cavity (see
the image below), which ultimately ends in the death of the fetus. Without timely
diagnosis and treatment, ectopic pregnancy can become a life-threatening
situation.
In normal conception, the egg is fertilized by the sperm inside the fallopian
tube. The resulting embryo travels through the tube and reaches the uterus 3 to 4
days later. However, if the fallopian tube is blocked or damaged and unable to
transport the embryo to the uterus, the embryo may implant in the lining of the
tube, resulting in an ectopic pregnancy. The fallopian tube cannot support the
growing embryo. After several weeks the tube can rupture and bleed, resulting in a
potentially serious situation.
Sepilian, Vicken P. 2016. Ectopic Pregnancy. Lancet. 366(9485):583-91.
 RISK FACTORS
The risk factors for ectopic pregnancy are:
Previous ectopic pregnancy (odds ratio (OR) 13). Approximately 10% of spontaneous pregnancies
after an ectopic pregnancy will be recurrent ectopic pregnancies. One recent study from Denmark
suggests this figure is closer to 17%.
History of PID (OR 7)
History of infertility or assisted conception (OR 3)
Conception with IUD in situ (OR 3)
Smoking (OR 2)
Conception whilst using POP
Use of emergency contraception in current pregnancy
Pelvic or tubal surgery

A, Avsar FA, Batioglu S.Risk factors for ectopic pregnancy: a case-control study. Aust N Z J Obstet Gynaecol 2006; 46(6)
m WM, Mol BW, van d, V, Bossuyt PM.Risk factors for ectopic pregnancy: a meta-analysis. Fertil Steril 1996; 65(6):1093-10
CLINICAL FEATURES
Sharp or stabbingpain that may come and go and vary in intensity. (The pain may bein the pelvis, abdomen, or even the
shoulder and neck due to bloodfrom a ruptured ectopic pregnancy gathering up under the diaphragm).
Vaginal bleeding, heavier or lighter thanyour normal period
Gastrointestinal symptoms
Weakness,dizziness, or fainting
The typical history is of an abnormal period where the bleeding is prolonged with brown prune juice spotting. The woman
may not realise that she is pregnant if the bleeding started around the time of her expected period. The patient may also
complain of shoulder tip pain if the ectopic pregnancy is causing intraperitoneal bleeding. Some women do not experience
severe pain despite intraperitoneal bleeding, but may only have mild discomfort or diarrhoea.
A French collaborative study set out to develop a symptom score to predict ectopic pregnancy rupture. The study examined
a number of different pain variables, the most significant being: vomiting during pain, diffuse abdominal pain, pain lasting
more than 30 minutes and flashing pain. The presence of one or more of these pain features gave a detection rate for
rupture of 93%, a 44% specificity and a negative likelihood ratio of 0.16. What this means is that most ectopic pregnancies
have one or more of these pain features but they are not very specific in other words other conditions will also give rise
to these symptoms. The absence of any of these factors usually, although not exclusively, means rupture has not
happened yet.
 CLASSIFICATIONS
he incidence of ectopic pregnancy is about 1-3%, depending on the population studied.
95-97% of ectopic pregnancies are tubal pregnancies.

Bourne, Tom. 21 April 2016. Clinical Features Of An Ectopic Pregnancy.

Taken at : http://www.ectopic.org.uk/professionals/clinical-features/
DIAGNOSE
TREATMENT
EXPECTANT MANAGEMENT
 MEDICAL TREATMENT

Kovaleva. 2016. Methotrexate-treatedEctopic Pregnancy: Beta Human Chorionic Gonadotropin Serum Changes
A Success Predictor Using A Mathematical Model Validation. Eur J Obstet Gynecol Reprod Biol.2016 Oct 27;210:35-38.
i: 10.1016/j.ejogrb.2016.10.022.
SURGICAL TREATMENT
PROGNOSIS
COMPLICATION