ECTOPIC PREGNANCY (KEHAMILAN

EKTOPIK)
Kehamilan Tuba
Kehamilan Abdomen
ETIOLOGI
 Ectopic pregnancy usually results from conditions that delay or
prevent the transit of a fertilized ovum through the
fallopian tube.
 Over 50% are associated with tubal inflammatory changes
(previous or chronic salpingitis).
 Other important etiologic factors include zygote abnormalities,
transmigration of the ovum, postmidcycle ovulation–fertilization,
or exogenous hormones.
 Unfortunately tubal rupture cannot be safely predicted by any
known risk factor, serum hCG level, or sonographic finding and
occurs in approximately 20% of patients in developed countries.
 Only early diagnosis and treatment will prevent the sequelae of
tubal rupture.
 Ectopic pregnancy is a major cause of maternal mortality
mainly because of uncontrolled hemorrhage and shock
KLASIFIKASI
 Tubal (98–99%)
 the anatomic section involved: ampullary (55%), isthmic (25%), fimbrial
(17%), interstitial (angular, cornual) (2%), and bilateral (very rare)
 Ovarian (0.5%)
 following fertilization of an unextruded ovum.
 Abdominal (1/15,000 pregnancies)
 primary = initial implantation of the zygote outside the tube (e.g., on the
liver)
 secondary = to expulsion or rupture of a tubal pregnancy.
 Cervical implantation (rare)
 by a greatly enlarged cervix (often as large as the nonpregnant uterus,
known as the “hourglass sign”)
 An enlarged, highly vascularized, bleeding cervix, with tight internal os and a
gaping external os.
 Uterine ectopic gestations (rare)
 may occur with implantation in the cornua, a uterine diverticulum,
uterine sacculation, rudimentary horn, or the muscular wall
(intramural).
 Combined intrauterine pregnancy (heterotopic).
 This occurs in 1/17,000–30,000 pregnancies.
 Other rare possibilities include intraligamentous.
PATOFISIOLOGI
 Normally = the usual early signs of pregnancy are noted in the
cervix
 EP = the uterus becomes minimally enlarged and slightly softened
with an ectopic gestation.
 The endometrium contains decidua (but no trophoblast) and has a
characteristic microscopic appearance termed the “Arias-Stella
reaction.”
 Slight endometrial bleeding generally occurs, presumably with abnormal
hormonal patterns, following a variable interval of amenorrhea.
 Endometrial separation and bleeding occur when the trophoblast is
withdrawn (e.g., with rupture).
 Only in uncommon interstitial pregnancy does blood from the tube drain
via the uterus into the vagina.
 Lower abdominal, pelvic, or low back pain may be secondary to tubal
distention or rupture.
 Isthmic pregnancy usually ruptures in about 6 weeks, and hemorrhage
due to ampullary pregnancy occurs at 8–12 weeks.
 Cornual pregnancies are most commonly carried to the second trimester
before rupture.
 Intraabdominal pregnancy may terminate anytime with bleeding.
 A pelvic mass is caused by enlargement of the conceptus, hematoma
formation, bowel distortion by adhesions, or infection.
 If the fetus dies without extensive bleeding, it may become infected,
mummified, calcified (lithopedian), or an adipocere (fatty replacement).
SURGICAL TREATMENT LAPAROSCOPY VS. LAPAROTOMY
 The standard operative procedure for the treatment of ectopic
pregnancy in the developed world is laparoscopy
 The benefits = less blood loss, less analgesia, less postoperative pain,
shorter recovery period, decreased hospital costs.
 Because of lower peri- and postoperative morbidity, lower cost, and
equivalent efficacy, laparoscopy is preferred to laparotomy for the
treatment of ectopic pregnancy.
 The only absolute contraindication = shock or hemodynamic instability
PHARMACOLOGICAL TREATMENT: METHOTREXATE
 Methotrexate is a folinic acid antagonist that inactivates
dihydrofolate reductase  in the depletion of tetrahydrofolate, a
cofactor essential for deoxyribonucleic acid and ribonucleic acid
synthesis  interferes with DNA synthesis, repair, and cellular
replication.
 Actively proliferating tissue, such as trophoblast cells of an ectopic
pregnancy, is generally more sensitive to these effects of methotrexate.
 Methotrexate is considered to be the treatment of choice for
ectopic pregnancy
 Indication: Hemodynamically stable patients without active
bleeding or signs of hemoperitoneum
 Contraindication:
PROGNOSIS
 A serum β-hCG of less than 1000mIU/mL, accompanied by a small
adnexal mass (<4cm)  spontaneous resolution in 75% of cases,
whereas falling levels of β-hCG predict resolution in around 90% of
ectopic pregnancies.
 However, failure of β-hCG levels to decline and suspected tubal
rupture due to abdominal pain  needs immediate intervention
and abandonment of the expectant management.
 Initial serum β-hCG level was the best predictor for the
successful outcome of expectant management.
REFERENSI
 Obstetri Willaims
 Clinical Obstetrics

 Benson Pernolls Handbook of Obstetrics