Ectopic pregnancy.presentation slides pt
- 1. ECTOPIC PREGNANCY DR. Ngong N. Amet (PT) Bsc. In Rehabilitation Medicine St. Mary’s University College – Juba Higher Diploma in Medical Education College of Physicians & Surgeons – Juba
- 2. Learning outcomes Define Ectopic pregnancy Explain the pathophysiology & incidence of ectopic pregnancy Outline the aetiology & clinical features of ectopic pregnancy Explain the differential diagnosis of ectopic pregnancy Describe relevant investigations for ectopic pregnancy Describe the clinical manage of ectopic pregnancy
- 3. COMPETENCE To diagnosis & manage ectopic pregnancy
- 4. ECTOPIC PREGNANCY DEFINITION It is a condition where by a fertilised ovum is implanted on any tissue other than lining of the uterine cavity e.g. fallopian tube Also known as extra uterine pregnancy POSSIBLE SITES OF IMPLANTATION Abdominal cavity Cervix The ovary Ampullar Isthmus Infundibular
- 6. Pathophysiology Mechanical or functional factors prevent or interfere with the passage of the fertilized egg to the uterine cavity .e.g.pelvic infection The fertilized egg then implants itself inside the tube. If implantation occurs into a site of the tube that offers a sufficient area for placentation, the process is very similar to that of an intrauterine pregnancy, because the conceptus penetrates the tubal mucosa & becomes embedded in the tissues of the tubal wall.
- 7. Pathophysiology As the fertilised ovum increases in size the tube becomes more & more distended, until finally 4 to 6 weeks after conception, rupture takes place & the ovum is discharged into the abdominal cavity. The trophoblast penetrates the full thickness of the muscular layer of the tube to reach the subserosa & the tubal ovarian circulation
- 8. PATHOTHYSIOLOGY This event is usually accompanied by fetal death Occasionally, following the rupture the fetus retains sufficient attachment to its bld supply to maintain viability & secondary abdominal preg can proceed to term If the ectopic pregnancy miscarries, the uterine decidua may slough off as a cast, or more commonly as fragments mixed with small blood clots.
- 9. INCIDENCE More common in low social economic status women & the incidence has increased because of PID, the increase use of intra uterine devices, progesterone only oral contraceptive It is also common in older women (35-44 yrs.) who have had previous pregnancies than in teenagers due to degeneration of the lumen of the fallopian tubes.
- 10. AETIOLOGY The cause is unknown.
- 11. RISK FACTORS Multiple factors contribute to the relative risk of ectopic pregnancy. In theory, anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation. Previous history of Ectopic pregnancy Use of IUCD causes tubal damage due to salpingitis. IUCD can be the source of infection.
- 12. RISK FACTORS The most logical explanation for the increasing frequency of ectopic pregnancy is previous pelvic infection. Pelvic inflammatory diseases due to ascending infection e.g. cervicitis, salpingitis which can be caused by Chlamydia, Neisseria gonorrhoea. Congenital abnormalities of the tubes.
- 13. RISK FACTORS History of prior ectopic pregnancy After one E/P, a pt incurs a 7- to 13-fold increase in the likelihood of another E/P Overall, a pt with prior E/P has a 50-80% chance of having a subsequent intrauterine gestation, & a 10-25% chance of a future tubal pregnancy. History of tubal surgery & conception after tubal ligation Prior tubal surgery increases the risk of developing ectopic pregnancy.
- 14. DIAGNOSIS Subjective data History is very important History of amenorrhoea of about 6-8 wks but may be longer if implantation occurs in the interstitial portion of the tube, or in abdominal pregnancy History of persistent mild lower abdominal pains History of sharp colicky pain & a sudden excruciating pain when tube has ruptured History of backache History of dizziness, nausea &vomiting
- 15. DIAGNOSIS Objective Data Physical examination On palpation:-There is a unilateral lower quadrant tenderness Generalised abdominal pain when rupture has occurred. This is due to spilling of blood into the peritoneum Tender boggy mass in cul-de-sac may indicate pelvic haematocele.
- 16. DIAGNOSIS Objective Data Vaginal bleeding, slight, dark brown Intermittent / continuous, due to falling hormones due to fetal death Adnexal tenderness Abdominal tenderness Adnexal mass
- 17. DIAGNOSIS Patient rapidly goes into shock with decreased BP, rapid weak pulse rate, pallor, sweating, low body temperature and cold extremities If there’s hemoperitonitis, temperature will be high 38°C or more
- 18. Investigations Ultrasonography:- May show extra uterine gestational sac Laparoscopy:- Confirms tubal pregnancy through visualisation of distended tube or site of implantation Dilatation and curettage:- May confirm ectopic pregnancy through pelvic examination under anaesthesia or rule out if placental tissue is obtained from endometrium Culdoscentesis – the passing of a wide bore needle through the posterior fornix. Old blood is very suggestive, but the absence of blood does not exclude an ectopic pregnancy.
- 19. Investigations Human chorionic gonadotrophin & transvaginal ultrasound o The (Hcg) & USS findings must be interpreted together. o One of the most important parameters is the discriminatory Hcg level above which the gestational sac of an intrauterine pregnancy should be detected by ultra sound (usually 1000i./L)
- 20. DIFFERENTIAL DIAGNOSIS Threatened abortion incomplete abortion Corpus luteum cyst Salpingitis UTI Acute appendicitis
- 21. CLINICAL MANIFESTATIONS Unruptured tube oLower abdominal pains & tenderness that may be generalised or unilateral oSigns of pregnancy like amenorrhoea, nausea, vomiting & breast tenderness oPelvic mass may be palpable. Ruptured tube oSevere abdominal pain that is sudden & stabbing. oDizziness &Fainting oReferred supraclavicular pain oVaginal bleeding & Pallor
- 22. CLINICAL MANIFESTATIONS CT- Ruptured tube oCervical pain during vaginal examination oProgressive supine hypertension oTachycardia & tachypnea oDecreased haematocrits value oShock
- 23. MANAGEMENT EMMERGENCY SURGERY: In cases where the preg is located on cervix, ovary, or in the interstitial or the cornual portion of the tube is often associated with increased risk of hemorrhage, often resulting in hysterectomy or oophorectomy. Salpingectomy or salpingoophorectomy depending on findings Medical Management Methotrexate
- 26. References 1. Davison J. Prepregnancy care and counselling in chronic renal patients. Eur Clin Obstet Gynaecol 2006;2:24–29. 2. McKay DB, Josephson MA, Armenti VT et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005;5:1592– 1599. 3. Lindheimer MD, Kanter D. Interpreting abnormal proteinuria in pregnancy. Obstet Gynecol 2010;115:365–375. 4. Robert Casanova & etal. Dewhurst’s textbook of obstetric & gynecology,- ninth edition 5. D. Keith & etal, Beckmann & Ling’s Obstetric & Gynecology, eighth edition
- 27. Evaluation 1. Which one of the following is not a clinical feature of ectopic pregnancy A. Dizziness &Fainting B. Referred supraclavicular pain C. Vaginal bleeding & Pallor D. Dystocia 2. Outline the differential diagnosis of ectopic pregnancy 3. Briefly explain any risk factors associated with ectopic pregnancy
- 28. Ans. 1. D 2. Threatened abortion, incomplete abortion, Corpus luteum cyst, Salpingitis, UTI & Acute appendicitis 3. Pelvic inflammatory diseases due to ascending infection e.g. cervicitis, salpingitis which can be caused by Chlamydia, Neisseria gonorrhoea. Congenital abnormalities of the tubes. History of prior ectopic pregnancy After one E/P, a pt incurs a 7- to 13-fold increase in the likelihood of another E/P Overall, a pt with prior E/P has a 50-80% chance of having a subsequent intrauterine gestation, & a 10-25% chance of a future tubal pregnancy.
- 29. Thanks once again Any question please, you can reach me online through ngongamet@gmail.com Contact:+211925030088/+211985030088/+211913031317