ECTOPIC PREGNANCY

Introduction Ectopic pregnancy Pregnancy develops outside of endometrial of intrauterine cavityCould be emergency situation! The incidens increasing every years Leading cause of maternal death in first trimester

ECTOPIC PREGNANCY RISK FACTORCLINICAL TRIAD OF ECTOPIC PREGNANCYDIAGNOSTIC PROCEDUREMANAGEMENT

CasePatient, I, 40 years entered in VK IRD RSUD AA Pekanbaru wednesday, February 22nd 2007 at 05.28 PM, with :

Chief complainConsciousness deficit 15 minute before entered in IRD RSUD AA Pekanbaru.

Present illness15 minute before entered in IRD RSUD AA Pekanbaru. Patient down of consciousness and falled down, stomatache (+), nausea and vomitus (+) and fell cold.

4 hour before came to the hospital, weakness (+), headache (+), dizziness (+). 3 weeks ago, bleeding from vagina, some time, brownies, no pain

Amenore (+). The first day last menstruation : 28-12-2006.Febris (-).Feel pain and burn at pelvic area (-).She didnt have ektopic pregnancy before.Patient havent be operate in pelvic area beforeComplain about urinary (-).Complain about leukorrhoe (-).Smoker (-).

Physical ExaminationA. General StateGeneral condition: weak and paleConsencious : ComposmentisVital sign: Blood pressure : 60/pulse Heart rate : Soft and quick Respiratory rate: 24 x/bpm Temperature : 37,5C

Conjungtiva : anemiaLips, tongue and skin : PaleEar, nose, throats: NormalyHaight: 154 cmWeight : 51 kg Nutrition : GoodThoraks: NormalyEkstremities: Normaly

B. Ginecological stateFace: Kloasma gravidarum (-)Mammae: NormalyAksila: Normaly Abdomen Inspeksi: plate,umbilical normaly, sikatrick (-), striae (-) Palpasi: Push pain (+) Hepar, lien and renal difficult to measure Perkusi : redup Auskultasi: peristaltik (+)

Genitalia Inspeksi : vulva and vagina normalyInspekulo: portio : Livide (+), blood from OUE (-), erosi (-), mass (-)

VT bimanual: Pain portio, uterus ante fleksi, measure of uteri more bigger than normal uteri, pain at left and right adneksa(+), douglass crise (+).

Laboratory evaluationPlano test: (+)Hb: 9,1 gr%Leukocit: 20.500/mm3Trombocit: 145.000/mm3BT: 2CT : 4Ht: 29 vol%Ureum : 42 mg%Creatinin : 1,4 mg%

Working diagnose

Shock hipovolemik + acute abdomen e.c suspect rupture ectopic pregnancy G4P3A0L3 (gravid 8-10 Weeks)

TherapyRepair general conditionIVFD NaCl 0,9% give 4 flash in one hourO2 10 liter/minutePrepare Whole Blood transfusion 1000 ccDauer Catheter urine (-)General Observe and vital signUSG

Plaining :Laparatomy cito

PROGNOSIS : Bonam

FOLLOW UP22nd February 2007 at 7.30 PMS: Abdominal pain (+), bleeding from vagina(-), all of ekstremity ColdO: Conscious composmentis Blood presure : 90/60 mmhg, pulse : 110 prm soft and regular, RR: 22 prm, temperature : 36C.IVFD NaCl 5 kolf Dauer Catheter: 50 cc, Transfusion (-)

USG uterus > normally, gravid ekstra uterine fluid in cavum Douglasi and cavum abdomenConclution Rupture Ektopic pregnancyA :Shock handled.Acut abdomen e.c Rupture Ectopic pregnancy + G4P3A0L3 (gravid 8-10 weeks)P : Laparatomy cito

08.00 PMSalpingektomy by Laparotomi surgery with general anastesi Durante operasionum:Insisi linea mediana 7 cmAbdominal cavity fill with blood Look for the source of bleeding salping dekstraSalpingectomy dekstra Bleeding control Subcuticular and cuticular suture

Therapi post op:Fasting until bowel peristaltik (+)IVFD RL : D5% + 2 Vials syntocinon 30 gtt/minuteAmbacin 3 x 1Kalnex 3 x 1Pronalges supp 2 x 1Transfusion until Hb 10gr%Pkl : 21.00 Operation done

23 th February 2007 07.00AM

S: nausea and vomit (+), head ace (+), fever (-), flatus (+),Bowel (-), O: General Condition : awake.Conscious : composmentisVital sign : Blood pressure: 110/80 mmHg Heart rate : 88 prm RR : 18 prm Temperature : 36,5C

Conjungtiva : anemiaDauer catheter : 600 cc (10 hours)Transfusion Whole blood 500 ccA: Post Laparatomy indication Rupture ectopic pregnancy Ist dayP: Cek Hb post operation Blendered meal Th/ Goes

24th February 2007 07.00 AM

S: nausea (+), head ace (+), fever (-), flatus (+), bowel (-), O: General condition goodConscious : composmentisVital sign : Blood pressure: 110/80 mmHg HR : 80 prm RR: 16 prm Temperature: 36,5C

Konjungtiva : anemisDauer catheter : 1000 cc (10 hours)Transfusi Whole blood 250 ccHb : 8,0 gr%A: Post laparatomy indication rupture ectopic pregnancy 2nd dayP: oral therapy diet high calory high protein

25th February 2007 02.00 PM

S: nausea (+), head ace (-), fever (-), flatus (+), bowel (-), cought (+)O: General condition goodConscious : composmentisVital sign : Blood pressure: 110/70 mmHg HR : 84 prm RR : 16 prm Temperature: 36,9C

Conjungtiva : anemisDauer catheter : affTransfusi Whole blood 250 ccHb : 8,0 gr%A: Post laparatomy 3th dayindication rupture ectopic pregnancyP: Oral therapy Diet High calory high protein Changes verband

26th February 2007 07.00 AM

S: nausea (+), head ace (-), fever (-), flatus (+), bowel (-), cought (-)O: General condition goodConscious : composmentisVital sign : Blood pressure: 110/70 mmHg HR : 88 prm RR : 18 prm Temperature : 36,7C

Konjungtiva : anemisDauer catheter : affHb : 8,0 gr%A: P3A1L3 post laparatomy 4th day indication rupture ectopic pregnancy P: oral therapy diet High calory high proteinHome care

ECTOPIC PREGNANCYDefenitionAn ectopic pregnancy is a pregnancy that develops outside of endometrial of intrauterine cavity.

80%12%2%1,4%5%0,2%0,2%

EpidemiologyCenters for Disease Control (CDC) USA 1970 - 1984 : 4-fold Fatality rate decrease 90%Maternal death in USA 12%In Cipto Mangunkusumo Hospital 1987 1 in 26 . 20 40 years old.

EtiologyRISK FACTORSHigh RiskModerate RiskSlight RiskTubal connective surgery- Tubal sterilizationPrevious ectopic pregnancy- In utero DES exposureDocumented tubalpathologyInfertilityPrevious genital infMultiple partners- Previous pelvic or abdominal surgery- Smoking- Intercourse before 18 years old

Patophysiology

Clinical ManifestationsClinical Triad of Ectopic PregnancyVaginal BleedingPainAmenorea

Supporting ExaminationsRoutine Blood ExamB-HCG LevelProgesteron concentrateAbdominal USGTransvaginal USGColor flow Doppler USCuldocentesisUterine CurretageLaparoscopy

Expectant ManagementMedical TherapySurgical TherapyManagementSalpingostomySalpingectomy

MTXNo Intervension

Complication

Ruptur of TubaLaparatomy ComplicationMassive BleedingShockDICBleedingInfectionsDestruction of surrounding organ

PrognosisRecurrent Ectopic Pregnancy Risk

After First 5-12%After Second32%

DiscussionDiagnoseEtiologyManagement

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