OB CASE PRESENTATIONZshari Zxilka T. TanggolMedical InternDepartment of Obstetrics and GynecologyAugust 2010
Preceptor: Dr. Fernandez
GENERAL DATA
N.A. 31 y/o G3P3 (3003) Married Islam Pasig City
PAST MEDICAL HISTORY
No hypertension, diabetes mellitus, bronchial asthma, cancer, thyroid disease
Previous operation: s/p CS III x, Ix for CPD (1997, 2008, 2005)
No known allergies No history of blood transfusions
FAMILY HISTORY
(+) Hypertension – mother (+) Diabetes Mellitus – mother No bronchial asthma, heart disease, cancer,
thyroid abnormalities
PERSONAL AND SOCIAL HISTORY
Nonsmoker Non-alcoholic beverage drinker
MENSTRUAL HISTORY
Menarche: 12 y/o Regular 5 days 3 pads per day (-) pain
LMP: June (3rd or 4th week) 2010 PMP: May 2010
OBSTETRIC HISTORY
G3P3 (3003)
Year AOG Type of Delivery
Place of Delivery
Fetomaternal Complication
G1 (1997)
FT Primary CS for CPD
Zamboanga None
G2 (1998)
FT RCS Zamboanga None
G3 (2005)
FT RCS Zamboanga None
GYNECOLOGIC AND SEXUAL HISTORY
Coitarche: 18 y/o Sexual Partner: 1 Sexually active Family Planning Method: None (-) Pap smear (-) use of OCPs (-) abnormal vaginal discharge
HISTORY OF PRESENT ILLNESS
(+) Right lower quadrant pain, stabbing, nonradiating, 7/10 intensity, intermittent(-) fever, nausea, vomiting(-) vaginal bleeding(-) vaginal discharge(+) Amenorrhea ~5 weeksNo consult done nor medications taken
7 days PTA
3 days PTA
(+) Recurrence of RLQ pain(+) Associated with minimal vaginal bleeding with passage of blood clots
HISTORY OF PRESENT ILLNESS
(+) Symptoms persisted Patient sought consult with AMD where ultrasound was done (Zamboanga) which showed, right ovary: 3.9 x 3.7 thin walled anechoic mass
2 days PTA
Few hours PTA
(+) Increase in RLQ pain(+) Generalized weaknessConsult at SLMC where TVS done which showed right adnexal mass highly suggestive of an ectopic gestational sac probably tubal with small leak or rupture stat gyne laparotomy: ADMISSION
REVIEW OF SYSTEMS General: no weight loss, anorexia, easy
fatigability Eye: no visual dysfunction, itchiness,
lacrimation or redness Ears: no dizziness, tinnitus, deafness,
discharge or vertigo Nose: no congestion, no discharge, no
hyperemia Mouth: no lesions or discharges Neck: no hoarseness or stiffness
REVIEW OF SYSTEMS Pulmonary: no dyspnea, no cough Cardiac: no chest pains, no palpitations, no
PND Vascular: no phlebitis, varicosities, cyanosis Gastrointestinal: no change in bowel
movements, vomiting Genitourinary: no frequency, urgency, flank
pains Endocrine: no polyuria, polydipsia,
polyphagia, heat/cold intolerance
REVIEW OF SYSTEMS Musculoskeletal: no joint stiffness, swelling
or numbness, Hematopoietic: no pallor or easy
bruisability Neurologic: no headache, vertigo or
seizures Psychiatric: no anxiety, depression,
interpersonal relationship difficulties, illusion, delusion
PHYSICAL EXAMINATION Awake, conscious, coherent, ambulatory Not in cardiorespiratory distress Vital Signs: 120/80 mmHg, 78 bpm
regular, 20 cpm regular, 37.3° C Weight: 65 kg Height: 157.48 cms BMI: 26.21 kg/m2 (Overweight)
PHYSICAL EXAMINATION
Skin: warm, smooth Head: normocephalic, normal pattern of
distribution Face: no facial asymmetry Eyes: pink palpebral conjunctivae, anicteric
sclerae, pupils 2-3mm briskly reactive to light Ears: patent ear canal; tympanic membrane non
perforated, pearly white, with intact cone of light, bilateral
Nose: nasal septum midline, pink nasal mucosa, no nasal congestion.
Throat: non-hyperemic tonsillopharyngeal walls
PHYSICAL EXAMINATION Neck: supple neck, no masses, no
lymphadenopathies Chest/Lungs: symmetrical chest expansion, no rib
retractions, equal tactile and vocal fremitus; clear breath sounds in all lung fields
Breast/Thorax: symmetrical, no palpable masses or tenderness
Heart: adynamic precordium, normal rate and regular rhythm, apex beat at 5th L ICS-MCL, no heaves, no thrills, no murmurs.
PHYSICAL EXAMINATION Abdomen: Flabby, normoactive bowel sounds,
tympanitic, soft, (+) direct tenderness on right lower quadrant, no masses palpated
External pelvic examination: No lesions, redness, excoriations, hyper/hypopigmentations
SE: cervix pink, smooth, (+) minimal to moderate vaginal bleeding
IE: Cervix is long, closed; uterus not enlarged, (+) cervical motion tenderness, (+) right adnexal tenderness and fullness, no left adnexal mass or tenderness
Full and equal pulses; No edema, no cyanosis Neurologic exam: Essentially normal
SUBJECTIVE SALIENT FEATURES
31 y/o G3P3 (3003) (+) severe stabbing right lower quadrant
pain (+) amenorrhea (+) minimal vaginal bleeding (-) abnormal vaginal discharge, urinary or
bowel changes s/p CS III (Ix for CPD) Sexually active, (-) use of OCP
OBJECTIVE SALIENT FEATURES Conscious, coherent, not in distress Stable vital signs Abdomen: Flabby, normoactive bowel sounds,
soft, (+) RLQ direct tenderness, no masses palpated
External pelvic examination: No lesions, redness, excoriations, hyper/hypopigmentations
SE: cervix pink, smooth, (+) minimal to moderate vaginal bleeding
IE: Cervix is long, closed; uterus not enlarged, (+) cervical motion tenderness, (+) right adnexal tenderness and fullness, no left adnexal mass or tenderness
DIFFERENTIALS
Abortion Ovarian Cyst Pelvic Inflammatory Disease Subchorionic Hemorrhage Ectopic Pregnancy
CLINICAL IMPRESSION
31 y/o G4P3 (3013) Ovarian Cyst, Right Amenorrhea 5-6 weeks R/o Tubal Pregnancy,
right Previous Caesarian Section IIIx, Ix for
Cephalopelvic Disproportion (1997, 1998, 2005)
ECTOPIC PREGNANCY
ECTOPIC PREGNANCY
Ektopos: (Greek) out of place Implantation of a fertilized ovum outside
the endometrium lining the uterine cavity Implantation in any other site considered
ectopic Located mostly in the oviducts Other reported sites are the cervix, uterine
cornu, ovaries, abdomen broad ligament, spleen, liver, retroperitoneum and diaphragm
RISK FACTORS: CLASSIFICATION
Mechanical Functional Assisted reproduction Failed contraception
MECHANICAL FACTORS Prevent or retard passage of ovum to uterine cavity Tubal kinking and narrowing secondary to:
Prior tubal surgery: highest risk (failed tubal ligation, tubal fertility surgery, partial salpingiectomy)
Peritubal adhesions 2o to post-abortal/puerperal infection, appendicitis, endometriosis
Salpingitis (previous ectopic): narrowing/blind pockets
Myomas/adnexal masses
MECHANICAL FACTORS
Reduced ciliation 2o to infection: PID (Chlamydia trachomatis), Salpingitis
Developmental tubal abnormalities (diverticula, accessory ostia, hypoplasia)
FUNCTIONAL FACTORS
Altered tubal motility 2o to changes in serum levels of estrogen and progesteroneProgestin only contraceptives IUD devices with progesteronePost-ovulatory high dose estrogenOvulation inductionLuteal phase defects
Cigarette smoking: nicotine is known to alter tubal motility, ciliary activity or blastocyst implantation
Increasing age
ASSISTED REPRODUCTION
Increased incidence with gamete intra-fallopian transfer (GIFT) and in-vitro fertilization (IVF) techniques (atypical implantations more common)
FAILED CONTRACEPTION
With any form of contraceptive, the absolute number of ectopic pregnancies is decreased because pregnancy occurs less often
In some contraceptive failures, however, the relative number of ectopic pregnancies is increased.
RISK FACTORS
Multiple sexual partners Prior Caesarian section
EPIDEMIOLOGY
Increasing absolute number and rate of ectopic pregnancy
Non-Caucasians > Caucasians Increased age 2% of all pregnancies 10% of all pregnancy-related deaths Most common cause of maternal
mortality in the 1st trimester
PATHOPHYSIOLOGY
SITES OF ECTOPIC IMPLANTATION: CLASSIFICATION
Tubal (95-96%) Ampullary (70%) Isthmic (12%) Fimbrial (11%) Cornual and interstitial (2-3%)
Abdominal (1%) Cervical (<1%) CS scar (<1%) Ovarian (3%)
NORMAL ANATOMY OF FALLOPIAN TUBE
ECTOPIC PREGNANCY: CLINICAL PRESENTATION
PAIN. Severe sharp/stabbing or tearing lower pelvic and abdominal pain (95%)
ABNORMAL BLEEDING. Amenorrhea with some degree of vaginal spotting or bleeding (60-80%)
Abdominal and pelvic tenderness (75%) on palpation with or without palpable pelvic mass (20%)
Vasomotor disturbance (vertigo/syncope) with signs of hemodynamic compromise (20%)
CLINICAL PRESENTATION
First trimester uterine changes (25%) Cervical motion tenderness Bulging of posterior fornix
CLASSIC CLINICAL TRIAD: Pain, amenorrhea, vaginal bleeding
ECTOPIC PREGNANCY: DIAGNOSIS
Complete history and physical examination Urinary pregnancy tests: positive in 50% to
95%
ECTOPIC PREGNANCY: DIAGNOSIS
Serum B-hCG serial values lower than in normal
pregnancy best correlated with ultrasound in first 6 weeks of normal gestation,
serum HCG rises exponentially: doubling time is noted and is relatively constant
doubling time does not occur in gestation destined to abort or are ectopic
ECTOPIC PREGNANCY: DIAGNOSIS
Serum progesterone (inconclusive 5-25 ng/ml) A single progesterone measurement can
be used to establish with high reliability that there is a normally developing pregnancy: value exceeding 25 ng/mL excludes ectopic pregnancy with 92.5 % sensitivity
Values <5 ng/mL suggest either an intrauterine pregnancy with a dead fetus or an ectopic pregnancy
Has limited clinical utility
ECTOPIC PREGNANCY: DIAGNOSIS
Novel serum markers under investigation: vascular endothelial growth factor (VEGF), cancer antigen 125 (CA125), creatine kinase, fetal fibronectin, and mass spectrometry-based proteomics
DIAGNOSIS: ULTRASONOGRAPHY Abdominal sonography
Identification of tubal pregnancy products is difficultUterine pregnancy usually is not recognized using
abdominal sonography until 5 to 6 menstrual weeks or 28 days after timed ovulation
Vaginal sonographyUterine pregnancy 1 week after missed menses
with B-hCG >1500 mIU/ml Identification of fetal pole within the uterus with
FHT
PATIENT: TRANSVAGINAL USG
Normal sized AV uterus w/ no myometrial lesion Thin nonspecific endometrium (0.60) Normal right ovary Corpus luteum cyst (3.0x2.8x2.6cm), left ovary Inferomedial and adjacent to right ovary is a
complex mass with a 1.0cm gestational sac-like structure within (~5weeks and 5days AOG).
Slightly echogenic free fluid in the cul-de-sac ~5.2x1.8x3.5cm, volume 11cc with amorphous echogenic structure suggestive of blood clot
IMPRESSION: right adnexal mass highly suggestive of an ectopic gestation, probably tubal with small leak or rupture
VAGINAL COLOR AND PULSED DOPPLER ULTRASOUND
Uterine or extrauterine site of vascular color in characteristic placental shape
Ring of fire pattern High-velocity low impedance flow
pattern compatible with placental perfusion
Ectopic pregnancy: “cold” pattern outside uterus
ECTOPIC PREGNANCY: DIAGNOSIS
Culdocentesis Laparoscopy
MULTIMODALITY DIAGNOSIS: 5 COMPONENTS
Ectopic pregnancies are identified with the combined use of clinical findings along with serum analyte testing and transvaginal sonography.
Transvaginal sonography Serum B-hCG level—both the initial level and
the pattern of subsequent rise or decline Serum progesterone level Uterine curettage Laparoscopy, laparotomy
ECTOPIC PREGNANCY: MANAGEMENT
Medical management Expectant management Surgical management
MEDICAL MANAGAMENT
Medical therapy (Methotrexate) for the patient who is asympotomatic, motivated and compliant
The single best prognostic indicator of successful treatment of single dose methotrexate is the initial serum B-hCG level
Methotrexate: rapid absorption of placental tissue
EXPECTANT MANAGEMENT
Tubal ectopic pregnancies only Decreasing serial -hCG levels Diameter of the ectopic mass not >3.5 cm No evidence of intra-abdominal bleeding or
rupture by transvaginal sonography.
According to the American College of Obstetricians and Gynecologists (2008), 88 percent of ectopic pregnancies will resolve if the B-hCG is <200 mIU/mL.
SURGICAL MANAGEMENT
Laparoscopy - shorter operative time, less blood loss, less analgesic requirement, and shorter hospital stay
Laparotomy Salpingectomy – may be used for both
ruptured or unruptured ectopic pregnancies Salpingostomy - used to remove a small
pregnancy that is usually less than 2 cm in length and located in the distal third of the fallopian tube
Salpingotomy – same with salpingostomy but incision is closed with delayed absorbable suture
SURGICAL MANAGEMENT
SOME PRACTICE GUIDELINES*
Less than half of the patients with ectopic pregnancy present with the classic triad of a history of amenorrhea, abdominal pain, and irregular vaginal bleeding (C).
Definite cervical motion tenderness and peritoneal signs are the most sensitive and specific examination findings for ectopic pregnancy--91% and 95%, respectively (A).
*Ectopic pregnancy: forget the "classic presentation" if you want to catch it sooner: a new algorithm to improve detection. Journal of Family Practice. May 2006. Ramakrishnan, K., and Scheid, D.C.
SOME PRACTICE GUIDELINES
Beta-hCG levels can be used in combination with ultrasound findings to improve the accuracy of the diagnosis of ectopic pregnancy (A).
Women with initial nondiagnostic transvaginal ultrasound should be followed with serial beta-hCGs (B).
SOME PRACTICE GUIDELINES
Despite advanced detection methods, ectopic pregnancy may be missed in 40% to 50% of patients on an initial visit.
Most women with ectopic pregnancy have no risk factors and the classic triad of a history of amenorrhea, abdominal pain, and irregular vaginal bleeding is absent in more than half of cases.
Early diagnosis not only decreases maternal mortality and morbidity; it also helps preserve future reproductive capacity--only one third of women with ectopic pregnancy have subsequent live births. (2)
PATIENT: INTRAOP FINDINGS Hemoperitoneum, approx. 50cc + blood clots The right fallopian tube was dilated to 4x3x3cms
from the cornual end to the infundibular area, with no point of rupture noted
Uterus is small with pink and smooth serosal surface There was 3x2cm corpus luteum cyst in the right
ovary The left ovary and fallopian tube were grossly normal
Procedure: Evacuation of Hemoperitoneum + Right Salpingectomy + Left Fallopian Tube Ligation
PATIENT: LABORATORY/HISTOPATHOLOGY
Urine hCG (+) for pregnancy Serum total B-hCG: 1351 mIU/ml CBC, PT and PTT: Normal
Histopathology:A. Tubal Pregnancy, right fallopian tubeB.Unremarkable segment of left fallopian
tube
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