4th stage
نسائية
Lec-3 تكملة
.د
احمد جاسم
2/11/2015
Treatment:
Acute presentation (rupture ectopic) = surgery
immediate resuscitation and intravenous fluid with blood transfusion as rapid as possible
and as needed.
under general anesthesia laprotomy or laproscopy done.
simple salpingectomy to affected tube with conservation of ovaries.
Subacute/asymptomatic presentation (unruptured ectopic)
Immediate treatment is essential and the aim to preserve tube and treat the condition
before rupture of tube .
Types of treatment:
medical treatment
There is no role for medical management in the treatment of tubal pregnancy or suspected
tubal pregnancy when a patient shows signs of hypovolaemic shock.
It can be chosen for patient who has (all of following):
size of ectopic pregnancy less than 4 cm.
unruptured tube.
Serum hCG level less than 1500 IU/lit.
No evidence of embryonic cardiac activity (fetal heart negative by ultrasound.chose for
patient has:
size of ectopic pregnancy less than 4 cm.
unruptured tube.
Serum hCG level less than 1500 iu/lit.
Non viable pregnancy (fetal heart negative) by ultrasound.
Women should be able to return easily for assessment at any time during follow-up.
Drug used in medical treatment: methotrexate, prostaglandin( PGE2 ,PGF2α), potassium
chloride, mifipristone.
Route of administration:
systemic methotrexate , mifipristone.
Local injection of drug into gestational sac by laproscopy, transvaginal , transcervical).
Follow up:
The treatment need Follow up by Ultrasound combined with serial hCG which are essential
at interval of 1-2 days.
Active management are needed (switch to surgical treatment) if :
a. hCG level rise during follow up.
b. suspicious clinical symptoms.
c. sonographic finding develops.
2. surgery:
a. laproscopy
b. laprotomy
Surgical approach can be by :
a. laproscopy.
b. laprotomy.
The surgery of ectopic pregnancy were either conservative surgery (tubal conservation) or
radical surgery (removal of the tube) and the choice between them should be made
depending on the circumstances in each individual case. In general tubal conservation
should be attempted if a woman desires further pregnancies and there is evidence of
contralateral tubal damage.
conservative surgery.
1.Conservative surgery (removal of ectopic pregnancy and preserve affected tube) can be
done by one of following:
a. Salpingotomy (opening tube and left open to heal by secondary intention). It should be
considered as the primary treatment when managing tubal pregnancy in the presence of
contralateral tubal disease and the desire for future fertility. Women must be made aware
of the risk of a further ectopic pregnancy.
b. Fimbrial evacuation.
c. Mid tubal resection with or with out re-anastmosis.
2.Radical surgery for ectopic is salpingectomy which is indicated in :
1. severely damaged tube.
2. women who complete her family.
3. uncontrolled bleeding from implantation site.
4. large tubal pregnancy (>5 cm).
5. recurrent ectopic pregnancy in same tube
.
Persistent trophoblastic disease:
viable trophoblastic tissue remains after medical treatment and/or conservative surgical
treatment in about 5-10% and require further treatment either by methotrexate or surgery.
3.Expectant management (non-interventional ) methods:
not common to use and not suitable for all patient as it needs follow up by ultrasound and
hCG and may need active management at any time.
Remember:
If the woman is Rh-negative and her husband is Rh-positive or unknown Rh, (250unite) anti-
D immune globulin should be given intramuscularly to prevent anti-D isoimmunization.
Prognosis:
Significant factors affect future fertility after treatment of ectopic pregnancy which are:
1.Condition of controlateral tube.
2.history of infertility.
3.Extent of surgery.
Intrauterine pregnancy rates following ectopic pregnancy range between 50 and 70% .
Recurrent ectopic pregnancies occur in 6–16% of women with previous history of ectopics
and these women should be offered early scans in all future pregnancies to detect recurrent
ectopics before complications can occur.
Pregnancy rates are similar in patients treated by either laparoscopy or laparotomy.
In women with a damaged or absent controlateral tube, in vitro fertilization is likely to be
required if salpingectomy is performed.
Non tubal pregnancy
Abdominal pregnancy:
Rare condition and it is associated with high morbidity and mortality, with the risk for
death 7 to 8 times greater than from tubal ectopic pregnancy and 90 times greater than
from intrauterine pregnancy.
Symptoms and signs:
1.history suggest ectopic pregnancy in early pregnancy sometimes.
2.a symptomatic and suspected from examination.
3.persistant abnormal lie.
4.fetal parts are readily palpated.
5.enlarged uterus felt separate from fetus.
Investigations:
1.ultrasound show no clear outline of gestational sac and oligohydramnios and early
intrauterine growth resriction (IUGR).
In women with a clinical suspicion of abdominal pregnancy a transvaginal scan should be
performed to assess the uterus and establish the continuity between the cervical canal,
uterine cavity and gestational sac
2.X-ray of abdomen showed maternal intestinal gas superimposed on fetus.
3.oxytocin infusion which cause uterine contraction which felt separately from fetal part
course:
1.alive fetus reaches viability.
2. fetus die and thrombosis of vessel at placental site gradually occur and there will be
either no symptome ,or complications could arise.
Treatment
Treatment of abdominal pregnancy is surgical by laprotomy as soon as viability is achieved
because fetus will die once labour begin.
The fetus should be removed, the cord cut short and the placenta should be left in situ. Any
attempt to remove the placenta may result in massive uncontrollable haemorrhage. the
residual placental tissue will absorb slowly over a period of many months, sometimes a few
years.
Complications of abdominal pregnancy:
1.maternal complications:
A. complication arising due to placenta in situ:
infection.
adhesion.
obstruction.
coagulopathy.
B . complication arising due to fetal death in peritoneal cavity:
Adhesion
infection of sac and severe toxic effect
Fetus complications:
Pressure deformity.
Increase perinatal mortality to 75% or more.
Hetrotopic pregnancy:
Is combined ectopic and intrauterine pregnancy .
Treated by either:
injection of hyperosmolar glucose in ectopic site.
Surgical removal of ectopic.
Prognosis:
75% of intrauterine pregnancy reach term.
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Ectopic pregnancy in women should be in mind in every emergency room.