Ecthopic pregnancy

Pathology
Most ectopic pregnancies occur in fallopian. The most frequent site of implantation is the ampulla, and isthmus, fimbriae, cornua, and the uterus intersisialis. While non-tubal ectopic pregnancy is extremely rare, but can occur in the abdomen, ovaries, or cervix. Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%, (B) Isthmic, 12%, (C) Fimbrial, 5%, (D) Cornual / Interstitial, 2%, (E) abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%. Based on the implantation of the conceptus on the tube, there is: Pars interstitial pregnancy Pregnancy pars ismika Pregnancy pars ampullaris pregnancy infundibulum Which included tubal ectopic pregnancy outside are: Intraligamenter cervical pregnancy abdominal pregnancy Rudimentary uterine horn Fetus in an ectopic pregnancy can not grow properly and perfectly, for a variety of needs for fetal growth and development can not be fulfilled outside of the uterus, including the decidual reaction, blood circulation, as well as the need for space. But the early stages of gestation can still occur outside the uterus. In general, the fetus can not survive due to rupture or involution of the gestational sac. Nidasi egg in the fallopian may occur kolumner or interkolumner. Further development is limited by the lack of vascularization, so that the eggs usually die early, then diresorbsi. Hormones estrogen and progesterone, produced by the corpus luteum and trophoblast graviditatis, the uterus enlarges and becomes flaccid, also can turn into endometrial decidua. Arias-Stella phenomenon can also be found, namely a large epithelial cells with hypertrophic nuclei, hiperkromatik, lobuler, and irregularly shaped, perforated or foamy cytoplasm, and sometimes found mitosis. Bleeding in ruptured ectopic pregnancy (KET) is derived from a degenerative release of decidua.

Pathogenesis of Tubal Pregnancy

Tuba is not a place for the growth of the products of conception, so the fetus can not grow in their entirety. Tuba not have the submucosal layer, so that the fertilized ovum will invade epithelium and directly into the muscular layer. At the periphery of the zygote contained capsule that consists of trophoblast cells with high proliferation rate, which continues to invade and erode the muscularis layer underneath. At the same time, maternal blood vessels open and blood flows out into the space between the trophoblast or the surrounding tissue. Tubal wall is exposed to a zygote has only a very limited custody of trophoblast invasion, making it easy perforation occurs. Most ectopic pregnancies at 60-10 weeks of gestation. Some things that can happen to the products of conception: Products of conception and early death diresorbsi Abortion into the lumen of the fallopian Ruptured tubal wall Tuba abortion. Frequency of occurrence of tubal abortion depends on the site of implantation of the zygote. Abortion is most common in tubal pregnancy pars ampullaris, whereas rupture is more common in pregnancy pars isthmus. Direct result of the occurrence of bleeding is a disturbance of the relationship between the placenta, membranes, and the tube wall. If there is complete separation of the placenta, the products of conception can be removed through the tip of the fimbriae to the peritoneal cavity. At this time, bleeding is reduced and the symptoms gradually disappeared. Some persistent bleeding occurs during product conception was still in the tube. Blood will flow slowly into the peritoneal cavity and collected in the Douglas pouch retrouterina. When the tip of fimbriae have occlusion, fallopian tubes can terdistensi slowly by the blood, resulting in hematosalpink. Tubal rupture. Invasion of the products of conception can lead to tubal rupture. Generally cases of ectopic pregnancy ruptures in trimester I. When discovered the existence of tubal rupture in the first weeks of pregnancy, ectopic pregnancy tubal isthmus located in pars. Rupture may occur spontaneously or associated trauma such as coitus or bimanual examination. After the rupture, patients typically show signs of hypovolemia. In rare cases, young products of conception removed from the tube and implanted in the peritoneal cavity, getting adequate circulation of the organs around so that it can ultimately survive and thrive. However, generally the result of conception is still small will diresorbsi. If the size is larger, the conceptus can survive in the body and calcifies into lithopedion.

Clinical picture
Clinical picture of ectopic pregnancy varies depending on the presence or absence of rupture. Classic triad of ectopic pregnancy are pain, amenorrhea, and vaginal bleeding. In each patient woman in reproductive age, who came with complaints of amenorrhea and lower abdominal pain, should always consider the possibility of an ectopic pregnancy. In addition to these symptoms, patients may also experience vasomotor disturbances in the form of vertigo or syncope; nausea, breast feels full, fatigue, abdominal pain lower, and dispareuni. Can be also found signs of intraperitoneal bleeding irritating the diaphragm when quite a lot, in the form of severe cramps and pain in the shoulder or neck, especially during inspiration. On physical examination can be found pelvic tenderness, enlarged uterus, or a mass in the adnexa. But the signs and symptoms of ectopic pregnancy must be distinguished from Appendisitis, salpingitis, ruptured corpus luteum cyst or ovarian follicles. On vaginal examination, there is pain when the cervix is moved, Douglas pouch protruding and painful to touch. In general, patients showing symptoms of early pregnancy, such as pain in the lower abdomen, vagina uterus enlarged and flabby, which may be incompatible with gestational age. Tubes containing the products of conception becomes difficult because of soft felt. Pain is a major complaint. In ruptures, the pain occurs suddenly with a high intensity accompanied by bleeding, so patients can fall in a state of shock. Vaginal bleeding occurred the death of the fetus showed Amenorrhea is also an important sign of ectopic pregnancy. But some patients do not experience amenorrhea due to fetal death occurred before the next menstruation. In general, signs and symptoms of ectopic pregnancy are: Lower abdominal or pelvic pain, accompanied by amenorrhea or spotting or vaginal bleeding Abnormal Menstruation A soft abdomen and pelvis Changes in the uterus that can be pushed to one side by the mass of the pregnancy, or displaced due to bleeding. Can be found in the decidual cells of the uterine endometrium. Decrease in blood pressure and tachycardia occurs when hypovolemia. Pelvic mass Kuldosentesis. For the identification of hemoperitoneum characterized by long fluid mixed with blood clots or fluid mixed with blood.

Diagnosis
Diagnosis of ruptured ectopic pregnancy on the type of sudden did not experience any difficulty, but on the type of chronic or atypical can be difficult at all. In general, with a careful history and thorough examination of the diagnosis can be established. Menstruation usually too late for some time and sometimes there are symptoms of early pregnancy subjective. Lower abdominal pain, shoulder pain, tenesmus, can be expressed. Vaginal bleeding occurs after lower abdominal pain. On general examination, among others, found the patient in pain and looked pale. If there is bleeding in the abdominal cavity, signs of shock can be found. On the type does not suddenly lower abdomen only slightly bulging and tenderness. Some of the following symptoms may help in diagnosing ectopic pregnancy: Pain: pelvic or abdominal pain almost happened almost 100% of cases of ectopic pregnancy. Pain can be unilateral or bilateral, localized or diffused. Hemorrhage: Abnormal uterine bleeding, usually forming patches. It usually occurs in 75% of cases Amenorhea: Almost the majority of women with ectopic pregnancies who had filed for bleeding at the time they get a period, and they do not realize they are pregnant On gynecological examination, can be found signs of early pregnancy. Cervical movement causes pain, which causes the lower portion rocking pain. If the uterus can be palpated, it will be felt slightly enlarged and sometimes palpable tumor on the side of the uterus with a hard limit specified. Douglas pouch that stands out and the pain indicate hematokel retrouterina touch. The temperature sometimes rises, so that constrict the difference with pelvic infection. Examination of hemoglobin and red blood cell count is useful in establishing the diagnosis of pregnancy is interrupted, especially when there are signs of bleeding in the abdominal cavity. In the case of species not normally found sudden anemia. However, it must be remembered that a decrease in hemoglobin is only visible after 24 hours. Examination of pregnancy with -hCG levels examination urine memunjukkan positive results. Calculations indicate the presence of leukocytes in a row when bleeding occurs leukocytosis. To distinguish ectopic pregnancies from pelvic infection can be considered the number of leukocytes. The number of leukocytes that normally exceeding 20,000 indicate pelvic infection, and rarely encountered in cases of ruptured ectopic pregnancy. Positive pregnancy test showed positive results will help the diagnosis, but negative results do not rule out the possibility of an ectopic pregnancy because of the death of the conceptus and trophoblast degeneration can lead to decreased production of -hCG and lead to negative test results. Apart from clinical symptoms and laboratory tests, can also be dilated and scrapings to support the diagnosis of ectopic pregnancy, although this is not recommended anymore. Various reasons do not dianjurkannya dilatation and curettage include:

The possibility of a pregnancy within the uterus with an ectopic pregnancy Only 12-19% of ectopic pregnancies scrapings showed decidual reaction Changes in the form of endometrial Arias-Stella reaction is not typical for ectopic pregnancy. However, if the tissue removed along with the bleeding consisted of decidua without villi koriales, it may strengthen the diagnosis of ruptured ectopic pregnancy. Several investigations are useful in the diagnosis of ectopic pregnancy are: Kuldosentesis Kuldosentesis is a way of checking to see if there is blood in the Douglas pouch. This method is very useful in helping the diagnosis of pregnancy is interrupted. Do suction cavity with psuit Douglas, then see if there is blood ejected in the form:

Fresh red blood will freeze in minutes. This blood comes from an artery or vein is punctured Old blood brown to black that is not frozen, tau in the form of small clots. Blood, indicating hematokel retrouterina. Ultrasonography Ultrasonography is useful in the diagnosis of ectopic pregnancy. Ultrasound image of ectopic pregnancy varies, depending on gestational age, presence or absence of disorders of pregnancy (rupture, abortion), as well as many and duration of intra-abdominal bleeding. Definitive diagnosis is when the bag was found outside the uterine gestation in which fetal heart rate looks. It is only found in approximately 5% of cases of ectopic pregnancy. However, this result remains to be believed again that is derived from intrauterine pregnancies in cases uternus bikornis. Uterus size may be normal or slightly enlarged inconsistent with gestational age. Ekhogenik thickened endometrium as a result of decidual reaction. Uterine cavity is often filled with fluid exudate produced by decidual cells, which on examination is seen as a ring structure anekhoik called "pseudogestasional sac" or fake gestational sac. With a small sac size and irregular when compared with the actual picture of the pregnancy sac. Often found in areas adnexal tumor mass, the picture is very varied. It may seem that gestation bag still intact and contains the embryo, maybe just a ekhogenik mass with irregular borders, or mass of the complex which consists of parts and anekhoik ekhogenik. Mass of non-specific description may be difficult to distinguish from the picture caused by inflammation of adnexa, ovarian tumor, mass or endometrioma. In 15-20% of cases of ectopic pregnancy, there are no adnexal masses. Intra-abdominal hemorrhage caused by ruptured ectopic pregnancy also did not provide a specific, depending on the number and duration of the bleeding. The picture can be anekhoik mass in Douglas cavity which may extend up to the top of the abdominal cavity. If the blood clot has occurred, the picture is not a homogeneous mass ekhogenik.

Source: http://embryology.med.unsw.edu.au/Movies/usoundab/ectopic1.jpg Left ectopic Tube - The scan then moves to the left uterine tube (LT) where ectopic implantation has occurred. Also visible is the left ovary (OV L) and the uterus (UT). Laparoscopy Laparoscopy is used only as a last diagnostic aids for ectopic pregnancy, if the results of other diagnostic procedures assessment questionable. Through a laparoscopic procedure, the inner content of the tool can be assessed. Systematically assessed the state of the uterus, ovaries, fallopian, Douglas pouch, and broad ligament. The presence of blood in the pelvic cavity may complicate visualization tool content, but this is an indication for laparotomy.

Differential Diagnosis
Have a tubal pregnancy symptoms are similar to other diseases, especially with infection pelvic region. Some disorders that have symptoms similar to tubal pregnancy include: Salpingitis : Swelling and enlargement of bilateral tubal, high fever and a negative pregnancy test. Can be found purulent cervical lymph. Abortion (imminens or inkomplitus) : The dominant clinical symptoms are bleeding, generally occur prior to any abdominal pain. Bleeding red, not dark brown as in ectopic pregnancy. Abdominal pain is usually colicky and spasm (cramps). Uterus enlarged and flabby, there is dilatation of the cervix. Products of conception can be recognized from the examination of the vagina. Appendicitis : The soft areas located higher and is localized in the right iliac fossa. Swelling can be found when there is an appendix abscess, but is not located in the pelvis such as the swelling of the tube. Higher fever and the patient looks ill. Pregnancy tests were negative. Torsion of ovarian cyst : Palpable mass that is separate from the uterus, while the tubal pregnancy is generally felt attached to the uterus. Abdomen soft and may have fever due to intraperitoneal bleeding. Signs and symptoms of pregnancy may not be found but there is a history of recurrent attacks of pain that disappears by itself. Ruptured corpus luteum : It is very difficult to distinguish from tubal pregnancy, but the rupture of the corpus luteum is very rarely found.

Treatment
Patients who have been diagnosed with an ectopic pregnancy should be re-evaluated clinically. There are three approaches in the management of ectopic pregnancy, namely: If the patient is in a stable and reliable Expectant management Based on data taken from the American Family Physician 2000, at least 14 studies show that 68-77% of ectopic pregnancies has improved its own without intervention. However, there have been no sign or marker that can identify with certainty the subset of patients with selflimited travel, as well as the journey that ended in tubal rupture. At least one in four women with ectopic pregnancy decreased levels of -hCG, and 70% of this group showed success in the expectant management with close observation. Initial hCG levels are low also related a complete spontaneous resolution. Reported that -hCG levels below 1000 mIU / mL 88% success rate associated with the management of this. Expectant management can be an option for the management of: Patients with ectopic pregnancies are small (largest dimension less than 3.5 cm) -hCG levels are declining Patients with good compliance and accept the possibility of a ruptured tubal Medical Treatment First, management of ectopic pregnancy is limited to surgery. With the development of science, including the experience of the use of methotrexate, there was a revolution in the management of ectopic pregnancy. Selection of medical therapy compared to surgery based on a consideration to reduce the morbidity due to surgery and general anesthesia, tubal damage minimization, and minimization of funds and the need for inpatient care in hospitals. Early diagnosis of ectopic pregnancy allows for medical therapy as an option in the management of ectopic pregnancy. One advantage is to avoid surgery and its complications, preservation of tubal patency and function, as well as lower costs. The chemical agents have been investigated for medical treatment of ectopic pregnancy is a hyperosmolar glucose, urea, cytotoxic agents (methotrexate and actinomycin), prostaglandins, and mifeproston. As mentioned previously, the most studied agent is methotrexate, a folic acid antagonist

(antimetabolite chemotherapeutic agent) that are metabolized in the liver and excreted by the kidneys. Methotrexate works by inhibiting the synthesis of purine and pyrimidine bases by binding to dihidofolat reductase enzyme, so it can intervene in DNA synthesis and cell multiplication. Cells with high division rates most sensitive to methotrexate. By its nature, this drug works on trophoblastic tissue, and also have an effect on the buccal mucosa, gastrointestinal tract, bladder, bone marrow and skin. Methotrexate has long been known to be effective in the treatment of leukemia, lymphoma, and carcinoma of the head, neck, breast, ovarian, and bladder. Methotrexate is also used as an immunosuppressive agent to prevent graft vs. host reaction, for the treatment of psoriasis and rheumatoid arthritis. Side effects related to the use of methotrexate can be divided into two, namely due to drug side effects and effects of therapy. Drug side effects include nausea, vomiting, stomatitis, diarrhea, gastric distress and dizziness, temporary increase in liver enzymes. At higher doses may cause bone marrow suppression, dermatitis, pleuritis, pneumonitis, and alopecia, but rarely occurs in doses for the treatment of ectopic pregnancy. Therapy with methotrexate also cause complaints such as abdominal pain increased, elevated levels of -hCG on days 13 of therapy, as well as spotting or vaginal bleeding. Although methotrexate has the potential to cause serious toxic side effects, low doses of methotrexate used in patients with ectopic pregnancies generally cause only a mild reaction and self-limited. Therefore, if the diagnosis of ectopic pregnancy has been established and the ectopic mass has the greatest dimension of less than 3.5 cm, methotrexate therapy may be considered. In addition, -hCG levels should be considered in patients before therapy. A study showed that -hCG levels of more than 1500 mIU per mL was associated with risk of treatment failure is higher. The same study also showed that patients with -hCG levels of more than 5000 mIU per mL are generally not responsive to methotrexate therapy. complication Ectopic pregnancy complications can occur secondary to misdiagnosis, late diagnosis, or management of the approach. Failure diagnosis quickly and accurately may result in tubal or uterine rupture, depending on the location of the pregnancy, and this can cause massive bleeding, shock, DIC, and death. Complications arising from the surgery include bleeding, infection, damage to surrounding organs (bowel, bladder, ureters, and major blood vessels). In addition there are also complications related to anesthetic action. prognosis Death due to ruptured ectopic pregnancy tend to fall with early diagnosis and adequate

blood supply. In general disorder that causes bilateral ectopic pregnancy. Some women become sterile, having had an ectopic pregnancy, or may have an ectopic pregnancy in the fallopian other again. Recurrent ectopic pregnancy rates were reported between 0-14.6%. The possibility of a normal pregnancy after an ectopic pregnancy may be lower than normal, but depending on the cause of ectopic pregnancy and other medical history. When the tube is maintained, the chances of normal pregnancy up to 60%. Baru! Tahan tombol shift, klik, dan tarik kata-kata di atas untuk menyusun ulang. Singkirkan

complication
Ectopic pregnancy complications can occur secondary to misdiagnosis, late diagnosis, or management of the approach. Failure diagnosis quickly and accurately may result in tubal or uterine rupture, depending on the location of the pregnancy, and this can cause massive bleeding, shock, DIC, and death. Complications arising from the surgery include bleeding, infection, damage to surrounding organs (bowel, bladder, ureters, and major blood vessels). In addition there are also complications related to anesthetic action.

prognosis
Death due to ruptured ectopic pregnancy tend to fall with early diagnosis and adequate blood supply. In general disorder that causes bilateral ectopic pregnancy. Some women become sterile, having had an ectopic pregnancy, or may have an ectopic pregnancy in the fallopian other again. Recurrent ectopic pregnancy rates were reported between 0-14.6%. The possibility of a normal pregnancy after an ectopic pregnancy may be lower than normal, but depending on the cause of ectopic pregnancy and other medical history. When the tube is maintained, the chances of normal pregnancy up to 60%.