igi[ fi-:rFl;ij+ ri:lij+jiiii.illj.i :!1::ii:li! ECt$plC PregnAncy llij:.:rjl:":l :1 ni:,1.i:.i ;;1;; '.'' ,r:: ;.; :-::. ,., ::: and Abortion Ectopic Pregnancy Spontaneous Abortion ,.,...ll.i'..;FetalDeath. Abortion The student should understand that ectopic pregnancy is a leading cause of maternal morbidity and nror- tality, and that early diagnosis and intervention-can p."."ru" fertility and save f t"r. sira""ir"n""'j O" able to define the types of spontaneous abortion (spontaneous, recurrent, incompfete, and septic) and explain their diagnosis and management, including the differential diagnosis of bleeding in the first trirnester. Students should also be able to explain the indications, rfsks and benefits, and means for elec- live and therapeutic'labortion. Students should be able to evaluate and manage fetal death in each trimester, including appropriate counseling for the parents, g g1\ :: i:.'T'r,} r' {.- 5r ia: il# il'""i lr,$ i"" Y tissue can then either regress or reimplant in the abdomi- ual cavity. a.tbal rupture is associatecl u,ith sienificant '.,r ectopic {}r extrauterine pregnanc}'is one in ll,lrich intra-a bdonrinal hemorrharqc, clften necessitatins surgical "-." biastoc'r.st irnplanffi nr, r'here other than rhe cndrlrnc- inten endon. :-,rl lining of the uterine ca\riry. As slrr:\{ n in Figure 1 "i. I , i'j'il of ectopic presnancies irnplant in the fellerpian tube, (-)tirer- :rir 80% occurring in the aiTlpullar"rt scgnrent. $.F,,&,'E-rai tg*g,u"l:=?{ +1 g;g,,!' x.\- i.: -ffi}:*;." Far:'g"s"}g{-5 -'Lttions include, but are not lirnitecl to, dre oval-\,', cervir, eppreciation "'t1 abclomen. ln solrle fcrrtn, the1, account for 1.3-7r, ta 29b ;tn of risk factors for ectcpic pregnanc\-r leircls to a timeltr diagnosis r,vith impror.ecl rnatern:rl suraii\rAl anLl 'r'e ported pregnancies in the Llnited Stirtes. In the past) ectopic pregnarlc.l,- was life-threafeniug. f-utlrre rcpro(lucti ve poten tial. : irlier diagnosis rnacle possillle br. the rle\\,- ahilin tri detect Inflarnrnation has hccn implicilte(l in the role cf tubal tJamage that predisposes - c B-sulnrnit of hLrman chorionic gonedotropin (htlG), to ectopic pr"egnancies. Inflarn- .,nrbined rvith high-resoludon trnrlsvaejnal son(xrrirplrti ltlat()nr processcs, such as salpingitis and salpingrtis isth- i \-S). has reducecl this threrrt. ltierrertheless, ectopic: mica nodosa' ma],'also pla)' a role. Acute pathol{.}S,r, suci} :-;,rgrlancies rernilin an irnportant cfluse of morbiditlr and as chlamydial infection, caubes intraluminrll infl$nrmil- ':i-irtaliry in dre United Stetes. The incidence of ectopic tion and sutrsecluent frbrin deposition u.ith tutral scnn'ing. -.,:'rq'narty has increasecl ronsistent rn'ith the rise in clrla- I)espite nesatiie cnlnircs, per-sistent chIarnr.diaI :rntig-e;s , .,-.-dial infections. crln trigger r clelir)'ed hrpersensitjviti' relctiun u"ith corl- tinuecl,scarrin g. !\,''hereas endotoxin-proclucinq -\'ei-il ru'r# *,".; ii g'otron'lt()(ttt causes virulent pe lvic inflarntlratir)n il.ith a rapid * fl-ic} *;= i il*t*r:i{:'' ffrm*..*; Frilv $- d clinical onset, chlanrrclial inflanrrniltcry resL)r)nse is indo- "'llthout intervention, the nanrral course of a tul:ai preg- lent and peaks at 7 to 14 davs. inc\r can lead ro ftrbal abortion, nrbal rupnu'e, ol' sp()nta- Altlrough pregnarlc],r atter sterilizrttion is t'are. rvhen it ,,.olrs resolution. Tuhal abortion is the expulsion oi rloes occ:ur, there is a sutrstantial risk thar the pregnanc,\r :.,i':ducts of-conceptiorr thr*ush the firnbriater{ encl. l]lhis u'ill he ectcpic. ,l'dost forrns r:f contraception decrc*se dre ,cS .S -4 i4+ f i 4? Cbstetrics anC Gr,.er5 ,3gi, F:i':ilF?ri I \l \l _\* 1:,:4 13 - lncics-cel! I\._lUtv uv ,:. Natural conosptian Ccnception after ART types ct ecicnjc c.*.1^3-i. lsthmic hir inr-:-..^,. i ?* :tq t-'=-{ Cornual Cornual *J v Er vis-s luDal Tubat 'u*r'- = 12% QROA I (interstitial) (interstitial) PAAFn A 4 rJYI llJ tiltli]iitF*\ I -70J 82/o t \,lJt VVri;4. t v .v b: v + ? v* / Z*ia tla ,, Anrpullary ,.t ' ,, I .,,i.;'i..:*.,, Ampultary r''@"t ''' t,t :;l'i'::,, i,t" B0% r_, -,, S3% .,,,,,i,i!! ''' , ':il-.,, ,/ .i,:r'- .:;..ltt 6/,/ Fimbrial 6"h Abdominat 1*2jrL Cervical Cervical 0" 1 5?'. 1.5% l:,=irr:,:! ' ,. '11:.iilui;1,., .ii:l:r:t:j.l 13 Ectopic pregnancy :i:.:ltd:-l and ,Abortion i .t;- l:l::.i*.,. r: i:::: i:tr:i::r' :::li:iri'..:. rjrr+ti : qregnancies have fi,orlnftl doubling tinres. Der,-iarion fi:om ri.::!:t:,: ,: ::,:l"l:i I rh i p e t ffi e rn h o u I d ra i s e s u s p i c i o rr' fn ; ; .s ;,; ;", -*" ;h ;; ;; n?t_ proceeding normally, inclucling ..iopln pregnarlcv, ugh in.nltgtrop,iutely,isirtg '4lrho seruti * cc trvoti' rtt ggrs.tt .:,,:E),. F- (but '::;,!1ir do nat r{iagnose) nn nhnarrirrl pr'€gr?ilrrry, r o *' I they-'' do nrstTirrr- rtfi its lomtioi ::r ',r,ti':', ' ::j:i: A key adjuncr r'inli':.' ro serial quanriratir.e levels of hcG is ' '1,,:i::! : ,,i:r: pelvic ulmasonosraphy (I.-ig. 13,2). Ffigh-resalutian *1* ' , :t',:1.: ::: 't:.::.a:. trils#nography has revolutionized the cLinical manase- tllent of llrCItren r.l'itl'r a suspected ectopic presnair.. ,, :jiiriri. , : Llsing T\is, a gesrarional L)J *u* is usuailrr uiribi* #;-;; At i t F ':'i.i':l:: 4/: and 5 w'eeks fi:om the last ffienstrual pcriod, the yolk ' :rilll' ' l f |ffiLJRffi i3"3" Ectopic pregnancy with an extrauterine ges- tational sac containing a live embryo, {A) Coronal transvagi- nal view of the right id.r**u demonstrates an extrauteriie sac (arrows) containing an embryo (calipers). (B) Sagittal trans- vaginal view of the uterus reveals no evidence of a gestational sac. (From Doubilet PM, Benson CB. Atlas of U/tiasound in Obstetrics and Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:319.) t d$4 Obstetrics and Gynecoiogy sac appeafs befne'en 5 ,rntl ii \.r tcl'S. *n{1 a futrrl pole_oi*l cardiac actirrit,ri is hrsr el*icctrii itt iyi tn 6 r'r.eeks Wi*l - transabclcmin u l sr i ir o r-r;r pir r iir c s* st ftr(:rllrcs irre vi sual i z*cl slightlv lirter. Erch iirr-r -,-itir in Ilurst define il F-htl{) dis- crilninatorr- r'alue* thri ii ** ltlu.'er. limit of hfiG ei r,q,hich sn e \;l iiti::ul' t'rtt rcli;tllh' r,isualize pregnancy otl -ir trltrtso Lrg..1. l r rt ir r r-c icnsitive tlilnsvrlginal ttltrasollogri]* ph]- stroui.-l .i:l'",i. fitu pfc{ttrittcy ltv the tirttt the hC(i ]evel ii}f;ll ,u' ', i'-,r i 1i--,'1. Transabdolnina] ulmason*gr*pirv ir .ir* slr*ui.1 ,;irjc rr] i.leirtit"r'rrn intrtruterine gestaficxr ttv the tirnc lirc i:{-G lcr-el re,rches 5000 to 6f100 IU/L. Accurate riirlgr:i,l:is i'i- su:nogr*phl.' is three titles more liliely if tlre ir:irjr:: *-]:{.{;ler-el is alrove this r.aiue.'tr'h._ absent-e eif i,tui':l.- prr"cg-lttj'tcl,- rvidr [3-h{]f; lerrels ab*r'e thc discrir:ri- 11:1rq-irr- r-':1ue sienifieS an ahnarmal pregnfinc\''-ectolllC' cr:lnpletecl iltlor-tion. i:lcri:::plete ahortir:n, clr _resolving {-:it-c l:rusl tle taken to ditferentiate tr1t1'een a uterfute gel- lrti*n and il pseudogestational sac. This rtne*la,ver stc is ..irr lcsr:lt ni *,-, intiac*vitary fluid collcctior-l c'rused bv sl,;ughilg of the rlecidga wpicalh' sitrtatecl in dre rnittline *f tlie gterine carrirt,, rn hereas a normal gesr;ld*nal sac is cccentricnrll]- lo.tted (Fig. 1 3 "3) Serum pt*g*rterone concentriltion has alsr: heen used ilS tt Scfeenll llg test for ectopic prcqnarlcv. There' is ntinimal r-ariirtir:nitr5flruI]1progesteroneConCenn.ailoI r befu'een 5 rnd l0 rvceks' gestirtion, thus a single value is suflicient. A serum proqesterone level of <5 ng/rnl has been used to i fi c i ti'- i rlen ti h a non l'i a ble preqn il nc\,' s'i th lt ear-perfcc t spec Uter Bladder - Bowel f i#i.jruff 1;T,"t" Pseudogestational sac. Sagittal transabdam- inal view of the uterus demonstrates a pseudogestational Blood ln within the uterus. D^oubilet, PM, sac, a collestion of fluid iFrom cul-de-sac Benson CB. Atlas of lJltrasound in Obstetrics,.a"d {{tit:Fgl piriladelphia, PA: l-ippincott Williams & Witkins; 2003:320.] Culdocentesis. 13 Ectopic Pregnancy and Abortion i -en Absmf r*ts: Sneestfeeding cverl or lahoratary evidence of irnmunodeficiency Afcoh*lism, atcchaiic {iver' *ir*ir;,-2 ;;;;;; *rr.onlirv'|r'v liverdiseasg Presxisting blaod dyscr"asias, such as bsne marrow hypoplasia, leukopenia, or thrombocytopenia, or significant anemia Known sensitivity to methctrexate Active pulmonary disease Peptic ulcer disease Hepatic, renal, or hematologic dysfunction ffie$mtivs: Gestational sac greater than 3.S cm Embryonic _' cardiac motion i :*4!r+i:ri-_*r44?:r*-:i+! _,fi a Arv:ii5.-r4rb_J.re+ i 4S Obstetrics and GYnecology Fiffii.-iHA t 3.5. Surgical manage- ment of ectoPic Preglan.cy' {A} Site of linear incision for lin- ear salpingostomY. (Bi Linear in- cision. (C) Segmental resection' {D) Tubal reanastomosis. tA) tts) #.:.:;i,i:,.:or , tc) {D} iIl:M i 4ffi Obstetrics and Gynecofogy tg Ectopic Pregnancy and Abartion 150 Obstetr:ics and Gynecology _" usually preients with fever, pain, a tender utenrs, and mild + bleeding, Oral antibiotics and andpyredcs are usually suf- Postabortal sytdrome develops u,'hen the uterus fails *aia *it*infeclffis''if,*ts *** .-1..,, r,trr:,r.,,:''.t,-::.t,.a,t.,;l:,,;,,i.,,,: eted **,0*'t the uteflls (incomplete aborcion), t repeat suction curet- i#** * in ivefther;p#e't*$# tag;e is necessaq'.