EXTRA UTERINE OR ECTOPIC PRENANCY
2 likes1,234 views
This document discusses various types of ectopic pregnancies. It begins by defining an ectopic pregnancy as implantation outside the uterine cavity, most commonly in the fallopian tubes. It then discusses the signs, symptoms, risk factors, diagnosis and treatment of tubal, abdominal, ovarian, angular, cornual and cervical ectopic pregnancies. Medical treatments include methotrexate, while surgical treatments include laparoscopy or laparotomy to remove the ectopic pregnancy. Complications can include rupture and internal bleeding. The document provides detailed information on the locations, causes and management of different ectopic pregnancy types.
EXTRA UTERINE OR ECTOPIC PRENANCY
- 1. ECTOPIC PREGNANCY MRS.ELIZEBETH RANI , READER, VHS- MACCON
- 2. Introduction An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow.About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes.
- 4. An ectopic pregnancy is one in which the fertilized ovum is implanted & develops outside the normal uterine cavity.
- 5. Factors The factors causing this are- Chronic inflammatory diseases of the tube. Developmental defects of the tube. Distortion of the tube. Iatrogenic. Tubal spasm.
- 6. Sites Of Implantation Angular Primary Secondary Intraperitonial Extra-peritoneal
- 7. Tubal pregnancy The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopics), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%).Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur.
- 8. Causes Of Tubal Pregnancy High Risk Factors Previous ectopic pregnancy Women who have had one ectopic pregnancy face a 10% chance of having another. Abnormal fallopian tubes Anatomical abnormalities of the fallopian tubes can make implantation in the tubes much more likely than in women without tubal abnormalities. Maternal DES use The drug DES (or diethylstilbestrol) has been shown to cause congenital abnormalities of the uterus in girls born to mothers who took the drug during pregnancy.The fallopian tubes in these girls can also be formed in a way that makes ectopic pregnancy more likely. Doctors stopped prescribing DES to pregnant women in the early 1970s. Endometriosis The disorder increases the chance of scar tissue and adhesions that interfere with the ability of the fertilized egg to reach the uterus. History ofTubal Surgery Having had surgical procedures involving the fallopian tubes, such as tubal ligation, can make an ectopic pregnancy more likely. Use of IUD device
- 9. Causes Cont.. Moderate Risk Factors History of sexually transmitted infections or pelvic inflammatory disease Sexually transmitted diseases can lead to pelvic inflammatory disease. History of infertility Some medical factors that cause infertility might also make ectopic pregnancy more likely, and researchers also believe that the drugs commonly used to treat infertility might also increase ectopic pregnancy risk. Multiple sexual partners The reason why having multiple sexual partners increases risk is most likely due to an increased chance of acquiring a sexually transmitted infection. Exposure to cigarette smoke The greater the exposure to smoke, the higher the risk for ectopic pregnancy. One study found that women who smoked 20 or more cigarettes per day were almost four times more likely to have an ectopic pregnancy than women who never smoked. Low Risk Factors Douching Some doctors think that douching could potentially cause abnormal bacteria present in the vagina to ascend higher in the reproductive tract and lead to inflammation of the tubes. Past abdominal surgery In one study, women who had an appendectomy for a ruptured appendix had an increased risk of miscarriage. Age Risk of an ectopic pregnancy appears to increase for older moms, with moms over 40 having the highest risk.
- 11. Clinical Features ACUTE (RECENT) UNRUPTURED SUB-ACUTE /CHRONIC /OLD
- 12. ACUTE ECTOPIC ( 30 % ) LESS COMMON : Associated with tubal rupture or tubal abortion with intraperitonel haemorrhage. The four important symptoms - ◦ Amenorrhoea (no periods) of short duration – 6 – 8 weeks ◦ Severe abdominal pain – colicky pains, Causes of pain : 1. Distention of the tube by blood 2. Colic of the tubal muscless 3. Peritoneal irritation Pain may be referred to the shoulder due to diaphragmatic irritation.
- 13. ◦ Cont…… ◦ Vaginal bleeding : slight,sanguinous or dark coloured & usually continuous. ◦ Feeling of Nausea, vomiting and fainting attacks even of syncope may be present. On examination ◦ Patient is extremely pallor. ◦ features of shock : evidenced by the rapid & feeble pulse, fall in BP & cold & clammy extremities. ◦ Abdomen Examination : Tense, timid & tender and painful to touch. Tenderness limited to the lower abdomen
- 14. Cont…… Bimanual Examination: more intraperitonal bleeding due to manipulation. Vaginal mucosa – blanches white Uterus seems normal in size or slightly bulky Extreme tenderness on fornix palpation or on movement of the cervix ( 75 % ). No mass is felt through the fornix. the uterus floats as in water.
- 15. UNRUPTURED TUBAL ECTOPIC Symptoms : ◦ Presence of delayed period or spotting with features suggestive of pregnancy. ◦ Uneasiness on one side of the flank which is continuous or at times colicky in nature. Signs :
- 16. CHRONIC OR OLD ECTOPIC ◦ May be of slow onset. Symptoms of- ◦ Ammenorrhoea of short duration. ◦ Abdominal pain may have been an severe initially, from which patient recovers and has dull aching pain. ◦ Scanty bleeding from vagina. ◦ Other symptoms like frequency of urine, fever etc. On examination patient looks sick, varying degree of paleness is present, features of shock are not there, rise of temperature, abdomen is painful to touch. On internal examination a mass is felt.
- 18. DIAGNOSIS Adominal Examination Plvic Examination Ultrasound Examination Blood Examination Culdocentesis Laparoscopy Dilatation & curettage laparotomy
- 19. Tubal Pregnancy : The tubal pregnancy ends in following way- Formation of some thing called a tubal mole Tubal abortion through fimbrial end (one end of the tube). Tubal rupture.
- 20. Salpingotomy for unruptured ectobic pregnanccy
- 21. Treatment Medical Surgical Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment since at least 1993. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic mass > 3.5 cm. If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy).The first successful surgery for an ectopic pregnancy was performed by Robert LawsonTait in 1883.
- 22. COMPLICATIONS The most common complication is rupture with internal hemorrhage which may lead to hypovolaemic shock. Death from rupture is rare in women who have access to modern medical facilities.
- 24. DEFINITION An abdominal pregnancy is a form of an ectopic pregnancy where the pregnancy is implanted within the peritoneal cavity outside the fallopian tube or ovary and not located in the broad ligament. While rare, abdominal pregnancies have a higher mortality rate than ectopic pregnancies in general but, on occasion, can lead to a delivery of a viable infant. Incidence 1% of ectopic pregnancies in the United States are abdominal or about 10 out of every 100,000 pregnancies. Nigeria places the frequency in that country at 34 per 100,000 deliveries. Ectopic pregnancies occur in about 1 out of every 60 pregnancies. Over 40 percent of ectopic pregnancies occur in women between the ages of 20 and 29.
- 25. Anatomy Implantation site Peritoneum outside of the uterus The rectouterine pouch (culdesac of douglas) Omentum, bowel and its mesentery, mesosalpinx Peritoneum of the pelvic wall and the abdominal wall The growing placenta may be attached to several organs including tube and ovary. Rare other sites have been the liver and spleen. giving rise to a hepatic pregnancy or splenic pregnancy, respectively.Even an early diaphragmatic pregnancy has been described in a patient where an embryo began growing on the underside of the diaphragm.
- 26. IMPLANTATION Primary implantation Secondary implantation A primary abdominal pregnancy refers to a pregnancy that implanted directly in the abdominal cavity and its organs Secondary implantation which means that it originated from a tubal (less common an ovarian) pregnancy and re-implanted.
- 27. Abdominal pregnancy Symptoms Signs 1. H/o recurrent attacks of abdominal pain with vaginal bleeding in early pregnancy. 2. Minor ailments of normal uterine pregnancy are often exaggerated. 1. Abdominal swelling with foetus is felt superficial,tender,on one side of midline ; foetus is easily palpable. 2. Braxton hicks contraction absent. 3. FHS may be present or absent. 4. Foetus lies above brim in intraperitoneal pregnancy , remains low in pelvis in intraligamentary pregnancy.
- 28. Diagnosis Sonography Outside an empty uterus, there is no amniotic fluid between the placenta and the fetus, no uterine wall surrounding the fetus, fetal parts are close to the abdominal wall, and the fetus is in abnormal lie. MRI Elevated alpha-fetoprotein levels Treatment Potential treatments consist of surgery with termination of the pregnancy (removal of the fetus) via laparoscopy or laparotomy, use of methotrexate, embolization, and combinations of these. Complication 1. Placental hemorrhage 2. Fetal death 3. Fetal malformation 4. Infection of gestational sac
- 30. Introduction Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary.Typically the egg cellis not released or picked- up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra- abdominal bleeding and thus may become a medical emergency. Incidence Ovarian pregnancies are rare Only about 0.15-3% of ectopics occur in the ovary. The incidence has been reported to be about 1:3,000 to 1:7,000 deliveries[
- 31. Etiology and pathology Etiology of ovarian pregnancy is unknown suggested that patients who undergo IVF therapy are at higher risk for ovarian pregnancy. An ovarian pregnancy is usually understood to begin when a mature egg cell is not expelled or picked up from its follicle and a sperm enters the follicle and fertilizes the egg, giving rise to an intra follicular pregnancy . It has also been debated that an egg cell fertilized outside of the ovary could implant on the ovarian surface, perhaps aided by a deicidal reaction or endometriosis .Ovarian pregnancies rarely go longer than 4 weeks; nevertheless, there is the possibility that the trophoblas finds further support outside the ovary and thus may affect the tube and other organs .In very rare occasions the pregnancy may find a sufficient foothold outside the ovary to continue as an abdominal pregnancy, and an occasional delivery has been reported.
- 32. Diagnosis Ultrasonography pelvic examination : A unilateral adnexal mass may be found Symptoms Abdominal pain and, to a lesser degree Vaginal bleeding during pregnancy Patients may present with hypovolemia or be in circulatory shock because of internal bleeding. Spiegel berg's criteria in (1878 ) diagnosis of ovarian pregnancy : The gestational sac is located in the region of the ovary. The gestational sac is attached to the uterus by the ovarian ligament. Ovarian tissue is histologically proven in the wall of the gestational sac. The oviduct on the affected side is intact (This criterion, however, holds not true for a longer ongoing ovarian pregnancy).
- 33. Management Traditionally, an explorative laparotomy was performed Once the ovarian pregnancy was identified, an oophorectomy or salpingo-oophorectomy was performed, including the removal of the pregnancy. Today, the surgery can often be performed via laparoscopy Ovarian pregnancies have been successfully treated with methotrexate
- 36. Definition ◦ When the implantation occurs in the angle (or ) cornu of the uterus overlying the tubal ostium , it is called ‘ angular pregnancy’. Clinical features : 1. Pain on one side of midline 2. Astmmetric enlargement of uterus 3. Abortion occurs through uterine cavity 4. Retained placenta occurs
- 38. An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside of the uterine cavity in that part of the Fallopian tube that penetrates the muscular layer of the uterus . The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.
- 39. Cornual pregnancy Pregnancy occurring on the rudimentary horn of a bicornuate uterus. Horn does not communicate with uterus. Rupture usually occurrs at second trimester of pregnancy. Diagnosis : Usually made on rupture. Management : Rudimentary horn is removed. If pedicle is wide , hysterectomy may be needed.
- 40. Cervical pregnancy Pregnancy implants on cervical mucosa below internal os. It may may be due to rapid passage of the fertilized ovum for fertilization of the ovum after it reaches the cervical canal. It is rare & seldom lasts beyond the 20th week. Signs &symptoms : 1. Painless bleeding soon after the time of implantation. 2. Palpation of the cervical mass with distention & thinning of the cervical wall. 3. Partial dilatation of the external os & a slightly enlarged uterine fundus. Treatment : Removal of the products of conception by curettage & packing of the cervical canal ( or ) total abdominal hysterectomy.
- 41. REFERENCE Bobak, I.M., & Leonard, D. (1995). Text Book Of Maternity & Gynecologic Care :The Nurse & The Family (4th ed.). Mosby Publication. Diane., Fraser., & Margret. (2003). Text Book for Midwives (14th ed.). Elsevier Publishers. Dutta, D.c., & Hiralal Konar. (2013). Text Book of Obstetrics (7th ed.). Jaypee Brothers Medical Publishers. Elizabeth, M (2014). Midwifery for Nurses (2nd ed.). Sathish Kumar Jain Publishers. Jacob, A. (2008). A Comprehensive textbook of Midwifery & Gynecological Nursing (4th ed.). Newyork: Jaypee Brothers Medical Publishers. Kumari Neelam., Sharma Shivani., & Gupta Preethi. (2010). A Text Book of Midwifery and Gynecological Nursing. Ladewig, L. Maternal & Newborn Nursing (3rd ed.). Cumming Publication. Nurse Midwifery Helen Varney (2nd ed.). Parulekar, V. S. Textbook for Midwives. (2nd ed.). Mumbai: Vora Medical Publications. Raman, A. V. (2014). Maternity nursing (1st ed.). Wolters kluwer publishers. Richa S. Snapshort In Obstetrical & Gynaecology. Jaypee Brother’s Medical Publisher.