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: CLASSIFICATIONTubal (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 COMPONENTSEctopic 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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