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Pembimbing
Coass
Sites of implantation of 1800 ectopic pregnancies from a 10-year populationbased study. (Reproduced,
with permission, from Cunningham FG, Leveno KJ, Bloom SL,
et al (eds). Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill; 2010. Data from
Callen PW (ed). Ultrasonography in Obstetrics and Gynecology. 4th ed. Philadelphia,
PA: WB Saunders, 2000; p. 919. Bouyer J, Coste J, Shojaei T, et al: Risk factors for ectopic pregnancy: A
comprehensive analysis based on a large case-control, populationbased study in France. Am J
Epidemiol 157:185, 2003.)
There has been a marked increase in both the absolute number and rate of ectopic
pregnancies in the United States in the past two decades.
Reasons for Increased Ectopic Pregnancy Rate in the United States
1. Increased prevalence of sexually transmitted tubal infection and damage.
2. Earlier diagnosis of some ectopic pregnancies otherwise destined to resorb
spontaneously.
3. Popularity contraception predisposes failures to be ectopic.
4. Use of tubal sterilization techniques that increase the likelihood of ectopic
pregnancy.
5. Use of assisted reproductive techniques.
6. Use of tubal surgery, including salpingotomy for tubal pregnancy and tuboplasty
for infertility
classification
95 percent tuba;
fimbrial
ampullary,
isthmic, or
interstitial tubal pregnancies
TubaL Pregnancy
Fertilized ova may develop in any portion of the oviduct,
giving rise to ampullary, isthmic, or interstitial (cornual)
tubal pregnancies. Te ampulla is the most frequent site
of tubal ectopic pregnancies, with interstitial pregnancy
accounting for only about 2 percent of all tubal
gestations.
Risk
Abnormal fallopian.
previous ectopic pregnancy10%
tubal infection Salpingitis
Congenital fallopian tube anomalies.
use of ART (assisted reproductive technologies)
Smoking
contraceptive method failures
Clinical Manifestations
delayed menstruation, pain, and vaginal bleeding or spotting.
tubal rupture lower abdominal and pelvic pain that is frequently described as sharp, stabbing, or tearing.
Abdominal palpation Tenderness
uterus may be pushed to one side by an ectopic mass
Symptoms of diaphragmatic irritation
pain in the neck or shoulder,
Multimodality Diagnosis
miscarriage, infection, degenerating or enlarging leiomyomas, molar
pregnancy, or round-ligament pain.
Adnexal disease may include ectopic pregnancy; hemorrhagic,
ruptured, or torsed ovarian masses; salpingitis; or tuboovarian abscess.
physical findings, transvaginal sonography (TVS), serum -hCG level
measuremen
In pregnancies without these expected rises or falls in hCG levels, distinction between a nonliving intrauterine
and an ectopic pregnancy may be aided by repeat hCG level evaluation (Zee,2013).
Serum Progesterone
A single serum progesterone measurement may clarify the
diagnosis in a few cases (Stovall, 1989, 1992b).
A value exceeding 25 ng/mL excludes ectopic pregnancy with
92.5-percent sensitivity (Lipscomb, 1999a; Pisarska, 1998).
Conversely, values below 5 ng/mL are found in only 0.3 percent
of normal pregnancies (Mol, 1998).
Thus, values < 5 ng/mL suggest either a nonliving uterine
pregnancy or an ectopic pregnancy.
Transvaginal Sonography
Endometrial Findings.
During endometrial cavity evaluation, an intrauterine
gestational sac is usually visible between 4 and 5 weeks.
The yolk sac appears between 5 and 6 weeks, and a fetal pole
with cardiac activity is first detected at 5 to 6 weeks.
In contrast, with ectopic pregnancy, a trilaminar endometrial
pattern can be diagnostic
Anechoic fluid collections, which might normally suggest an early intrauterine gestational
sac, may also be seen with ectopic pregnancy. These include pseudogestational sac and
decidual cyst.
First, a pseudosac is a fluid collection between the endometrial layers and conforms to the
cavity shape. If a pseudosac is noted, the risk of ectopic pregnancy is increased.
Second, a decidual cyst is identified as an anechoic area lying within the endometrium but
remote from the canal and often at the endometrial-myometrial border.
These two findings contrast with the intradecidual sign seen with intrauterine pregnancy.
This is an
early gestational sac and is eccentrically located within one of the endometrial stripe
layer
Adnexal Findings.
The sonographic diagnosis ofectopic pregnancy rests on visualization of an adnexal
mass separate from the ovary.
If fallopian tubes and ovaries are visualized and an
extrauterine yolk sac, embryo, or fetus is identified, then an ectopic pregnancy is
clearly confirmed.
hyperechoic halo or tubal ring surrounding an anechoic sac can be seen.
Alternatively,
an inhomogeneous complex adnexal mass is usually caused by hemorrhage within
the ectopic sac or by an ectopic pregnancy that has ruptured into the tube.
Hemoperitoneum
In women with suspected ectopic pregnancy, evaluation
for hemoperitoneum can add valuable clinical
information. More commonly, this is completed using
sonography, but assessment can also be made by
culdocentesis. Sonographically, hemoperitoneum is
anechoic or hypoechoic fluid. Blood initially collects in
the dependent retrouterine cul-de-sac, and then
additionally surrounds the uterus as it fills the pelvis.
Laparoscopy
Direct visualization of the fallopian tubes and pelvis by
laparoscopy offers a reliable diagnosis in most cases of
suspected ectopic pregnancy.
There is also a ready transition to definitive operative
therapy, which is discussed subsequently.
Treatment Options
options for ectopic tubal pregnancy treatment include
medical and surgical approaches.
Medical therapy traditionally involves the antimetabolite
methotrexate. Surgical choices include mainly
salpingostomy or salpingectomy.
Medical Management
Regimen Options
Surgical Management
Laparoscopy is the preferred surgical treatment for ectopic
pregnancy unless a woman is hemodynamically unstable.
ruptured tubal pregnancies or interstitial pregnanciescan
safely be managed laparoscopically by those with suitable
expertise.
Before surgery, future fertility desires of the patient should
be discusse.
Salpingostomy
This procedure is typically used to remove a small
unruptured pregnancy that is usually < 2 cm in length
and located in the distal third of the fallopian tube.
Natale and associates (2003) reported that serum -hCG
levels > 6000 mIU/mL are associated with a higher risk of
implantation into the muscularis and thus with more tubal
damage.
INTERSTITIAL PREGNANCY
These pregnancies implant within the proximal tubal
segment that lies within the muscular uterine wall.
Risk factors are similar to others discussed for tubal
ectopic pregnancy, although previous ipsilateral
salpingectomy is a specific risk factor for interstitial
pregnancy.