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ECTOPIC PREGNANCY

(English Case)

Presented By :
dr. Wahyuridistia Marhenriyanto
Resident Of Obstetrics dan Ginaecology

Guidance :
dr. Hj. Ermawati, Sp.OG (K)

OBSTETRICS AND GYNAECOLOGY MEDICAL DEPARTMENT


FACULTY OF ANDALAS UNIVERSITY
DR. M. DJAMIL CENTRAL GENERAL HOSPITAL PADANG
2017

TABLE OF CONTENTS

1
TABLE OF CONTENTS .............................................................................. i
LIST OF PICTURE .................................................................................... ii
CHAPTER I PREFACE .............................................................................. 1
CHAPTER II CASE REPORT .................................................................... 3
CHAPTER III ECTOPIC PREGNANCY ................................................... 11
A. Definition ............................................................................................ 11
B. Risk Factor .......................................................................................... 12
C. Sign and Symptoms ............................................................................ 13
D. Multimodality Diagnosis ..................................................................... 14
E. Treatment Options ............................................................................. 18
CHAPTER IV DISCUSSION .................................................................... 22
CHAPTER VI SUMMARY......................................................................... 24
REFERENCES ......................................................................................... 25

LIST OF PICTURE

Figure 1. Site of implantation of ectopic pregnancy .................................. 11

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Figure 2. Double decidual sign ................................................................. 14
Figure 3. Pseudogestational sac .............................................................. 15
Figure 4. Heterotopic pregnancy .............................................................. 16
Figure 5. Ring of fire sign ......................................................................... 16
Figure 6. Hemoperitoneum & culdocentesis ............................................. 17
Figure 7. Linear salphingostomy .............................................................. 20
Figure 5. Surgical management of ectopic pregnancy ............................. 21

CHAPTER I
PREFACE

Ectopic pregnancy is a implantation of a fertilized ovum outside the uterus. Ectopic


pregnancy is a major health problem for women of reproductive age and is the leading

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cause of pregnancy-related death during the first 20 weeks of pregnancy. Accurate
diagnosis and treatment of ectopic pregnancy decreases the risk of death and optimizes
subsequent fertility (Ezeddin 2008)

The blastocyst normally implants in the endometrial lining of the uterine cavity.
Implantation anywhere else is considered an ectopic pregnancy. It is derived from the
Greek ektopos—out of place. According to the American College of Obstetricians and
Gynecologists (2008), 2 percent of all first-trimester pregnancies in the United States are
ectopic and these account for 6 percent of all pregnancy-related deaths. The risk of death
from an extrauterine pregnancy is greater than that for pregnancy that either results in a
live birth or is intentionally terminated. Moreover, the chance for a subsequent successful
pregnancy is reduced after an ectopic pregnancy. With earlier diagnosis, however, both
maternal survival and conservation of reproductive capacity are enhanced (Cunningham,
Leveno et al. 2014).

The diagnosis of an ectopic pregnancy is usually unexpected and is often


emotionally traumatic. Many women may have only recently discovered they were
pregnant when they receive the diagnosis. Some women diagnosed with an ectopic
pregnancy do not even know they are pregnant and suddenly must think about the
possibility of major surgery or medical treatment (Cunningham, Leveno et al. 2014)

Ectopic pregnancy, in which the gestational sac is outside the uterus, is the most
common lifethreatening emergency in early pregnancy. The incidence in the United
States has increased greatly in the last few decades, from 4.5 per 1000 pregnancies in
1970 to an estimated 19.7 per 1000 pregnancies in 1992. Although spontaneous
resolution of ectopic pregnancy can occur, patients are at risk of tubal rupture and
catastrophic hemorrhage. Ectopic pregnancy remains

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an important cause of maternal death, accounting for about 4% of the
approximately 20 annual pregnancy-related deaths in Canada. Despite the
relatively high frequency of this serious condition, early detection can be
challenging. In up to half of all women with ectopic pregnancy presenting to an
emergency department, the condition is not identified at the initial medical
assessment.6 Although the incidence of ectopic pregnancy in the general
population is about 2%, the prevalence among pregnant patients presenting to an
emergency department with first-trimester bleeding or pain, or both, is 6% to 16%.
Thus, greater suspicion and a lower threshold for investigation are justified
(Cunningham, Leveno et al. 2014)

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CHAPTER II
CASE REPORT

IDENTITY

 Name : Miss. M
 Age : 34 years old
 MRNo : 00 72 03
 Date : May, 3rd 2017
 Adress : Dhamasraya

CHIEF COMPLAIN

A 34 years old patient was admitted to the Delivery Room of Dhamasraya District
Hospital on May 3rd, 2017 at 10.30 am with chief complaint acute abdominal pain
since 3 hours ago.

PRESENT ILLNESS HISTORY

 Lower right abdominal pain a little bit since ± 1 days ago.


 This morning around 07.00 increasing pain during activity and perceived
continuously, no pain radiating to the back.
 Blood staining from vagina since 1 day ago, staining a piece of panty, black
redish colored but the patient didn’t consult to anyone.
 Meat-like tissue out from the vagina was (-)
 Fish bubbles like tissue out from the vagina was (-)
 Amenorrhea since 2 month ago.

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 First date of last menstrual period March, patients did not know she was
pregnant
 This was the second pregnancy
 No complaint in urinary and bowel system.
 History of fever (-)
 History of fluor albus 6 month, white secrete, smelly.a
 Menstrual History : menarche at 12 years old, no regular cycle, every 28 days
which last for about 4-5 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain.
PREVIOUS ILLNESS HISTORY

There wasn’t previous history of heart, lung, liver, kidney, DM, hypertension and
allergic history.

FAMILY ILLNESS HISTORY

There wasn’t history of hereditary disease, contagious and physicological illness


in the family.

Marriage history : once in 2010

History of pregnancy/abortion/delivery : 2/ 0 / 1

1. 2012, male, 3000 gr, term pregnancy, Spontan, midwife, alive


2. Present

History of family planning : contraception injection every 3 mounth

History of immunization : (-)

History of education : senior high school

History of occupation : house wife

History of habitual : smoking, alcohol and drug abuse were


absent

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Physical Examination :

General Appearance : Moderate

Consiousness : Composmentis cooperative

Blood Pressure : 90/60 mmHg

Pulse rate : 130 x/mnt

Respiration rate : 26 x/mnt

Temperature : 37°C

Body height : 156 cm

Body weight before pregnancy : 51 kg

Body weight : 52 kg

Upper arm circumference : 25 cm

BMI : 20,95 (normoweight)

 Eyes : Conjunctiva anemic, Sclera wasn’t icteric


 Neck : JVP 5-2 cmH2O
 Chest : H/L normal
 Abdoment : OR
 Genitalia : OR
 Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -
/-

 Obstetric Record:
Abdoment

Inspection : Abdomen didn’t seem enlarge, cicatrix (-)

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Palpation : Uterine fundal was hard to palpate, abdominal tenderness (+),
defence muscular (-)

Percution : Tympani

Auscultaion : Peristaltic sound was dicress

Genitalia

Inspection : V/U normal, Bleeding pervaginam (+)

Inspeculo

Vagina : tumor (-), laceration (-), fluxus (+) black redish blood
seemed to accumulate in the posterior fornix.

Portio : multiparous, size equal to 1st digiti of plantar pedis,


tumor (-), laceration (-), fluxus (+) There was black redish
blood oozing from cervical canal, EUO was closed.

VT bimanual

Vagina : tumour (-)

Portio : multiparous, size equal to 1st digiti of plantar pedis, tumor


(-), motion pain of the servix (+), EUO was closed

CUT : hard to examine

AP : hard to examine

Douglas’ pouch: bulging

Laboratory finding :

No Parameter Result

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1 Haemoglobin 8,3 gr/dl

2 Haematocryte 30 %

3 Leucocyte 19.100/mm3

4 Trombocyte 182.000/mm3

5 PT 11,4 seconds

6 APTT 34,7 seconds

7 Plano Test +

USG

Diagnose

Acute abdomen due to aborted ectopic pregnancy in G2P1A0L1 8-10 weeks of


pregnancy + moderate anemia (Hb: 8,3 gr%)

Advice:

 Control GA, VS
 Pre-operation room
 Consult to anasthesiologist and operative room
 Resuscitation + Transfusion 3 units of PRC

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 Informed consent
Plan :

 Emergency laparotomy

11.00 am

- Laparatomy was performed

 After opening the peritoneum, abdominal cavity filled with blood, suctioning
was performed. Exploration the source of bleeding coming from the right tubal
pars ampularis, there is mass size 4x3x2,5 cm.
Impression : Aborted tube pars ampularis caused by ectopic pregnancy.

Plan : Right Salphingectomy

 Uterine shape and size larger than normal, the left fallopian tube and ovary
both shape and size within normal limits
 Salphingectomy was performed

D/ P1A1L1 post right salphingectomy on indication aborted tube pars ampularis et


causa ectopic pregnancy + moderate anemia on theraphy

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Follow - up May, 4th 2017

A/ Fever (-), Bleding from vagina (-), Urine (+) with catetter

Physical Examination :

GA Cons BP HR RR T

Mdt CMC 100/70 92 21 36,8

Obstetric Record:

Abdoment

Inspection : Abdomen didn’t seem enlarge. Incicion of laparatomy was good

Palpation : Uterine fundal was hard to palpate, abdominal tenderness (-),


defense muskular (-), rebound tenderness (-)

Percution : Tympani

Auscultation : Peristaltic sound was normal

Genitalia

Inspection : V/U normal, Bleeding pervaginam (-)

Laboratory Result :

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No Parameter Result

1 Haemoglobin 10,3 gr/dl

2 Haematocryte 35 %

3 Leucocyte 11.100/mm3

4 Trombocyte 272.000/mm3

Diagnose :

P1A1L1 post right salphingectomy on indication aborted tube pars ampularis et


causa ectopic pregnancy

Advice :

 Control GA, VS
 gradual mobilization
 High protein and carbohidrate in diet

Theraphy :

 Aff IVFD 28 gtt


 Cefotaxime 2 x 1 gr
 Mefenamic acid 3x500 mg
 Vit C 1x1
 SF 1x1

Follow - up May, 5th 2017

A/ Fever (-), Bleding from vagina (-), Urine (+)

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Physical Examination :

GA Cons BP HR RR T

Mdt CMC 120/80 85 24 36,8

Obstetric Record :

Abdoment

Inspection : Abdomen didn’t seem enlarge. Incicion of laparatomy was good

Palpation : Uterine fundal was hard to palpate, abdominal tenderness (-),


defense muskular (-), rebound tenderness (-)

Percution : Tympani

Auscultaion : Peristaltic sound was normal

Genitalia

Inspection : V/U normal, Bleeding pervaginam (-)

Diagnose :

P1A1L1 post right salphingectomy on indication aborted tube pars ampularis et


causa ectopic pregnancy

Advice :

 Control GA, VS
 gradual mobilization
 High protein and carbohidrate in diet

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Theraphy :

 Cefixime 2x200 mg
 Mefenamic acid 3x500 mg
 Vit C 1x1
 SF 1x1

Follow - up May, 6th 2017

A/ Fever (-), Bleding from vagina (-), Urine (+)

Physical Examination :

GA Cons BP HR RR T

Mdt CMC 120/80 80 20 36,8

Obstetric Record :

Abdoment

Inspection : Abdomen didn’t seem enlarge. Incicion of laparatomy was good

Palpation : Uterine fundal was hard to palpate, abdominal tenderness (-),


defense muskular (-), rebound tenderness (-)

Percution : Tympani

Auscultaion : Peristaltic sound was normal

Genitalia

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Inspection : V/U normal, Bleeding pervaginam (-)

Diagnose :

P1A1L1 post right salfingectomy on indication aborted tube pars ampularis et


causa ectopic pregnancy

Advice :

 Control GA, VS
 gradual mobilization
 High protein and carbohidrat in diet

Theraphy :

 Cefixime 2x200 mg
 Mefenamic acid 3x500 mg
 Vit C 1x1
 SF 1x1

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CHAPTER III

ECTOPIC PREGNANCY

A. Definition
An ectopic pregnancy is one that implants outside the uterine
cavity. Implantation occurs in the fallopian tube in 95% to 99% of
patients. The most common site of implantation in a tubal pregnancy
is the ampulla (70%), followed by the isthmus (12%) and fimbriae
(11%). Implantation may also occur on the ovary, the cervix, the
outside of the fallopian tube, the abdominal wall, or the bowel. The
incidence of ectopic pregnancies has been increasing over the past
10 years. Currently, more than 1:100 of all pregnancies are ectopic.
This is thought to be secondary to the increase in assisted fertility,
sexually transmitted infections (STIs), and pelvic inflammatory
disease (PID). Patients who present with vaginal bleeding and/or
abdominal pain should always be evaluated for ectopic pregnancy
because a ruptured ectopic pregnancy is a true emergency. It can
result in rapid hemorrhage, leading to shock and eventually death.
While early diagnosis and treatment of this condition has dramatically
decreased the mortality risk (Callahan and Caughey 2013).

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Figure 1. Sites of implantation of 1800 ectopic pregnancies from a 10-
year population-based study (Cunningham, Leveno et al. 2014)

Following fertilization and fallopian tube transit, the blastocyst


normally implants in the endometrial lining of the uterine cavity.
Implantation elsewhere is considered ectopic and comprises 1 to 2
percent of all first-trimester pregnancies in the United States. This
small proportion disparately accounts for 6 percent of all pregnancy-
related deaths. In addition, the chance for a subsequent successful
pregnancy is reduced after an ectopic pregnancy. Fortunately, urine
and serum beta-human chorionic gonadotropin (β-hCG) assays and
transvaginal sonography have made earlier diagnosis possible. And
as a result, both maternal survival rates and conservation of
reproductive capacity are improved (Cunningham, Leveno et al.
2014)

B. Risk Factor
The most common denominator is tubal obstruction and injury.
Previous pelvic inflammatory disease, especially when caused by
Chlamydia trachomatis, is a major risk factor for ectopic pregnancy. The
adjusted odds ratio (OR) for previous pelvic infectious disease was recently
found to be 3.4 (95% confidence interval, CI: 2.4–5.0). Other factors
associated with an increased risk of ectopic pregnancy include prior ectopic
pregnancy (which increases the risk for subsequent ectopic pregnancy 10-
fold), a history of infertility (and specifically in vitro fertilization), cigarette

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smoking (causing alterations in tubal motility and ciliary activity), prior tubal
surgery, diethylstilbestrol exposure (which alters fallopian tube
morphology), and advanced maternal age (E. Albert Reece 2007).

While use of an intrauterine device (IUD) for birth control


decreases the overall rate of pregnancy, in case the contraceptive
fails, there is an increased rate of ectopic pregnancy in those women
who become pregnant because the IUD prevents normal intrauterine
implantation. This risk may be as high as 25% to 50%(Callahan and
Caughey 2013).

C. Sign and Symptoms


Clinical manifestations of ectopic pregnancy are varied and depend
on whether rupture has occurred. The classic symptom triad of ectopic
pregnancy includes amenorrhea, irregular bleeding, and lower abdominal
pain. However, it is present in only one-half of patients and most commonly
when rupture has occurred. The most common complaint is sudden severe
abdominal pain, which is present in more than 90% of patients (E. Albert
Reece 2007).

There is tenderness during abdominal palpation. Bimanual pelvic


examination, especially cervical motion, causes exquisite pain. The
posterior vaginal fornix may bulge from blood in the rectouterine cul-de-sac,
or a tender, boggy mass may be felt to one side of the uterus. Although
minimal early, later the uterus may be pushed to one side by an ectopic
mass. The uterus may also be slightly enlarged due to hormonal
stimulation. Symptoms of diaphragmatic irritation, characterized by pain in
the neck or shoulder, especially on inspiration, develop in perhaps half of
women with sizable hemoperitoneum (Cunningham, Leveno et al. 2014).

Fever is not expected, although a mild elevation in temperature in


response to intraperitoneal blood may occur. A temperature of 380C may
suggest an infectious cause to a patient’s symptoms. Abdominal distension
and tenderness, with or without rebound, rigidity, or decreased bowel
sounds, may be seen in cases of intra-abdominal bleeding. Abdominal
tenderness is variable; it is present in 50% to 90% of patients with ectopic

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pregnancies. Cervical motion tenderness caused by intraperitoneal
irritation and adnexal tenderness are commonly found. An adnexal mass is
present in roughly one-third of cases, but its absence does not rule out the
possibility of an ectopic implantation. The uterus may enlarge and soften
throughout the first trimester, thus simulating an intrauterine pregnancy. A
slightly open cervix with blood or decidual tissue may be found and
mistaken for a threatened and/or spontaneous abortion (Beckmann, Ling
et al. 2010)

Tubal ectopic which located in ampulla can’t get aterm, most of


them will aborted at 8-10 weeks of pregnancy. Zygote implanted in
columnar cell, because space in ampulla much larger, zygote tends to grow
in the direction of fimbria and easier to penetrate thin layer of decidua
capsularis. Bleeding that caused by tubal aborted filled cavum douglas and
become retrouterine hematocele. In some case, end part of tubal was
closed because of adhesi and blood accumulated in tubal that can be called
hematosalphinx (Soelaiman, Djamhur et al, 2003).

D. Multimodality Diagnosis
A number of algorithms have been proposed to identify ectopic
pregnancy. Most include these key components: physical findings,
transvaginal sonography (TVS), serum β-hCG level measurement—both
the initial and the subsequent pattern of rise or decline, and diagnostic
surgery, which includes uterine curettage, laparoscopy, and occasionally,
laparotomy (Cunningham, Leveno et al. 2014). TVS and serial serum β -
hCG measurements are the most valuable diagnostic aids to confirm the
clinical suspicion of an ectopic pregnancy (Beckmann, Ling et al. 2010).
In a woman in whom ectopic pregnancy is suspected, TVS is
performed to look for findings indicative of intrauterine or ectopic
pregnancy. During endometrial cavity evaluation, an intrauterine
gestational sac is usually visible between 4½ and 5 weeks. The yolk sac
appears between 5 and 6 weeks, and a fetal pole with cardiac activity is
first detected at 5½ to 6 weeks. With transabdominal sonography, these
structures are visualized slightly later. In contrast, with ectopic pregnancy,
a trilaminar endometrial pattern can be diagnostic. Its specificity is 94

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percent, but with a sensitivity of only 38 percent (Cunningham, Leveno et
al. 2014).

Figure 2. Intrauterine pregnancy with double decidual sign


(Chudleigh and Thilaganathan 2004).

Approximately 90% of ectopic pregnancy may be visualized using


transvaginal sonography within 5 weeks of the last menstrual period. If an
intrauterine pregnancy is detected, this is taken to exclude a diagnosis of
ectopic pregnancy because coexistent intra and extrauterine pregnancies
(heterotopic) following spontaneous cycles are rare, with an estimated
incidence of 1 in 30 000 normal pregnancies. However, the incidence of
heterotopic pregnancy is increased by the use of assisted reproductive
technology, with an incidence of up to 1 in 100 normal pregnancies. The
early sonographic appearance of a normal gestational sac is characterized
by the double decidual sac sign, i.e., two concentric echogenic rings
separated by a hypoechogenic space. The double sac is believed to be the
decidua capsularis and decidua parietalis. The double decidual sign is
useful to the physician for early diagnosis of intrauterine pregnancy and for
the exclusion of ectopic pregnancy (Reece and Hobbins 2007)

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Figure 3. Transvaginal sonography of a pseudogestational sac within the
endometrial cavity. Its cavity-conforming shape and central location are
characteristic of these anechoic fluid collections. Distal to this fluid, the
endometrial stripe has a trilaminar pattern, which is a common finding with
ectopic pregnancy (Cunningham, Leveno et al. 2014).

Figure 4. Heterotopic pregnancy (Chudleigh and Thilaganathan 2004)

Color Doppler can help us to detect a vascular sign in early


pregnancy, this vascular sign called ring of fire. Ring of fire sign can be
seen when ectopic pregnancy located in adnexa (Fleischer, Manning et
al. 2001)

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Figure 5. Ring of fire sign (Fleischer, Manning et al. 2001)

Each institution must define a β-hCG discriminatory value, that is,


the lower limit of hCG at which an examiner can reliably visualize
pregnancy on ultrasound. The more sensitive transvaginal ultrasonography
should show the pregnancy by the time the hCG level is 1000 to 2000 IU/L.
Transabdominal ultrasonography should be able to identify an intrauterine
gestation by the time the hCG level reaches 5000 to 6000 IU/L. Accurate
diagnosis by sonography is three times more likely if the initial β-hCG level
is above this value. The absence of uterine pregnancy with β-hCG levels
above the discriminatory value signifies an abnormal pregnancy—ectopic,
incomplete abortion, or resolving completed abortion. Care must be taken
to differentiate between a uterine gestation and a pseudogestational sac
(Beckmann, Ling et al. 2010)

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 (Cunningham, Leveno et al. 2014). Culdocentesis was used
as a diagnostic technique for ectopic pregnancy before the widespread
availability of the vaginal ultrasound and β-hCG assay. Culdocentesis is
positive in around 80% of women with ectopic pregnancy who have
hemoperitoneum. In the remaining 20% of cases, the results are
nondiagnostic. A nondiagnostic finding cannot be used to exclude ectopic
pregnancy, and the test alters management only when it is positive. Thus,
it is rarely indicated and is performed only in places where facilities for
pregnancy testing and ultrasound are limited (E. Albert Reece 2007).

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Figure 6. Techniques to identify hemoperitoneum. A. Transvaginal
sonography of an anechoic fluid collection (arrow) in the retrouterine cul-
de-sac. B. Culdocentesis: with a 16 to 18-gauge spinal needle attached to
a syringe, the cul-de-sac is entered through the posterior vaginal fornix as
upward traction is applied to the cervix with a tenaculum (Cunningham,
Leveno et al. 2014)

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 (Cunningham, Leveno et al. 2014)

E. 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 (Cunningham, Leveno et al. 2014).

Methotrexate is the medical treatment usually used as an


alternative to surgical therapy. Methotrexate is a folic acid antagonist that
competitively inhibits the binding of dihydrofolic acid to dihydrofolate
reductase, which in turn reduces the amount of active intracellular
metabolite, folinic acid. Success rates with singledose methotrexate were
93% in cases with ectopic masses <3.5 cm. Cardiac activity and size
greater than 3.5 cm are considered relative contraindications to medical
management because these findings are associated with a lower success
rate (Beckmann, Ling et al. 2010).

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Candidates for medical therapy is patient with hemodynamically
stable patients without active bleeding or signs of hemoperitoneum and
they should comply with follow-up care. Absolute contraindications to
medical therapy include breastfeeding, immunodeficiency, alcoholism,
hepatic or pulmonary or renal or hematological dysfunction, known
sensitivity to methotrexate, blood dyscrasias, or peptic ulcer disease.
Relative contraindications for methotrexate treatments include embryonic
cardiac activity and a gestational sac of 3.5 cm or more (E. Albert Reece
2007).

Both single and multidose methotrexate regimens are available. A


single-dose regimen most commonly uses a 50 mg/m2 dose of
intramuscular methotrexate and requires fewer clinic or emergency
department visits. However, the success rate is slightly lower with a single-
versus a multidose regimen (93% vs. 88% respectively). Commonly, the β-
hCG level will rise the first few days after methotrexate therapy, but should
fall by 10% to 15% between days 4 and 7 of the treatment. If β-hCG does
not fall to these levels, the patient requires a second dosage of
methotrexate. Additionally, these women should be monitored for signs and
symptoms of rupture—increased abdominal pain, bleeding, or signs of
shock—and advised to come to the emergency department immediately in
case of such symptoms (Hanretty 2010).

Laparoscopy is the preferred surgical treatment for ectopic


pregnancy unless a woman is hemodynamically unstable (Cunningham,
Leveno et al. 2014). If a patient presents with a ruptured ectopic pregnancy
and is unstable, the first priority is to stabilize with intravenous fluids, blood
products, and vasopressor medications if necessary. The patient should
then be taken to the operating room where exploratory laparotomy can be
performed to stop the bleeding and remove the ectopic pregnancy. If the
patient is stable with a likely ruptured ectopic pregnancy, the procedure of
choice at many institutions is an exploratory laparoscopy, which can be
performed to evacuate the hemoperitoneum, coagulate any ongoing
bleeding, and resect the ectopic pregnancy (Beckmann, Ling et al. 2010).
The excellent benefits of laparoscopic treatment include less blood loss,
less analgesia, less postoperative pain, shorter recovery period, and

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decreased hospital costs. The only absolute contraindication for
laparoscopy is shock or hemodynamic instability (E. Albert Reece 2007).

The most commonly performed procedures (by either laparoscopy


or laparotomy) are radical salpingectomy (removal of the affected tube), or
salpingotomy (tubotomy that is closed) and salpingostomy (tubotomy that
is left open) that preserve the tube. Salpingectomy is preferred in cases of
ruptured ectopic pregnancy with uncontrolled bleeding, extensive tubal
damage, recurrent ectopic pregnancy in the same tube, and sterilization.
Higher rates of intrauterine pregnancy have been reported following
conservative surgery than with radical surgery an unruptured ectopic
pregnancy is rarely performed and linear salpingostomy is the procedure of
choice. Moreover, linear salpingostomy was found to be as effective as
segmental resection with reanastomosis, and is technically easier with a
shorter operative time. The ectopic pregnancy is removed through a linear
incision of 10–15 mm made into the tube on its antimesenteric border. The
products will extrude from the incision and can be flushed out and
evacuated. Both livebirth rates and recurrent ectopic pregnancy rates after
a tubotomy were similar, regardless of whether the incision was closed
(salpingotomy) or left open to heal by secondary intension (salpingostomy).
Because no differences in prognosis with or without suturing were found,
laparoscopic salpingostomy is the preferred surgical procedure for an
unruptured ectopic pregnancy (Reece and Hobbins 2007).

Figure 7. Linear salpingostomy for ectopic pregnancy. A. A linear incision


for removal of a small tubal pregnancy is created on the antimesenteric
border of the tube. B. Products of conception may be flushed from the tube
using an irrigation probe. Alternatively, products may be removed with
grasping forceps. Following evacuation of the tube, bleeding sites are

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treated with electrosurgical coagulation. The incision is not sutured
(Cunningham, Leveno et al. 2014).

FIGURE 5. Surgical management of ectopic pregnancy. (A) Site of linear


incision for linear salpingostomy. (B) Linear incision. (C) Segmental
resection. (D) Tubal reanastomosis (Callahan and Caughey 2013).

In case of aborted tubal, pregnancy product can be pulled out or


ekstrected and bleeding was controlled with cauter. This kind of
management can prevent salphingectomy and save patient productive
ability.

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CHAPTER IV

DISCUSSION

This case report discusses A 34 years old patient was admitted to the Delivery
Room of Dhamasraya District Hospital on May 3rd, 2017 at 10.30 am with chief
complaint acute abdomen since 3 hours ago. As a guide to the discussion on target
academically comprehensive scientific then we will discusss some of the reference
questions are as follows :

1. Whether the diagnose of this patient was right ?


2. Whether the management of this patient was appropriate ?
3. What the cause of Ectopic pregnancy disorder in this patiens ?

1. Whether the diagnose of this patient was right ?


Discussion based on the questions are : Known by anamnese this patient
was a Lower right abdominal pain a little bit since ± 1 days ago. Pain feel
increasing during activity and perceived continuously, bleeding from the
genitals slightly (+) blackish red underwear and 2 months amenorea. On
physical examination, conjunctiva anemic, abdominal tenderness (+), motion
pain of the servix, and Douglas’ pouch was bulging. Laboratory result shown
anaemia with Hb 8,3 g/dL and pack test (+). Abdominal sonography shows GS
extrauterine and hemoperitoneum.
From anamnesis, physical examination and laboratorium finding we
conclude that the diagnose this patient is right.

2. Whether the management of this patient was appropriate ?


This patient pregnancy was planned to be terminated by emergency
laparatomy. This procedure is recomended because the patient condition was
unstable. Intraoperative surgeon choose salphingectomy because limited
experience and theres no cauter available to control the bleeding.

3. What the cause of ectopic pregnancy in this patiens ?

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From the anamnesis this patient use contraseption (injection every 3
months). Tuba Motility influenced by estrogen and progesterone levels in
serum. Estrogen will increase the activity of smooth muscle of the uterus and
fallopian while progesterone lowers tonos smooth muscle. This mechanism
also explains the increased incidence of ectopic pregnancy in the use of birth
control pills containing only progestin.

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CHAPTER V

SUMMARY

From anamnesis, physical examination and laboratorium finding we


conclude that the diagnose this patient is ectopic pregnancy. This patient
pregnancy was terminated by emergency laparotomy, Intraoperative surgeon
choose salphingectomy because extensive tubal damage. The possible risk for
ectopic pregnancy in this patient was infection or contraceptive uses.

30
REFFERENCE

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Chapter 13, 141-150.

Callahan, T. L. and A. B. Caughey (2013). "Obstetrics and Gynecology." Sixth


Edition: Chap.2 13-14.

Chudleigh, T. and B. Thilaganathan (2004). "Obstetric Ultrasound." Third Edition:


33-58.

Cunningham, et al. (2014). "Williams Obstetrics." 24th Edition: Chapter 19, 2000-
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E. Albert Reece, J. C. H. (2007). "Clinnical Obstetrics." Third Edition.

Ezeddin (2008). "Gambaran kasus KET di RSUD Pekanbaru 2003-2005." 1-53.

Fleischer, A. C., et al. (2001). "Sonography Obstetric and Gynecology." Sixth


Edition: Chapter 6. 114-137.

Hanretty, K. P. (2010). "Obstetrics Ilustrated." Seventh Edition: Chapter 9, 161-


170.

Reece, E. A. and J. C. Hobbins (2007). "Clinnical Obstetrics." Third Edition: Chapter


12, 161-172.

Sulaiman Sastrawinata, Djamhoer Martaadisoebrata, Firman Wirakusumah (2003).


Obstetri Patologi. Second edition: Chapter 10, 110-112.

31