Professional Documents
Culture Documents
(English Case)
Presented By :
dr. Wahyuridistia Marhenriyanto
Resident Of Obstetrics dan Ginaecology
Guidance :
dr. Hj. Ermawati, Sp.OG (K)
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
2
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
3
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).
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
4
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)
5
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.
6
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.
History of pregnancy/abortion/delivery : 2/ 0 / 1
7
Physical Examination :
Temperature : 37°C
Body weight : 52 kg
Obstetric Record:
Abdoment
8
Palpation : Uterine fundal was hard to palpate, abdominal tenderness (+),
defence muscular (-)
Percution : Tympani
Genitalia
Inspeculo
Vagina : tumor (-), laceration (-), fluxus (+) black redish blood
seemed to accumulate in the posterior fornix.
VT bimanual
AP : hard to examine
Laboratory finding :
No Parameter Result
9
1 Haemoglobin 8,3 gr/dl
2 Haematocryte 30 %
3 Leucocyte 19.100/mm3
4 Trombocyte 182.000/mm3
5 PT 11,4 seconds
7 Plano Test +
USG
Diagnose
Advice:
Control GA, VS
Pre-operation room
Consult to anasthesiologist and operative room
Resuscitation + Transfusion 3 units of PRC
10
Informed consent
Plan :
Emergency laparotomy
11.00 am
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.
Uterine shape and size larger than normal, the left fallopian tube and ovary
both shape and size within normal limits
Salphingectomy was performed
11
Follow - up May, 4th 2017
A/ Fever (-), Bleding from vagina (-), Urine (+) with catetter
Physical Examination :
GA Cons BP HR RR T
Obstetric Record:
Abdoment
Percution : Tympani
Genitalia
Laboratory Result :
12
No Parameter Result
2 Haematocryte 35 %
3 Leucocyte 11.100/mm3
4 Trombocyte 272.000/mm3
Diagnose :
Advice :
Control GA, VS
gradual mobilization
High protein and carbohidrate in diet
Theraphy :
13
Physical Examination :
GA Cons BP HR RR T
Obstetric Record :
Abdoment
Percution : Tympani
Genitalia
Diagnose :
Advice :
Control GA, VS
gradual mobilization
High protein and carbohidrate in diet
14
Theraphy :
Cefixime 2x200 mg
Mefenamic acid 3x500 mg
Vit C 1x1
SF 1x1
Physical Examination :
GA Cons BP HR RR T
Obstetric Record :
Abdoment
Percution : Tympani
Genitalia
15
Inspection : V/U normal, Bleeding pervaginam (-)
Diagnose :
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
16
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).
17
Figure 1. Sites of implantation of 1800 ectopic pregnancies from a 10-
year population-based study (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
18
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).
19
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)
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
20
percent, but with a sensitivity of only 38 percent (Cunningham, Leveno et
al. 2014).
21
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).
22
Figure 5. Ring of fire sign (Fleischer, Manning et al. 2001)
23
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)
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).
24
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).
25
decreased hospital costs. The only absolute contraindication for
laparoscopy is shock or hemodynamic instability (E. Albert Reece 2007).
26
treated with electrosurgical coagulation. The incision is not sutured
(Cunningham, Leveno et al. 2014).
27
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 :
28
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.
29
CHAPTER V
SUMMARY
30
REFFERENCE
Cunningham, et al. (2014). "Williams Obstetrics." 24th Edition: Chapter 19, 2000-
2082.
31