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Transcript
OB CASE PRESENTATION Zshari Zxilka T. Tanggol Medical Intern Department of Obstetrics and Gynecology August 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 7 days PTA 3 days PTA (+) Right lower quadrant pain, stabbing, nonradiating, 7/10 intensity, intermittent (-) fever, nausea, vomiting (-) vaginal bleeding (-) vaginal discharge (+) Amenorrhea ~5 weeks No consult done nor medications taken (+) Recurrence of RLQ pain (+) Associated with minimal vaginal bleeding with passage of blood clots HISTORY OF PRESENT ILLNESS 2 days PTA Few hours PTA (+) 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 (+) Increase in RLQ pain (+) Generalized weakness Consult 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 progesterone Progestin only contraceptives IUD devices with progesterone Post-ovulatory high dose estrogen Ovulation induction Luteal 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 Fertilized ovum borrows through the epithelium Zygote reaches the muscular wall Trophoblastic cells at zygote periphery proliferate, invade, and erode adjacent muscularis Maternal blood vessels disrupted leading to hemorrhage Intratubal/intraperitoneal collection Rupture SITES OF ECTOPIC IMPLANTATION: CLASSIFICATION Tubal (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 (6080%) 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 spectrometrybased proteomics DIAGNOSIS: ULTRASONOGRAPHY Abdominal Identification of tubal pregnancy products is difficult Uterine pregnancy usually is not recognized using abdominal sonography until 5 to 6 menstrual weeks or 28 days after timed ovulation Vaginal sonography sonography Uterine pregnancy 1 week after missed menses with BhCG >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 COMPONENTS Ectopic 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 betahCGs (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 tube B. Unremarkable segment of left fallopian tube THANK YOU FOR LISTENING!