Case

ECTOPIC PREGNANCY
ADSEL KARTADINATA 2016 061 173
EDIVA PRADIPTALOKA 2017 060 10123
ROBERTO SUSANTO 2017 060 10164
CINDY MAHARANI PUTRI 2017 060 10193
Identity

 Name : Mrs. M
 Age : 30 YO
 Ethnic : Javanese
 Religion : Moslem
 Education : JHS
 Job : Private employees
 Date of care : 12 July 2018
History Taking

Chief complaint : Left lower quadrant pain +- 7 hours

before entering the hospital

 Additional complaint : blood colored spots coming out from

genitals 1 hour before admission

 First day of last mennstrual period : 5 Mei 2018

History Taking

History of present illness :

 Mrs.M, G3P1A1, 30 YO, 7-8 weeks of gravid according to USG,
came with complaints of lower left quadrant pain which
weighs since 7 hours of before entering hospital.
 Abdominal pain initially began to be felt since 11 hours of
before entering hospital. Pain has characteristics such as
punctured, felt constantly, felt not improved by any action
and does not spread and the patient can point the location
of pain by hand. Pain is felt with a degree of VAS 6. Patient
say she never had this complaint before. Since 7 hours before
entering hospital pain is felt increasingly burdensome.
History Taking

 Fresh red spots are felt going out from the genital of the patient
since 1 hour of before admission. Patients first notice the release of
spots while urinating and these complaints have never been felt
before. Complaints of abdominal cramps are denied by the
patient. The unbearable liquid release from the genitals is denied.
History of past illness:
 History of DM, asthma, TB, and other was denied
History of surgery:
 2016: curettage
Habitual history:
 Smoking : denied
 Alcohol consumption : denied
Menstrual history:
 Menarche : 12 years old
 Irregular rhytmic, 5-7 days, 20+-5 days interval, 4
pads a day, blood did not fill up the pads
cmpeltely, approx. 60 cc
Contraception history:
 Pills : denied
 Injection : last used in 2016
 Intrauterine device : denied
 Sterilization : denied
 Basic and traditional : denied
 Periodic abstinence : used
 Obstetric history
 Married once. 5 years.
Year gestation Delivery Complications Sex Current age Birth Breast milk
method weight
2014 38 months Vaginal - Female 3,5 2600 +
delivery
2016 Curettage

2018 Ectopic Pregnancy

Physical examination

◦ General condition : mildly ill

◦ Consciousness : compos mentis
◦ Blood pressure : 110/70 mmHg
◦ Heart rate : 84 bpm
◦ Respiratory rate : 19 times/minute
◦ Temperature : 36,9°C
◦ Weight : 56 kg
◦ Height : 156 cm
◦ BMI : 23 kg/m2
Physical examination

General examinations
◦ Head : normocephaly
◦ Face : symmetric
◦ Eye : anemic conjunctiva + / +, jaundice sclera - / -
◦ Nose : deformity (-), secret -/-
◦ Mouth : wet oral mucosa membrane
◦ Neck : thyroid enlargement (-), trachea is in the middle
Physical examination

 Heart : Regular 1st and 2nd heart sounds, gallop (-), murmur (-)
 Lung : Vesicular breath sounds +/+, rhonchi -/-, wheezing -/-, Crackles -/-
 Abdomen
 Inspection : flat
 Auscultation : bowel sound +, 8 times/minute
 Palpation : muscular defense (+), tenderness (+) Pain in left iliac region
 Percussion : tympanic
 Extremities : warm, edema -/-/-/-
physiological reflex ++/++/++/++; pathological reflex -/-/-/-
Physical Examination

 Gynecologic Examination
 Genitalia Externa: not examined
 Vaginal Toucher: not examined
 Inspeculo: cervix pink snot, brown discoloration (+)
Laboratory examination (23/4/18)
Hemoglobin 10,3 gr/dL

Hematokrit 30 %

Leukosit 22.700/uL

Trombosit 451.000/uL

Eritrosit 3.66

MCV 81.9

MCH 28.1

MCHC 34.6

Blood Type / rhesus O+

BT 3 min

CT 5 min

aPTT 28.7

Kontrol aPTT 27.5

Reagent HIV -

HbsAg -
Ultrasound Findings

 Empty uterus with extra uterine gestational sac in

cul de sac area with CRL no. 1,33mm. blood clot
(+) FHR (+)
Assesment

 Mrs.M, 30 YO, G3P1A1, 7-8 weeks of gravid with

vaginal bleeding e.c Ectopic pregnancy
Planning

On Hospital
 Explorative Laparotomy
with unilateral
salphyngectomy
 IVFD RLD5 20 tpm
 Cefotaxime 1 x 2g IV
 1 bag of PRC transfusion
Planning

Our Suggestion
 C : • Explain to patients that surgery should be done immediately to
remove the ovaries and fetal channels
 I : Describe the procedures and complications of laparotomy and
salphyngectomy
 E : Explain to the patient the case of fetal KET grows not in the uterus so
difficult to maintain
 Follow Up
Date S O A P

12-7-18 Hb : 8.5 g/dL Transfusi PRC 1 bag

13-7-18 Mobilization (-), Vital sign : P1A2 Post explorative  Cefotaxime 2 x 1 g IV

pain (+) vas 3, BP :120/70 laparotomy +  Cefadroxil 3x500 mg PO
urine on catheter, HR : 92x salphyngectomy due to  Doksisiklin 2x100 mg
defecate -, RR : 20x ectopic pregnancy POD I  Traneksamat Acid 3x500 mg PO
flatus +, Temp : 37°C  Mefenamat Acid 3x500 mg PO
Abdomen  Kaltrofen supp 3x1
 Inspection : Supple  Dysflatyl 2 x 1
 Auscutation : Bowel sounds 5x/  Tramadol 2 x 1
minute  Check Hb 4 hours after transfusion
 Palpation : supple in all region, pain
on papation on hypogastric region
 Percussion : tympanic in all region
 Gauzed wound on hypogastric area
with leakage (-) and bloood (-)
Lab : Hb 8,3g/dL, Ht 24%
 Follow Up
14-7-18  Mobilization (-), General Condition:Mildly Ill P1A2 Post explorative  RL + 1 amp tramadol + 1 amp
 pain (+) vas 2-3, Consciousness : Compos Mentis laparotomy + ranitidin
 urine on catheter, BP : 120/80 salphyngectomy sinistra due  Cefotaxime 2 x 1 g IV
 defecate -, HR : 88x to ectopic pregnancy POD II  Cefadroxil 3x500 mg PO
 flatus +, RR : 17x  Doksisiklin 2x100 mg
Temperature : 36.6°C  Traneksamat acid 3x500 mg
Abdomen PO
 Inspeksi : Supple  Mefenamat acid 3x500 mg
 Auscutation : Bowel sounds 5x/ PO
minute  Kaltrofen supp 3x1
 Palpation : supple in all region,  Dysflatyl 2 x 1
pain on papation on
hypogastric region
 Percussion : tympanic in all
region
 Gauzed wound on
hypogastric area with leakage
(-) and bloood (-)
 Follow Up
15-7-18  Mobilization (-), General Condition: Mildly Ill P1A2 Post explorative  Cefadroxil 3x500 mg PO
 pain (+) vas 2-3, Consciousness : Compos Mentis laparotomy +  Doksisiklin 2x100 mg PO
 urine on catheter, BP : 120/80 salphyngectomy sinistra due  Traneksamat acid 3x500 mg
 defecate -, HR : 80x to ectopic pregnancy POD III PO
 flatus +, RR : 16x  Mefenamat acid 3x500 mg
Temperature : 36.5°C PO
Abdomen  Ranitidine 2x150mg PO
- Inspeksi : Supple  Replace bandage
 Auscutation : Bowel sounds 5x/
minute
 Palpation : supple in all region,
pain on papation on
hypogastric region
 Percussion : tympanic in all
region
 Gauzed wound on hypogastric
area with leakage (-) and
bloood (-)
Literature review
Ectopic pregnancy

 Following fertilization and fallopian tube transit, the blastocyst normally implants
in the endometrial lining of the uterine cavity.  pregnancy in which the
blastocyst implants elsewhere outside the endometrial lining of uterine cavity
called by ectopic or extra uterine pregnancy

1-2 % of all 1st Black

trimester woman>white
pregnancies woman

6 % of all
pregnancy- Age > 35 years old
related deaths
Ectopic pregnancy
Risk Factor
Pathology

 In the early process of pregnancy, when the embryo

can not reach the endometrium for the nidation
process, the embryo may grow in the fallopian tubes

Death and resorbtion of embryo

Abortion to the lumen of the fallopian tube

Tubal rupture
Death and resorbtion of embryo

on implantation that is out of place, the fertilized ovum

dies from lack of vascularization and the ovum will be
totally resorbed.

patients only complain about a few days late

menstruation.
Abortion to the lumen of the
fallopian tube
Bleeding due to opening of the blood vessels by the chorrialis villi at the implantation site may
release the embryo from the wall.

When the release is thorough, the embryo will be removed in the lumen of the fallopian tube
and then pushed by the blood towards the tubal ostium pars abdominalis

On the imperfect release of conception results, bleeding will continue, this will cause the tube
being enlarge and bluish (hematosalping)

Blood will flow into the abdominal cavity through the tubal ostium and will converge in the
duglass cavity.
Tubal rupture

Tubal rupture often occurs when the ovum implants in istmus and usually in early pregnancies.
While the rupture in the pars interstitialis occur in a further pregnancy.

The main factor causing the rupture is the penetration of the chorrialis villi into the muscular
layer.

Tubal wall that has been thinned by invasion of trophoblast, broken because of blood
pressure in the tuba.

In this situation there will be bleeding in the abdominal cavity that can cause shock and
death.
Clinical Manifestation

History
 Symptoms and signs of ectopic pregnancy are often subtle or even
absent.
 a “classic” presentation is characterized by the triad of delayed
menstruation, pain, and vaginal bleeding or spotting.
 With tubal rupture, there is usually severe lower abdominal and
pelvic pain that is frequently described as sharp, stabbing, or
tearing.
 Some degree of vaginal spotting or bleeding is reported by 60 to 80
percent of women with tubal pregnancy.
Clinical Manifestation

Physical
 There is tenderness during abdominal palpation.
 Bimanual pelvic examination, especially cervical motion, causes
exquisite pain.
 uterus may be pushed to one side by an ectopic Mass.
 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.
 Blood pressure will fall and pulse will rise only if bleeding continues
and hypovolemia becomes significant.
Diagnosis

Physical findings Transvaginal Sonography serum β-hCG

Serum Progesterone Laparoscopy

Beta Human Chorionic
Gonadotropin
 Rapid and accurate.
 With bleeding or pain and a positive pregnancy test result, an initial
TVS is typically performed to identify gestation location.
 Empty uterus with a serum β-hCG concentration ≥ 1500 mIU/mL was
100-percent accurate in excluding a live uterine pregnancy.
 If the initial β-hCG level exceeds the set discriminatory level and no
evidence for a uterine pregnancy is seen with TVS,  failed uterine
pregnancy, completed abortion, or an ectopic pregnancy.
Serum Progesterone

 A value exceeding 25 ng/mL excludes ectopic pregnancy with

92.5-percent.
 Thus, values < 5 ng/mL suggest either a nonliving uterine pregnancy
or an ectopic pregnancy.
Transvaginal Sonography

 Endometrial Findings.
A. During endometrial cavity evaluation, an intrauterine gestational
sac is usually visible between 4.5 and 5 weeks.
B. The yolk sac appears between 5 and 6 weeks, and a fetal pole
with cardiac activity is first detected at 5 to 6 weeks
C. In contrast, with ectopic pregnancy, a trilaminar endometrial
pattern can be diagnostic.
D. Anechoic fluid collections, which might normally suggest an early
intrauterine gestational sac, may also be seen with ectopic
pregnancy. (pseudogestational sac and decidual cyst)
Transvaginal Sonography
Transvaginal Sonography

 Various transvaginal sonographic finding with ectopic tubal

pregnancies. Seen as a yolk sac and fetal polle with or without
cardiac activity within an exttrauterine sac.
Transvaginal Sonography

 An empty extrauterine sac with a hyperechoic ring

Transvaginal Sonography

 An inhomogenous adnexal mass. Color doppler shows a classic

“ring of fire”, which refflects increased vascularity typical of ectopic
pregnancy.
Transvaginal Sonography

 Adnexal Findings.
A. The sonographic diagnosis of ectopic pregnancy rests on visualization of
an adnexal mass separate from the ovary.
B. If fallopian tubes and ovaries are visualized and an extrauterine yolk sac,
embryo, or fetus is identified, then an ectopic pregnancy is clearly
confirmed.
C. 60 percent of ectopic pregnancies are seen as an inhomogeneous mass
adjacent to the ovary; 20 percent appear as a hyperechoic ring; and 13
percent have an obvious gestational sac with a fetal pole.
Transvaginal Sonography

 Hemoperitoneum
1. hemoperitoneum is anechoic or hypoechoic fluid.
2. Blood initially collects in the dependent retrouterine cul-de-sac,
and then additionally surrounds the uterus as it fills the pelvis.
3. Diagnostically, peritoneal fluid in conjunction with an adnexal
mass is highly predictive of ectopic pregnancy.
Transvaginal Sonography

 Techniques to identify hemoperitoneum : Transvaginal sonography

of an anechoic fluid collection (arrow) in the retrouterine cul-de-
sac.
Culdocentesis

 simple technique used commonly in the past to identify

hemoperitoneum.
 The cervix is pulled outward and upward toward the
symphysis with a tenaculum.
 a long 18-gauge needle is inserted through the posterior
vaginal fornix into the retrouterine cul-de-sac.
 If present, fluid can be aspirated.
 if the blood sample clots, it may have been obtained
from an adjacent blood vessel or from a briskly bleeding
ectopic pregnancy.
Culdocentesis

 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.
Laparoscopy

 Direct visualization of the fallopian tubes and pelvis by laparoscopy

offers a reliable diagnosis in most cases of suspected ectopic
pregnancy.
Complication

 Complications of ectopic pregnancy are tubal rupture, tubal

abortion, or failure of pregnancy by resolution.
 The most common in ectopic pregnancy is rupture with internal
bleeding that can lead to hypovolemic shock.
 Tubal ectopic pregnancy Usually rupture spontaneously but it can
also happen because of coitus or bimanual examination.
 Abortion is common in fimbrial pregnancies and ampullary
pregnancies, where rupture is common in people whose wombs
implant in isthmus.
Tinjauan pustaka

 Cunningham FG, Leveno KJ, Bloom SL, Spong CY et al. William

obstetric. 24th ed. New York. Mc Graw hill;2014. 377-83 p.
 Joshua HB, Edward M, Buchanan, Christina H. Diagnosis and
management of ectopic pregnancy. Am Fam Physician.
2014;90(1):34-40
 Ectopic Pregnancy: Practice Essentials, Background, Etiology. 2017
Sep 28 [cited 2018 Jul 18]; Available from:
https://emedicine.medscape.com/article/2041923-overview#a5
 Tenore JL. Ectopic Pregnancy. AFP. 2000 Feb 15;61(4):1080–8.
 Prawirohardjo, Sarwono., (2005). Ilmu kebidanan. Jakarta : Yayasan
Bina Pustaka.