A young lady with 6 weeks amenorrhea had nausea and vomiting with severe abdominal pain. Her BP was 100/80 mm Hg. Examination revealed a 5 x 5 cm adnexal mass. Is What the plan of management?
Ans-A Plan for immediate laparoscopic surgery (Ref: Dutta 7/e p180-182; Williams Obstetrics 24/e p385)In this patient, the size of an adnexal mass is 5 x 5 cm so expectant management cannot be done. But since the patient is hemodynamically stable, laparoscopic surgery will be the management of choice."Ectopic Pregnancy: Laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is hemodynamically unstable. "--Williams Obstetrics 24/e p385Ectopic PregnancyDefinition: Fertilized ovum implanted and developed outside the normal uterine cavity. MC site of ectopic pregnancy: TubalQ (97%)Rarest ectopic pregnancy: Primary abdominalQMC site of ectopic pregnancy in fallopian tube: AmpuIlaQ(Ampulla>lsthmus>lnfundibuluin >Interstitium)The least common site of ectopic pregnancy in fallopian tube: Interstitial partQEtiology:PID: PID is the MC cause of ectopic pregnancyQ. Chlamydia is the MC cause of PIDQIUCD failure: Highest rate with progesteroneQ; Lowest rate with levonorgestrelQPrior tubal damage either from a previous ectopic pregnancy or from tubal surgery to relieve infertility or for sterilization confers the highest risk for ectopic pregnancy. Risk factors for Ectopic PregnancyHigh-RiskModerate RiskSlight Risk* Tubal corrective surgery* Tubal sterilization* Previous ectopic pregnancy* Artificial reproductive technology* PID* Infertility* Contraceptive failure* Previous genital infection * Multiple partners* Previous pelvic or abdominal surgery* Smoking* Douching* Intercourse before 18 yearsClinical Features:Classical triad: Abdominal pain (100%) + Amenorrhea (75%) + Vaginal bleedingQ (7(1%)Classical triad is seen only in 50% casesQAmenorrhea is usually of short period (<6 weeks)Abdominal pain is acute, agonizing and colicky, located in the lower abdomenVaginal bleeding may he slight and continuousDanforth sign: Shoulder pain due to large intraperitoneal hemorrhage (observed in 10% of patients)QSite of Ectopic PregnancyName of CriteriaPrimary abdominal pregnancy* Studiford s criteriaQOvarian pregnancy* Spigelberg's criteriaQCervical pregnancy* Rubin's criteriaQDiagnosis:UltrasoundDiagnostic feature on USG: Absence of intrauterine pregnancy with a positive pregnancy fluid in the pouch of DouglasQBlob sign: Adnexal mass clearly separated from ovaryQBagel's sign: Typical intact tubal ringQColor Doppler USG: Ring of fire patternQCombination of quantitative hCG and SonographyThe lowest level of beta-hCG at which gestational sac is visible:For TAS: 6000 IU/LFor TVS: 1000-2000 IU/LBeta-hCG >1500 IU/L with the empty uterine cavity is suggestive of ectopic pregnancyQFailure to double the value of beta-hCG by 48-hours with empty uterine cavity: EctopicQSerum Progesterone>25 ng/mLViable intrauterine pregnancyQ<5 ng/mLEctopic or abnormal intrauterine pregnancyQCuldacentesis: Reserved for an emergency situation when USG is not possible; positive culdocentesis means bemoperitoneum.LaparoscopyDirect visualization of pelvis especially the tube, feasible in hemodynamically stable patient Gold standard for diagnosis of ectopic pregnancyManagement:Expectant managementMedical TherapySurgical Therapy(Laparoscopically or by microsurgical laparotomy)Systemic Medical Therapy (Methotrexate): CriteriaSalpingocentesis* Salpingostomy:- Procedure of choice in hemodynamically stable patient, who whishes to retain the fertility - Recommended surgical procedure for am pullary ectopic pregnancy* Salpingotomy: Not done nowadays* Segmental resection and anastomosis: Done in isthmic pregnancy* Fimbrial expression: Done in distal ampullary pregnancy1 < 6 wee ks preg nancyQ2. Hemodynamic stabilityQ3. Tubal diameter < 3.5 cmQ4. No fetal cardiac activityQ5. Beta-hCG <15,000 mlU/ mLQ* Local injection of drug in gestational sac * Drugs used are: * MethotrexateQ* Potassium chlorideQ * Actinomycin DQ* PGF-2-alphaQ* Hyperosmolar glucoseQSalpingectomy is done when whole of the tube is damaged; Contralateral tube is normal; Future fertility is not desired.Recurrence:Recurrence of ectopic pregnancy in 10-12% cases
Plan for immediate laparoscopic surgery
Send beta-hCG
Methotrexate
Give IV fluids, keep NPO and observe for 4--5 days