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INTRODUCTION

Almost 2 in every 100 pregnancies in the united states are ectopic and over 95 % of ectopic pregnancies involve the oviduct.
(1)

In Hasan Sadikin Hospital, incidence of

ectopic pregnancy is almost 3.8 %. The risk of death from an extra uterine pregnancy is more enlarge than that for pregnancy that either results in a live birth or intentionally terminated. Furthermore, prognosis for a successful subsequent pregnancy is reduce in this women. With earlier diagnosis, both maternal survival and conservation of reproductive capacity are enhanced.(1,2) On this case, we will talk about the ectopic pregnancy that occured in woman using hormonal contraception.

I. PATIENT IDENTITY
Name Age Address Education Occupation Date of admission Medical Record ANAMNESIS Referred by Diagnosis Main complain : Registered in Emergency non Surgery, Hasan Sadikin Hospital : Colic abdomen suspicious : - Adnexitis - Urinary tract infection : Lower abdominal pain P2A0 complained of her abdominal pain since 4 days before admission. Pain was felt continuos and more often since 3 hours before admission. Complain did not accompanied by nausea, vomitus, and fever. Bleeding from birth passage were felt about 5 days before admission for about 1 underwear/day. History of vaginal discharge, abdominal cramping and abdominal mass was denied. : Mrs. E : 33 years : Bandung : High school : House wife : August 11th, 2005 at 13.30 pm : 0504xxxx

OBSTETRICAL HYSTORY Pregnancy 1. 2. 3 Birth Attendant RSHS RSHS Outcome Term, 3000 g Term, 3000 g Type of delivery Spontaneous Spontaneous Sex Child Condition 12 yo, L 10 yo, L

Present pregnancy

Additional Summary Marital history: : age 20 years old, High school, House wife : age 23 years old, Diploma 1, Private History of contraception : Injection since 2000 until Mei 2005

Last menstrual period : June 26, 2005, 28 days of cycle, 3-5 days, reguler ANC :

HOME VISIT
Patient and her family live in a permanent house 6 x 12 m size, in the city of Bandung. She has been married for 13 years. Her husband was an Private. In the last 5 years she used hormonal contraception because she did not want to have another child. She had contraception injection every 3 months in Astana Anyar Hospital. She denied any vaginal discharge. Her menstruation period was normal every month about 4-6 days. Her last menstrual period was June 26th, 2005. In August 8th, 2005, she felt abdominal pain not accompanied by vomitus. She looked for a help to her mother and given analgetic. Since then, the pain was reduced, and 3 hours before admission she had vaginal bleeding and abdominal pain was worsen. The pain in her lower abdomen still exsisted accompanied by slight bloody vaginal discharge. So she looked for a help to Hasan Sadikin hospital.

PHYSICAL EXAMINATION
General condition Blood pressure Pulse rate Respiration rate Temperature : Composmentis : 100/60 mmHg : 96 x/minutes : 20 x /minutes : 36.5 C

GYNECOLOGICAL EXAMINATION
External examination Abdomen : Flat, tense DM (+), shifting dullness (-), tenderness (+), mass cannot be palpated Speculum examination : Fluxus from external ost Internal examination : Vulva and vagina Portio External ostium Uterus Douglas pouch : within normal limit : size/consistency within normal limit, tenderness on motion (+) : closed : size/consistency within normal limit : not bulging, tenderness (+)

Right /left uterus area : tense, tenderness (+)

LABORATORY FINDINGS
Haemoglobin : 11,4 g % Leukocytes : 8800/ mm3 Trombicyte : 238.000/mm3 Hematocryte : 34 % Pack Test : (+)

DIAGNOSIS
Suspicious of ectopic pregnancy

MANAGEMENT
Planned to perform culdocentesis Informed consent

Observation of BP, PR, RR

OBSERVATION
Time 13.30-14.00 GC CM BP (mmHg) 100/60 HR (bpm) 96 RR (x/min) 20 Informed consent Note

Planned to perform culdocentesis

At 14.00 pm

: culdocentesis was performed fluid containing frank unclotted blood Conclusion : culdocentesis (+)

Diagnosis Management :

: Ectopic pregnancy I.V line Infusion, cross match, prepare blood transfusion Laparotomy due to ectopic pregnancy, immediately informed consent Consult to anesthesia department, contact emergency operating theater Observation of GC, BP, PR, RR.

Observation before operation


Time GC BP (mmHg) 110/60 100/70 110/70 HR (x/min) 96 92 92 RR (x/min) 14.00-15.00 pm 15.00-16.00 Pm 16.00-17.00 pm CM CM CM 24 24 24 Note preparing the operation Waiting for emergency operating theater

At 17.00 pm At 17.30 pm

The mother arrived at emergency operating theater Operation began - There were blood and blood clot in peritoneal cavity + 500 cc - On the next exploration, there were enlargement of left tubal at isthmical portion, size 5x4x3 cm, black reddish and there were a torn at size 3x2 cm, actively bleeding. - The uterus slightly enlarge, left ovarium and right adnexal within normal limit.

Notion

: Left tubal ruptured at isthmical portion 4

Management At 18.30

: Left Tubal Salpingectomy. Operation finished Bleeding along operation Diuresis along operation : 200 ml : 300 ml

Diagnosis before operation Diagnosis after operation Operation type

: Ectopic pregnancy : Left tubal ruptured at isthmical portion : Left Salpingectomy

OPERATION REPORT
1. Performed an antiseptic procedure around the abdomen 2. Proceed mediana incision + 10 cm 3. After exposure peritoneum, there were blood and blood clot in peritoneal cavity + 500 cc. 4. On the next exploration, there were enlargement of left tubal at isthmical portion with size 5x4x3 cm, black reddish and irregular torn at size 3x2 cm, actively bleeding. 5. The uterus and left ovarium were slightly enlarge and right adnexa were within normal limit. Notion : Left tubal ruptured at isthmical portion Management : Left tubal Salpingectomy. 6. Tubal origin and a part of mesosalphing were clamped, incised and then ligated. 7. Performed care of hemorrhage. 8. Cleaned the abdominal cavity from blood and blood cloth until it`s pink. 9. Operation wound was stitched layer by layer. 10. Fascia was stitched with safil no 1. 11. Skin was sewed with sub cuticuler technic. 12. Hemorraghe during operation : + 200 cc, and urine out put : + 300 cc

LABORATORIUM EXAMINATION
11/08/2005 12.31 PT APTT Hb Leucocytes Ht Trombocytes Urine BJ Ph Protein Bilirubin Urobilinogen Keton Nitrit Eritrocytes Leucocytes Epitelial Pack test 11,4 8800 34 298000 1.010 8.0 <1 4-5 1-2 2-3 + 12/08/2005 09.43 8,8 8900 26 204000

HISTOPATHOLOGY FINDING (August 18, 2005) Conclusion: Tubal pregnancy

FOLLOW UP IN THE WARD


Date
11/8/2005 at 19.30 pm

Notes
Post operation follow up: GC : CM BP : 100/60 mmHg Pl : 80 x/mt Rr : 20 x/mt T : afebris Abd : flat, soft DM (-), SD(-), peristaltic sound (-), tenderness (-) OW : covered by bandage Urine : + 300 cc Post operation: Hb:8,6;L:16400; Tr:242000; Ht: 25 % GC : CM

Instructions
- Antibiotics : Amoxicillin 3 x 1 gr IV -Analgetic : Kaltrofen 2x1 suppositoria - fasting until peristaltic sound is present - Check the Hb level after surgery , if < 8 g % perform blood transfusion - Observed GC,BP,PR,RR

12/820/05

- Antibiotics : Amoxicillin 3 x 1 gr IV

POD I

BP : 100/80 mmHg Pl : 84 x/mt Rr : 20 x/mt T : afebris Abd : flat, soft DM (-), SD(-), tenderness (-) peristaltic sound (+) OW : covered by bandage Urine: 1 L 16.00 GC : CM BP : 100/60 mmHg T : afebris Abd : flat, soft DM (-), SD(-), tenderness (-) OW : covered by bandage peristaltic sound (+) Urine: 1000 cc GC : CM BP : 110/70 mmHg Pl : 80 x/mt Rr : 20 x/mt T : afebris Abd : flat, soft DM (-), SD(-) OW : covered by bandage Peristaltic sound: (+) 16.00 GC : CM, good BP : 110/80 mmHg Rr : 20 x/mt T : afebris Pl : 80 x/mt Abd : flat, soft DM (-), SD(-) OW : good GC : CM BP : 120/70 mmHg Rr : 20 x/mt T : afebris Pl : 88 x/mt Abd : flat, soft DM (-), SD(-) OW : good Urine/faeces :+/+

- Analgetic : Kaltrofen 2 x 1 suppositoria - Mobilitation

12/820/05 POD I

- Antibiotics : Amoxicillin 3 x 1 gr IV - Analgetic : Kaltrofen 2 x 1 suppositoria - Mobilitation - Feeding test

13/8/2005 POD II

- Antibiotics : Amoxicillin 3 x 1 gr IV - Analgetic : Kaltrofen 2 x 1 suppositoria - Mobilitation - ordinary drinking and eating - Off Catheter

14/8/2005 POD III

-mobilitation -Antibiotics : Amoxicillin 3 x 500 mg - Analgetic : Asam mefenamat 3 x 500 mg - Roborantia : 1 x 1 - care of OW

15/8/2005 POD IV

- Amoxicillin 3 x 1 gr IV - Asam mefenamat 3 x 500 mg - Roborantia 1 x 1 - the mother can discharge from hospital

II. PROBLEMS
1. How could an ectopic pregnancy occur on this patient? 2. How was the management of this patient? 3. How about her next pregnancy?

III. DISCUSSION
1. How could an ectopic pregnancy occur on this patient? Definition Blastocyst normally implants in the endometrial lining of the uterine cavity. Implantation anywere else is an ectopic pregnancy.(1) The risk of death from an extra uterine pregnancy is enlarge than that for vaginal delivery or an induced abortion. Ectopic pregnancy remain a leading cause of maternal mortality in the first trimester and accounts for 10 to 15 percent of all maternal deaths. With earlier diagnosis, both maternal survival and conservation of reproductive capacity are enhanced.(1,2) Approximately 55% of ectopic pregnancies occur in the ampullary, isthmic 25%, fimbrial 17% and interstitial 2%. The rare remaining locations include cervical, fimbrial, ovarian, and peritoneal ectopics. Also in combination with an intrauterine pregnancy in 1 in 15.000-40.000 spontaneous pregnancies.(3) Most ectopic pregnancies occur in women aged 25-34 years. Ectopic pregnancies are usually caused by conditions that obstruct or slow the passage of a fertilized ovum (egg) through the fallopian tube to the uterus. Normally, an egg is fertilized in the fallopian tube and then travels down the tube to the implantation site. Any mechanism that interferes with the normal function of the fallopian tube during this process increases the risk of ectopic pregnancy. This may be caused by a physical blockage in the tube.(1,3,4) Ectopic pregnancy may also be caused by failure of the zygote (the cell formed after the egg is fertilized) to move down the tube and into the uterus. Several factors increase the risk of ectopic pregnancy (Table 1). This risk factors share a common mechanism of action-namely, interference with fallopian tube function. The mechanism can be anatomic (e.g., scarring that blocks transport of the egg) or functional (e.g., impaired tubal mobility). Less than 50% of patients with proven EP have an identifiable "ectopic risk factor". Even in the absence of risk factors, a high index of suspicion must

be maintained in any sexually active woman with a history of irregular vaginal bleeding or abdominal pain.(5,6) Risk Factors for Ectopic Pregnancy Strong evidence for association Pelvic inflammatory disease Previous ectopic pregnancy Endometriosis Previous tubal surgery Previous pelvic surgery Infertility and infertility treatments Uterotubal anomalies History of in utero exposure to diethylstilbestrol Cigarette smoking Weaker evidence for association Multiple sexual partners Early age at first intercourse Vaginal douching In the general population, pelvic inflammatory disease is the most common risk factor for ectopic pregnancy. A published study of 745 women with one or more episodes of PID that attempted to conceive showed that 16% were infertile from tubal occlusion. Of those that conceived, 6.4% had ectopic pregnancies. (3,5,6) On this patient occurred pregnancy caused of failure hormonal contraception and the pregnancy become ectopic becaused of history of using hormonal contraception. As we know failure of using hormonal contraception is about 0.3 %. Hormonal contraception was Progesterone. This hormonal contraception was used by injection for 5 years (since year 2000 until Mei 2005). The mother used this hormonal contraception regularly, every 3 months. As we know or there were on literatures that one of risk factors of ectopic pregnancy was hormonal contraception. Estrogen and progesterone increase the risk of ectopic pregnancy because this hormones slow the movement of the fertilized egg through the fallopian tube. The use of progesteronesecretin intrauterine devices (IUDs), the morning after pill, and other hormonal methods of contraception often result in high estrogen and progesterone concentration and may increase the risk of ectopic pregnancy. Ectopic pregnancies are seen more commonly in patients undergoing infertility treatments. The administration of hormones (specifically estrogen and progesterone) can slow the normal movement of the fertilized egg through the tubal epithelium and result in

implantation in the tube. Women who become pregnant despite using progesterone-only oral contraceptives have a 5-fold increase in the ectopic pregnancy rate. We should have several criterias to diagnose an ectopic pregnancy, such as: Symptoms The classic presentation - which includes the triad of abdominal pain, vaginal bleeding and amenorrhea - is neither sensitive nor specific (found in > 60% of cases). describe presentation as:(7) Lower abdominal or pelvic pain ipsilateral lower abdomen Abnormal vaginal bleeding may be mild or absent, (usually scant amounts, spotting) in 50 - 75% of patients. Amenorrhea (cessation of regular menstrual cycle) may not always be present (absent in 5 - 25% of patients) Mild cramping on one side of the pelvis Symptoms of pregnancy (breast tenderness, weight gain, nausea) are uncommon (10 25% of patients) Nausea Low back pain Passage of tissue is uncommon (5 - 10% of patients) and represents passage of a decidual cast If rupture and hemorrhaging occurs before successfully treating the pregnancy, symptoms may worsen and include: Severe, sharp, and sudden pain in the lower abdominal area Feeling faint or actually fainting Referred pain to the shoulder area (secondary to diaphragmatic irritation by free intraperitoneal blood) Signs and Tests Patients with early normal intrauterine pregnancies often present with signs and symptoms similar to those encountered in patients with ectopic pregnancies and other gynecological or gastrointestinal conditions. The availability of various biochemical, ultrasonographic, and surgical modalities can aid the health care provider today in 10 is the most frequent symptom (90 - 100% of patients) and the pain may be sudden in onset, severe in intensity and localised to the
(7)

Others

establishing a definitive diagnosis and differentiating among various conditions. Hence, screen any female patient in the reproductive years presenting with abdominal pain, cramping, or vaginal bleeding for pregnancy.(5,8) No pathognomonic findings, the absence of physical findings does not exclude ectopic pregnancy. Physical examination is unreliable for clinicians who face this significant diagnostic challenge. Abbott et al and Stovall et al reported an alarming rate of missed and or delayed diagnoses in the ectopic pregnancy. Pelvic exam findings are variable and dependent on the duration of the pregnancy, degree of tubal distention, and presence, amount, and rate of intraperitoneal bleeding.(9) From abdominal and gynecology examination findings : Atypical abdominal pain (localised to the central or upper abdomen, or non-localised pain that is intermittent and of varying intensity) is common. Abdominal tenderness is common (80 - 95% of patients) and can vary in intensity from mild and poorly localised to frank peritonism with guarding +/- rigidity. Cervical and adnexal tenderness may be present . An adnexal mass is palpable in < 10 - 50% of patients. (and 20% of palpable masses are contra-lateral to the ectopic pregnancy - usually due to a corpus luteum cyst). Mild uterine enlargement (< 8 week size) may be present (20 - 30% of patients). Cul de sac fullness suggests a significant amount of pelvic blood

Other findings

There is usually a positive pregnancy test. The standard urine pregnancy test is 99 % sensitive and 99 % specific for pregnancy. Although used as the initial step in some settings, the urine pregnancy test is a qualitative rather than quantitative measure that identifies the presence of hCG in concentrations as low as 25 mIU per mL.

A hematocrit test may be normal or decreased. The white blood count may be normal or increased. A culdocentesis may be performed to determine if free blood is present in the abdomen. An ultrasound illustrates an empty uterus. A laparoscopy or a laparotomy may be necessary for adequate diagnosis.

11

Differential diagnosis of bleeding in early pregnancy In pregnancies :


Missed abortion vs. Threatened vs. Incomplete Early intra-uterine pregnancy Ectopic pregnancy Vesicular mole Polyp, rupture of varicose vein Corpus luteum cyst Rupture or torsion of ovarian cyst Pelvic Inflammatory Disease Appendicitis Gastroenteritis Ovarian cysts usually don't cause any symptoms. In fact, corpus luteum cysts

In gynecological or gastrointestinal conditions


appear toward the end of the menstrual cycle, last into early pregnancy, and then usually resolve over a period of time without any special treatment. Occasionally a cyst will rupture, causing several hours of pain, followed by an aching feeling for a few more days. The pain often will be severe. Diagnostic Evaluation Ectopic pregnancy has been described as the great masquerader.(6) Any woman who present with abnormal vaginal bleeding and mild abdominal or pelvic pain can have an ectopic pregnancy until the diagnosis is excluded. The clinical triad for ectopic pregnancy is nonspecific and present in less than 50% of ectopic pregnancies. The positive predictive value of the triad is only 14%.(4) Between 40 - 50 % of ectopic pregnancies are misdiagnosed at the initial visit to an emergency department. Failure to identify risk factors is cited as a common and significant reason for misdiagnosis. A proper history and physical examination remain the foundation for initiating an appropriate work-up that will result in the accurate and timely diagnosis of an ectopic pregnancy.(8,9) Other Diagnostic Modalities Culdocentesis

12

Culdocentesis is another rapid and inexpensive method of evaluation for ruptured ectopic pregnancy. It is performed by inserting a needle through the posterior fornix of the vagina into the cul-de-sac. Culdocentesis can reveal the presence of any free fluid. This is only indicated when the patient is hemodynamically stable with bedside ultrasonography is not immediately available and gynecologist needs to confirm the presence of a hemoperitoneum prior to laparotomy.
(10)

A positive test is defined as the aspiration of strongly

fluid containing frank unclotted blood or fluid with a hematocrit > 15% (bleeding from a ruptured uterus or ruptured corpus luteum cyst also causes a positive test), suggests the presence of a bleeding ectopic pregnancy. The finding of yellow or straw-colored fluid is more consistent with a ruptured ovarian cyst than an ectopic pregnancy. A negative test is the aspiration of serous fluid with a hematocrit < 15%. false-negative rate (10-14%) usually reflecting blood from an unruptured ectopic pregnancy, ruptured corpus luteum, incomplete abortion, and retrograde menstruation. A dry tap is indeterminate and should not influence medical decision-making. Ultrasonography Ultrasonography does not aid in differentiating an early intrauterine pregnancy, a missed abortion, and an ectopic pregnancy, infact 20-30% of ectopics have no detectable sonographic abnormality. (3,7,10) In a patient with stable condition, a full bladder should be present as a proper ultrasound window. To perform ultrasonography examination need skills, experience and good equipment. Both endovaginal and transabdominal examinations should still be performed with the acknowledgment of the limited, yet important, aspects of the transabdominal portion of the exam. Transabdominal examination enables better evaluation of the superior uterus and superiorly positioned adnexa. It may aid detection of free peritoneal fluid and/or hemorrhage beyond the cul-desac. Transvaginal examination provides a detailed evaluation of the endometrial cavity and ovaries, but the high frequency transducer that allows improved near field resolution compared to TA examinations suffers from limited sound penetration (far-field imaging). A definite intrauterine pregnancy is present when a gestational sac with a sonolucent center (>5 mm in diameter) is surrounded by a thick, concentric, echogenic ring located within the endometrium and contains a fetal pole, yolk sac, or both. The double decidual sac found with an early intrauterine pregnancy can be difficult to distinguish from the pseudogestational sac, which is seen in 20-50% of ectopic 13

pregnancies.(9,11) The double decidual sac is 2 concentric hyperechoic rings created by hypoechoic fluid between the decidua parietalis and the decidua capsularis. This sign is in distinct contrast to a single hyperechoic layer found with a pseudogestational sac. A pseudosac is a collection of fluid within the endometrial cavity created by bleeding from the decidualized endometrium, which is seen in 10-20% of ectopics. This is a sac in the uterus that is not a pregnancy but can look like one initially. The lack of a yolk sac, the more-irregular contours, and the more-central location within the endometrial cavity also help in delineating a pseudogestational sac from an early intrauterine pregnancies. Further support of a pseudogestational sac can be demonstrated by the absence of lowresistance endometrial arterial flow on color Doppler evaluation. However, Doppler evaluation has not been shown to be of value when attempting to delineate an adnexal ectopic pregnancy from a corpus luteum cyst, particularly as corpus luteum cysts can demonstrate marked peripheral color Doppler signal, simulating the 'ring of fire' sign. (5,7,8) A definite ectopic pregnancy is characterized by the presence of a thick, brightly echogenic, ringlike structure outside the uterus, with a gestational sac containing an obvious fetal pole, yolk sac, or both, adnexal mass, free cul-de-sac fluid . Because of the variety of ultrasonographic findings, this must be correlated with the clinical presentation and further evaluated to differentiate a possible ectopic pregnancy from an alternate diagnosis. Findings of an extrauterine ectopic pregnancy include the following: (8)
-

Live extrauterine embryo Absence of an intrauterine gestational sac Free fluid (particularly hemorrhagic) in the pelvis or peritoneum Adnexal mass Hematosalpinx Adnexal ring sign and a "ring-of-fire" sign on color Doppler images Absence of low-resistance endometrial arterial flow, an endometrial color Doppler finding highly suggestive of intrauterine pregnancy Compared with abdominal ultrasonography, transvaginal ultrasonography

diagnoses intrauterine pregnancies an average of one week earlier because it is more sensitive. An ectopic pregnancy can be suspected if the transvaginal ultrasound examination does not detect an intrauterine gestational sac.

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Laparoscopy Patients in pain and or those who are hemodynamically unstable should proceed to laparoscopy. Laparoscopy allows assessment of the pelvic structures, size and exact location of ectopic pregnancy, presence of hemoperitoneum, and presence of other conditions, such as ovarian cysts and endometriosis, which, when present with an intrauterine pregnancy, can mimic an ectopic pregnancy. Furthermore, laparoscopy provides the option to treat once the diagnosis is established.(2,9,10) Laparoscopy remains the criterion standard for diagnosis; however, its routine use on all patients suspected of ectopic pregnancy may lead to unnecessary risks, morbidity, and costs. Moreover, laparoscopy can miss up to 4% of early ectopic pregnancies, and, as more ectopic pregnancies are diagnosed earlier in gestation, the rate of false-negative results with laparoscopy would be expected to rise.

ECTOPIC PREGNANCY

Anamnesis Physical ex.

Suspected

Laparotomy

Culdocentesis

(+)

(-)

EP

Laparoscopic diagnostic

Not EP

Picture 2. Management scheme of ectopic pregnancy (adapted from Wijayanegara H, Suardi A, Wirakusumah FF, Permadi W. Pedoman diagnosis dan terapi obstetri dan ginekologi RSUP Dr. Hasan Sadikin ed 2. Bandung : Bagian/SMF Hasan Sadikin, 1998 : 54. 15 Obstetri Dan Ginekologi Fakultas Kedokteran Universitas Padjadjaran Rumah Sakit Umum Pusat Dr.

Complications Ectopic pregnancy is the leading cause of maternal death in the first trimester, accounting for 9-13% of all pregnancy-related deaths. In the United States, an estimated 30-40 women die each year form ectopic pregnancy.(2,4,7) Complications of ectopic pregnancy can be secondary to misdiagnosis, late diagnosis, or treatment approach. Failure to make the prompt and correct diagnosis of ectopic pregnancy could result in tubal or uterine rupture, depending on the location of the pregnancy, which could lead to massive hemorrhage, shock, disseminated intravascular coagulopathy (DIC), and death. (12,13) There was a true diagnosis in this case. When she came to Hasan Sadikin hospital, actually from the anamnesis, physical examination, and laboratory findings the mother already had symptoms that directed to an ectopic pregnancy. That following symptoms were : She was P2A0 not consider herself 2 months of pregnancy but consider amenorrhea for 2 months. Complained about lower abdominal pain Slight bloody vaginal discharge She denied having expulsion tissue from vagina. Four days ago, she felt lower abdominal pain. History of using hormonal contraception. From this symtoms, there already triad for ectopic pregnancy, and when she came to Hasan Sadikin Hospital, we had assumed that she had an ectopic precnancy. Physical examination and laboratory findings indicated disturbed haemodinamic status although she came in composmentis condition. Her blood pressure and pulse rate seems to be normal. In this case, from the anamnesis, physical findings and laboratory findings it should be considered that she might have an ectopic pregnancy. No pathognomonic findings, the absence of physical findings doesnt exclude ectopic pregnancy. When the signs from gynecological examination didnt support an ectopic pregnancy, it must be continuing by culdocentesis. If culdocentesis also have negative value, then the examination proceed by performing laparoscopy.(13) The bimanual exam is often normal in an ectopic pregnancy, and a normal pelvic exam cannot

16

be used to reliably differentiate an ectopic pregnancy from an abnormal intra uterine pregnancy. The uterus is often normal in size or only slightly enlarged, and an adnexal mass or significant cervical/adnexal tenderness is often absent.(5, 11) There was a bloody discharge from the vagina when inspected by spekulum. From bimanual examination there was only found that uterus was slightly enlarged with any pain when portio stimulated. There wasnt any adnexal mass or significant cervical/adnexal tenderness and Douglas pouch wasnt bulge either. In this case, bimanual exam didnt pointed to ectopic pregnancy but there were strong evident that ectopic pregnancy was suspected in this mother, so culdocentecis was true to be done on this patient. 2. How was the management in this patient ? The morbidity and mortality associated with ectopis pregnancy are directly related to the length of time required for diagnosis. Approximately 55% of ectopic pregnancies occur in the ampullary, isthmic 25%, fimbrial 17% and interstitial 2%. Anatomically, tubal ectopic pregnancies can be divided into two distinct tipes based on the anatomy of the tube. The first in the ampullary portion, and the other in isthmic portion.(2,14) The ampullary portion of the fallopian tube is made up of lining epithelium, loose connective tissue and an ill-defined muscularis and serosa. The muscular area (muscularis) between the outer tubal serosa and inner tubal lumen is relatively thin. Ectopic pregnancies in this area rapidly erode through the tubal epithelium into this loose area then occurs in the space between the serosa and tubal lumen. So that, tubal abortion is common in this pregnancy. Some bleeding usually persist as long as product remain in the oviduct. At this point, hemorrhage may cease and symptoms eventually disappear. Blood slowly trickles from the tubal fimbria into the peritoneal cavity and pools in the rectouterine cul-de-sac and forming hematocele. Pieces of the placenta or membranes may remain attached to the tubal wall and after becoming surrounded by fibrin and blood clots, then bleeding will stop. The isthmic portion has a very well-defined and muscularis and the muscular area (muscularis) between the outer tubal serosa and inner tubal lumen is very thick. Its primary function is to squeeze the zygote in to endometrial cavity. In the tubal isthmus (close to the uterus). Most often, isthmic ectopic pregnancies grow within the tubal lumen itself (since they can not break through the muscularis layer) and therefore the lumen is often destroyed as the pregnancy becomes larger in size. Rupture is the usual outcome with isthmic pregnancy and tend to rupture earliest, at 6-8 weeks gestation. Its usually 17

spontaneous, but it may caused by trauma. With intraperitoneal rupture, the entire conceptus may be extruded from the tube, or if the rent is small, profuse hemorrhage may occur. In ether event, the woman commonly shows signs of hypovolemia. Ectopic pregnancies cannot continue to term (birth), so removal of the developing cells is necessary to save the life of the mother. Once an ectopic pregnancy has been diagnosed, the patient should be reevaluated clinically. Three primary types of treatment are available for an ectopic pregnancy. This include surgical management, medical management, and expectant management. The most common treatment is surgical. Surgical Surgical laparotomy is performed to stop the immediate loss of blood (in cases in which rupture has already occurred), or to confirm the diagnosis of ectopic pregnancy, remove the products of conception, and repair surrounding tissue damage. (2,11) In some cases, removal of the involved fallopian tube may be necessary. In non-emergency cases, minilaparotomy or laparoscopy are the most common surgical treatments. Such procedures have similar outcomes. However, they are less invasive and are available at a lower cost because they require minimal hospitalization or outpatient treatment. A formal laparotomy is primarily indicated if: (6,9,13) The ectopic pregnancy has ruptured and the patient is hemodynamically unstable The ectopic pregnancy is very large The ectopic pregnancy is not implanted in the fallopian tube Laparoscopic surgery cannot be performed because of mechanical factors eg. Obese patient with dense pelvic adhesions Salpingectomy is used much less often than salpingostomy. It is preferred only in patients with uncontrolled bleeding, extensive tubal damage or recurrent ectopic pregnancy in the same tube. It is also used when the patient wants a sterilization procedure to be performed. The most frequent complications of surgery are recurrence of ectopic pregnancy (incidence ranging from 5 to 20 percent) and incomplete removal of trophoblastic tissue. It has been suggested that in very high-risk patients, a single dose of methotrexate should be given postoperatively as a prophylactic measure.30

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Medical management Non-surgical (medical) management for ectopic pregnancies without suspected immediate danger of rupture is being implemented in many medical centers . The potential advantages are the avoidance of surgery and its concomitant hazards, the preservation of tubal patency and function, and a lower cost. The most studied of this agents is methotrexate, a folic acid antagonist that is metabolized in the liver and excreted in the kidney.(3,6,12) Methotrexate inhibits the synthesis of purines and pyrimidines. Thus, it interferes with DNA synthesis and cell multiplication. Rapidly dividing cells are most vulnerable to methotrexate. When the diagnosis is certain and an ectopic mass is less than 3.5 cm in greatest dimension, methotrexate therapy is an option. The -hCG level needs to be considered in selecting patients for methotrexate therapy. One study found that -hCG levels higher than 1,500 mIU per mL are associated with a much higher risk of treatment failure. The same study also showed that patients with -hCG levels higher than 5,000 mIU per mL (5,000 IU per L) usually do not respond to methotrexate therapy. Criteriae for medical therapy with methotrexate include: A healthy, hemodynamically stable patient with normal liver/renal function tests and normal platelet count An unruptured tubal ectopic pregnancy < 4 cm in size with no associated iup Ideally a d&c showing no chorionic villi (or the patient's signed agreement to definitely terminate the pregnancy if methotrexate therapy fails) Absence of fetal heart sounds (only a relative requirement) Serum hcg < 10,000 (? Relative requirement) Patient commitment to follow through with the treatment plan, which may take up to 6 - 7 weeks Contra-indications to methotrexate therapy include: Non-tubal implantation Rupture Hemodynamically unstable patient Diameter of ectopic mass > 3.5cm Pain persisting > 24 hours 19

Laparoscopy needed for diagnosis Suspected heterotopic pregnancy

Although the potential for serious toxic effects exists, the low dosages of methotrexate that are used in patients with ectopic pregnancies generally cause only mild, self-limited reactions. Common side effects include nausea and vomiting, urinary frequency and mild diarrhea.. Expectant management Candidates for successful expectant management are asymptomatic and have no evidence of rupture or hemodynamic instability. Furthermore, they should portray objective evidence of resolution, such as declining -hCG levels. They must be fully compliant and must be willing to accept the potential risks of tubal rupture.(9,11,13) Approximately one fourth of women presenting with ectopic pregnancies have declining -hCG levels, and 70% of this group experience successful outcomes with close observation, as long as the gestation is 4 cm or less in greatest dimension. An initial low -hCG titer also correlates with successful spontaneous resolution. While data are limited on this matter, initial -hCG titers below 1000 mIU/mL have been demonstrated to predict successful outcome in 88% of cases managed expectantly. There were abdominal pain, bloody discharge from vagina and low level of Hb. In this case, there were an abortion of tubal pregnancy might be because of trauma from massage. Because if there were rupture, could lead to massive hemorrhage, shock, disseminated intravascular coagulopathy (DIC) that didnt happen in this mother. Maybe when abortion happened, the product of conception extruded from tubal through the intraperitoneal rupture or fimbriated end into the peritoneal cavity. At this point, hemorrhage may cease and symptoms eventually disappear. Blood slowly trickles from the tubal fimbria into the peritoneal cavity and pools in the rectouterine cul-de-sac and forming hematocele. Pieces of the placenta or membranes may remain attached to the tubal wall and after becoming surrounded by fibrin and blood clots, then bleeding will stop. Complications of ectopic pregnancy can be secondary to misdiagnosis, late diagnosis, or treatment approach. (8,9)

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The procedure that performed by the doctor in charged in Hasan Sadikin hospital was surgical laparotomy. The type of operation was tubal Salpingectomy. This decision was made up on history findings and gynecological examination that indicated an ectopic pregnancy. This was a right decision. In exploration during operation, there was retro uterine hematocele and left tubal slightly enlarged with size + 5 x 4 x 3 cm. It was bluish red with tearing rags and active hemorraghe. The uterus slightly enlarge, left ovarium and right adnexal within normal limit. 3. How about her next pregnancy ? After a tubal-saving procedure, ectopic pregnancy is equally likely to recure in the operated tube as in the other tube. Overall, delivery rates are very similar after salpingostomy or salpingectomy if there is no history of infertility and the other tube appears normal. However, if the other tube appears diseased and she has a history of infertility, salpingostomy gives a higher delivery rate (76% vs. 44% in one study) and also a higher risk of recurrent ectopic than would salpingectomy.(4,7,12) It is very important for the doctor and the woman to discuss issues regarding future reproductive desires before surgery (if possible) especially if she has a history of infertility. She should be aware of the risks of infertility, recurrent ectopic . In general the ratio of intrauterine to recurrent ectopic is about 6:1 but it rises to about 10:1 if the other tube appears normal. After one ectopic and a tubal sparing surgery: The subsequent delivery rate is about 55-60%. The recurrent ectopic rate is about 15% (so about 20% of pregnancies are ectopics). The infertility rate is about 25-30%. The subsequent delivery rate is about 45-50%. The recurrent ectopic rate is about 20% (so about 30% of pregnancies are ectopics). The infertility rate is about 30-35%. The subsequent delivery rate is about 30%. After 2 or more ectopics and conservative surgery: If the other tube is absent or blocked:

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Some women fail to become pregnant again, while others become pregnant and spontaneously abort during the first trimester. A slightly higher recurrent ectopic pregnancy rate exists in patients treated by laparotomy (7-28%), regardless of conservative or radical approach, when compared to laparoscopy (6-16%).(10) This surprising finding is believed to be secondary to increased adhesion formation in the group treated by laparotomy The success rates after methotrexate regimen are in the range of 91-95%, demonstrated by multiple investigators. One study of 77 patients desiring subsequent pregnancy showed intrauterine pregnancies in 64%, and recurrent ectopic pregnancy occurred in 11%. Other studies have demonstrated similar results, with intrauterine pregnancy rates ranging from 20-80%. The condition of the patient now is post salpingectomy, a P2A1, 36 years old and had secondary infertility. This was the risk factor in this mother. So she is at high risk condition of having another pregnancy especially ectopic pregnancy. Maybe it will be better if she had sterilization. The doctor incharged alredy explained to the patient and her husband but they refused to have sterilization.

IV. CONCLUSION
1. There was a failure of hormonal contraception that caused ectopic pregnancy. 2. The management in Hasan sadikin hospital was correct. 3. Sterilization is better to be done in this patient, unfortunately her husband and she refused.

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REFERENCES
1. 2. Cunningham FG, Bloom SL, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD. Williams obstetrics. 22nd ed. New york : McGraw-Hill, 2005: 254-69 Damario MA, Rock JA. Ectopic pregnancy. In: Rock JA, Jones HW, editors. Te lindes operative gynecology. 9th ed. Philadephia: Lippincott Williams & Wilkins, 2003: 507-33. 3. 4. 5. 6. 7. Albayram F, Hamper UM: First-trimester obstetric emergencies: spectrum of sonographic findings. J Clin Ultrasound 2002 Mar-Apr; 30(3): 161-77. Wong E, Suat SO: Ectopic pregnancy: a diagnostic challenge in the emergency department. Eur J Emerg Med 2000 Sep; 7(3): 189-94. Valley VT. Ectopic pregnancy. Retrieved at Sept 3rd, 2005. Available from Retrieved at Sept 3rd, 2005. Available from http://www.emedline Bourgon DR. Ectopic pregnancy. http://www.emedicine Garmel SH. Early pregnancy risks. In: DeCherney AH, Nathan L, editors. Current obstetric & gynecologic diagnosis & treatment. 9th ed. New york: McGraw-Hill, 2003 : 272 - 85. 8. 9. DeCherney AH, Meyer WR. Ectopic pregnancy. In: Sciarra JJ. editor. Gynecology and obstetrics. 2nd ed. Philadelphia: JB Lippincott company, 1995:2(25);1-17. Piercy CN, Williamson C. Medical disorders in pregnancy. In: Chamberlain G, Steer P, editors. Turnbulls obstetrics. 3rd ed. London: Churchill Livingstone , 2002 : 275-92. 10. Rosevear S. Bleeding I early pregnancy. In: James DK, Steer PJ, Weiner CP, Gonik W, editors. High risk pregnancy. 2nd ed. London: W.B. Saunders, 2001: 6185.

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11.

Thoma ME: Early detection of ectopic pregnancy visualizing the presence of a tubal ring with ultrasonography performed by emergency physicians. Am J Emerg Med 2000 Jul; 18(4): 444-8.

12. 13. 14.

Gracia CR, Barnhart KT: Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstetric Gynecology 2001 Mar; 97(3): 464-70. Stein MW, Ricci ZJ, Novak L, et al: Sonographic comparison of the tubal ring of ectopic pregnancy with the corpus luteum. J Ultrasound Med 2004 Jan; 23(1): 57-62. Raheem M, Abukhalil I. Ectopic pregnancy. Retrieved at Sept 3rd, 2005. Available from http://www.hmc.org.qa/mejem/MARCH2005/edited/review2.htm

Case Presentation Thursday, September 8th, 2005

ECTOPIC PREGNANCY THAT OCCURRED IN WOMAN WITH HORMONAL CONTRACEPTION

Presented by: Daniel R Hatalaibessy.

Moderator: dr. Ruswana A., SpOG

Resource person: dr. Duddy S. Nataprawira, SpOG (K) dr. Anita D. Anwar, SpOG (K) dr. Dodi Suardi, SpOG

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OBSTETRICS AND GYNECOLOGY DEPARTEMENT PADJADJARAN UNIVERSITY MEDICAL FACULTY DR.HASAN SADIKIN HOSPITAL BANDUNG 2005

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PENILAIAN CASE PRESENTATION


Nama : Daniel R Hatalaibessy. Semester : III Presentasi kasus ke : IV (English Case) Tanggal presentasi : 8 September 2005 Moderator : dr. Ruswana A., SpOG Penilai : Tanda tangan

ECTOPIC PREGNANCY THAT OCCURRED IN WOMAN WITH HORMONAL CONTRACEPTION

No 1. 2.

VARIABEL YANG DINILAI Ketepatan penentuan masalah dan judul, Data kepustakaan, diskusi. Kelengkapan data : Laporan kasus, informasi tambahan dari petugas terkait - Kunjungan rumah - Kepustakaan Analisa data: - Logika kejadian - Hubungan kejadian dengan teori Penyampaian data: Cara penulisan Cara berbicara dan audio visual

Nilai dalam SKS

3.

4.

5.

Cara diskusi : Aktif/ mampu menjawab pertanyaan secara logis Kesimpulan dan saran (harus sesuai dengan diskusi) Daftar pustaka TOTAL ANGKA Rata-rata Pengetahuan Keterampilan Sikap

6. 7. 8. 9. -

Catatan : Untuk perbaikan dilihat dari segi :

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