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ECt$plC PregnAncyand Abortion

Ectopic Pregnancy

Spontaneous Abortion

,.,...ll.i'..;FetalDeath.

Abortion

The student should understand that ectopic pregnancy is a leading cause of maternal morbidity and nror-tality, and that early diagnosis and intervention-can p."."ru" fertility and save f t"r. sira""ir"n""'j O"able to define the types of spontaneous abortion (spontaneous, recurrent, incompfete, and septic) andexplain their diagnosis and management, including the differential diagnosis of bleeding in the firsttrirnester. Students should also be able to explain the indications, rfsks and benefits, and means for elec-live and therapeutic'labortion. Students should be able to evaluate and manage fetal death in eachtrimester, including appropriate counseling for the parents,

:: i:.'T'r,} r' g {.- 5r ia: il# il'""i g1\ lr,$ i"" Y

'.,r ectopic {}r extrauterine pregnanc}'is one in ll,lrich"-." biastoc'r.st irnplanffi nr, r'here other than rhe cndrlrnc-:-,rl lining of the uterine ca\riry. As slrr:\{ n in Figure 1 "i. I ,

i'j'il of ectopic presnancies irnplant in the fellerpian tube,:rir 80% occurring in the aiTlpullar"rt scgnrent. (-)tirer-

-'Lttions include, but are not lirnitecl to, dre oval-\,', cervir,"'t1 abclomen. ln solrle fcrrtn, the1, account for 1.3-7r, ta 29b

'r'e ported pregnancies in the Llnited Stirtes.

In the past) ectopic pregnarlc.l,- was life-threafeniug.: irlier diagnosis rnacle possillle br. the rle\\,- ahilin tri detect- c B-sulnrnit of hLrman chorionic gonedotropin (htlG),.,nrbined rvith high-resoludon trnrlsvaejnal son(xrrirplrtii \-S). has reducecl this threrrt. ltierrertheless, ectopic:

:-;,rgrlancies rernilin an irnportant cfluse of morbiditlr and':i-irtaliry in dre United Stetes. The incidence of ectopic-.,:'rq'narty has increasecl ronsistent rn'ith the rise in clrla-, .,-.-dial infections.

ii*,".; *;= i il*t*r:i{: ffrm* fl-ic} Frilv'' $-

* ..*; d

"'llthout intervention, the nanrral course of a tul:ai preg-

inc\r can lead ro ftrbal abortion, nrbal rupnu'e, ol' sp()nta-,,.olrs resolution. Tuhal abortion is the expulsion oi:.,i':ducts of-conceptiorr thr*ush the firnbriater{ encl. l]lhis

tissue can then either regress or reimplant in the abdomi-ual cavity. a.tbal rupture is associatecl u,ith sienificantintra-a bdonrinal hemorrharqc, clften necessitatins surgicalinten endon.

$.F,,&,'E-rai tg*g,u"l:=?{ +1 g;g,,!' x.\- i.: -ffi}:*;." Far:'g"s"}g{-5

;tn eppreciation of risk factors for ectcpic pregnanc\-r leircls

to a timeltr diagnosis r,vith impror.ecl rnatern:rl suraii\rAl anLl

f-utlrre rcpro(lucti ve poten tial.Inflarnrnation has hccn implicilte(l in the role cf tubal

tJamage that predisposes to ectopic pr"egnancies. Inflarn-ltlat()nr processcs, such as salpingitis and salpingrtis isth-mica nodosa' ma],'also pla)' a role. Acute pathol{.}S,r, suci}as chlamydial infection, caubes intraluminrll infl$nrmil-tion and sutrsecluent frbrin deposition u.ith tutral scnn'ing.I)espite nesatiie cnlnircs, per-sistent chIarnr.diaI :rntig-e;scrln trigger r clelir)'ed hrpersensitjviti' relctiun u"ith corl-tinuecl,scarrin g. !\,''hereas endotoxin-proclucinq -\'ei-il ru'r#

g'otron'lt()(ttt causes virulent pe lvic inflarntlratir)n il.ith a rapidclinical onset, chlanrrclial inflanrrniltcry resL)r)nse is indo-lent and peaks at 7 to 14 davs.

Altlrough pregnarlc],r atter sterilizrttion is t'are. rvhen itrloes occ:ur, there is a sutrstantial risk thar the pregnanc,\ru'ill he ectcpic. ,l'dost forrns r:f contraception decrc*se dre

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i 4? Cbstetrics anC Gr,.er5 ,3gi,

F:i':ilF?r 1:, 1 lncics-ce ,:.i I \l \l _\* :4 3 - l! I\._lUtv uv

types ct ecicnjc c.*.1^3-i.hir inr-:-..^,. i ?* = :tq t-'=-{*J

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Natural conosptian Ccnception

Cornual(interstitial)

-70Jtla

after ART

Tubat82/o

,, .,,i.;'i..:*.,, Ampultaryi,t" t,t

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Cornual(interstitial)

Z*iaAnrpullary

B0%

Fimbrial6"h

Abdominat1*2jrL

Cervical1.5%

Cervical0" 1 5?'.

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13 Ectopic pregnancy and ,Abortion i .t;-

qregnancies have fi,orlnftl doubling tinres. Der,-iarion fi:omrh i t p e ffi e rn

.s h o u I d ra i s e s u s p i c i o rr' fn ; ; ;,; ;", -*" ;h ;; ;;

n?t_ proceeding normally, inclucling ..iopln pregnarlcv,'4lrho ugh in.nltgtrop,iutely,isirtg seruti F- * cc trvoti' rtt ggrs.tt(but do nat r{iagnose) nn nhnarrirrl pr'€gr?ilrrry, they do nrstTirrr-rtfi its lomtioi r o *' I -''

A key adjuncr ro serial quanriratir.e levels of hcG ispelvic ulmasonosraphy (I.-ig. 13,2). Ffigh-resalutian *1*trils#nography has revolutionized the cLinical manase-tllent of llrCItren r.l'itl'r a suspected ectopic presnair..Llsing T\is, a gesrarional *u* is usuailrr uiribi* #;-;;L)JAt i t F4/: and 5 w'eeks fi:om the last ffienstrual pcriod, the yolk

f |ffiLJRffi i3"3" Ectopic pregnancy with an extrauterine ges-tational sac containing a live embryo, {A) Coronal transvagi-nal view of the right id.r**u demonstrates an extrauteriiesac (arrows) containing an embryo (calipers). (B) Sagittal trans-vaginal view of the uterus reveals no evidence of a gestationalsac. (From Doubilet PM, Benson CB. Atlas of U/tiasound inObstetrics and Gynecology. Philadelphia, PA: LippincottWilliams & Wilkins; 2003:319.)

t d$4 Obstetrics and Gynecoiogy

sac appeafs befne'en 5 ,rntl ii \.r tcl'S. *n{1 a futrrl pole_oi*lcardiac actirrit,ri is hrsr el*icctrii itt iyi tn 6 r'r.eeks Wi*ltransabclcmin u l sr i ir o r-r;r pir r

- iir c s* st ftr(:rllrcs irre vi sual i z*cl

slightlv lirter. Erch iirr-r -,-itir in Ilurst define il F-htl{) dis-crilninatorr- r'alue* thri ii ** ltlu.'er. limit of hfiG ei

r,q,hich sn e \;l iiti::ul' t'rtt rcli;tllh' r,isualize pregnancy otltrltrtso Lrg..1. l

-ir r rt ir r r-c icnsitive tlilnsvrlginal ttltrasollogri]*

ph]- stroui.-l .i:l'",i. fitu pfc{ttrittcy ltv the tirttt the hC(i ]evel

ir ii}f;ll ,u' ', i'-,r i 1i--,'1. Transabdolnina] ulmason*gr*pirvslr*ui.1

.ir* ,;irjc rr] i.leirtit"r'rrn intrtruterine gestaficxr ttv the

tirnc lirc i:{-G lcr-el re,rches 5000 to 6f100 IU/L. Accurate

riirlgr:i,l:is i'i- su:nogr*phl.' is three titles more liliely if tlreir:irjr:: *-]:{.{;ler-el is alrove this r.aiue.'tr'h._ absent-e eif

i,tui':l.- prr"cg-lttj'tcl,- rvidr [3-h{]f; lerrels ab*r'e thc discrir:ri-

11:1rq-irr- r-':1ue sienifieS an ahnarmal pregnfinc\''-ectolllC'i:lcri:::plete ahortir:n, clr _resolving

cr:lnpletecl iltlor-tion.

{-:it-c l:rusl tle taken to ditferentiate tr1t1'een a uterfute gel-

lrti*n and il pseudogestational sac. This rtne*la,ver stc is

..irr lcsr:lt ni *,-, intiac*vitary fluid collcctior-l c'rused bv

sl,;ughilg of the rlecidga wpicalh' sitrtatecl in dre rnittline

*f tlie gterine carrirt,, rn hereas a normal gesr;ld*nal sac is

cccentricnrll]- lo.tted (Fig. 1 3 "3)

Serum pt*g*rterone concentriltion has alsr: heen used

llg test for ectopic prcqnarlcv. There is ntinimalilS tt Scfeenll ' r befu'een 5r-ariirtir:nitr5flruI]1progesteroneConCenn.ailoIrnd l0 rvceks' gestirtion, thus a single value is suflicient. A

serum proqesterone level of <5 ng/rnl has been used to

i rlen ti h a non l'i a ble preqn il nc\,' s'i th lt ear-perfcc t spec i fi c i ti'-

Uter

Bladder

- Bowel

f i#i.jruff 1;T,"t" Pseudogestational sac. Sagittal transabdam-

inal view of the uterus demonstrates a pseudogestational

sac, a collestion of fluid within the uterus. iFrom D^oubilet, PM,

Benson CB. Atlas of lJltrasound in Obstetrics,.a"d {{tit:Fglpiriladelphia, PA: l-ippincott Williams & Witkins; 2003:320.]

Blood lncul-de-sac

Culdocentesis.

13 Ectopic Pregnancy and Abortion i -en

cverl or lahoratary evidence of irnmunodeficiencyAfcoh*lism, atcchaiic {iver' *ir*ir;, ;;;;;; *rr.onli

liverdiseasg -2 rv'|r'v

Presxisting blaod dyscr"asias, such as bsne marrowhypoplasia, leukopenia, or thrombocytopenia,or significant anemia

Known sensitivity to methctrexateActive pulmonary diseasePeptic ulcer diseaseHepatic, renal, or hematologic dysfunction

ffie$mtivs:

Gestational sac greater than 3.S cm

Absmf r*ts:Sneestfeeding

Embryonic cardiac motion i_':*4!r+i:ri-_*r44?:r*-:i+! a_,fi

Arv:ii5.-r4rb_J.re+

i 4S Obstetrics and GYnecology

Fiffii.-iHA t 3.5. Surgical manage-

ment of ectoPic Preglan.cy'{A} Site of linear incision for lin-

ear salpingostomY. (Bi Linear in-

cision. (C) Segmental resection'

{D) Tubal reanastomosis.

tts)tA)

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tc) {D}

iIl:M

i 4ffi Obstetrics and Gynecofogy

tg Ectopic Pregnancy and Abartion

150 Obstetr:ics and Gynecology

usually preients with fever, pain, a tender utenrs, and mildbleeding, Oral antibiotics and andpyredcs are usually suf-*aia *it*infeclffis''if,*ts ***in the uteflls (incomplete aborcion), t repeat suction curet-tag;e is necessaq'. The second most common complica-tion followrng indriced abortion is bleeding" Risk of deaihfrom abordon during the first 2 months of pregnanc-l- is

less t}an I per i 00'000 proceduresrwith incr,ea.si"$ rates

as pregnanc]- progresses (versus 7 .,7 maternal deaths per100,000 Iir e hirihs).

Snrrtc AnaRT-Ioh{

A" irti**t*J *U"trion, either *o*pl*i* ot iniompleie, iskno*,n as a septic abortion. Patrents ma),' present r,vith

s*pois, sliock, ft**orrhage, and possibty te"al failure. Itr*r*t!- occurs *: * cornrylicition,of a legat abordon, but is

'Iry*oii, ttrose done illegallrt, under unsterile condi*ons, b!'per-sons who *"y hr,r* litde ot tto knowl*dg*e of medicine or

#iiid@iapg;'ax$$i@e*ait*a4,.'df@ .&vs,''iwd'{:

urted. A careful evaluation for trauma, includi*g perfora-tion of the uterus, vagin a, oi in*aabdominal structures,ihould also be carried out.

+ _"

Postabortal sytdrome develops u,'hen the uterus fails.-1..,, r,trr:,r.,,:''.t,-::.t,.a,t.,;l:,,;,,i.,,,:i#** eted * **,0*'t

ut etidu' ivefther;p#e't*$#+t*u:' itir,*i.r, ii* , nir,.,**d/ot.bleedffi d is found'td'-fiC+Ced' apett i*and a large, "softer-than-expected" ,rt**J, a result of the*ffi*#dd ,,b1ddd *h **a i

Iical presentadon is often indistinguishable from iniom-plete abordort. Soi*on .r'rietmge is the reatrnerr-t foi bathf$*d,id$**rPostevai"u***' ig*t deiir.-*dv*'** *iefi d,bi$iic*ed* ' ri strc af p tlsta,'b'o

A+d ' ib*A*fu **d infe*ion.

SUGGESTED READINGS

American College of Ohsterricians tnd Clrmecclogists. Managemenicllrecuruent early pregrtanry loss, A(IOG Prartice Bullean No. 24.

"-'6,6 8tt"2$$q,9.7. ,.l't"- ='-',,,.,, :,, .:: ;:.,,,,,.., .,,,'--I,'::"..-;'',

American College of Obstetricians and Gynecologists. Mecficai man-"'.*ge ; tsultetiu&'e;. obsterG"v^

l,'"',I,?t ./;,? ffiffip*8ai''.'"., "'. ".*"-J-; ffi G^-'.i llr*r-"icjans gd_qynecolo€tltr ft{tedical

ryT*S*_*eni of rubal pregnancy. ACOG Practice Bulletin lto. 3.

Obsret Gyzecol. 1 998;92(6): l-7.