OB CASE PRESENTATION

1. OB CASE PRESENTATION Zshari Zxilka T. Tanggol Medical Intern Department of Obstetrics and Gynecology August 2010 Preceptor: Dr. Fernandez

2. General Data • N.A. • 31 y/o G3P3 (3003) • Married • Islam • Pasig City

3. 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

4. Family History • (+) Hypertension – mother • (+) Diabetes Mellitus – mother • No bronchial asthma, heart disease, cancer, thyroid abnormalities

5. Personal and Social History • Nonsmoker • Non-alcoholic beverage drinker

6. Menstrual History • Menarche: 12 y/o • Regular • 5 days • 3 pads per day • (-) pain • LMP: June (3rd or 4th week) 2010 • PMP: May 2010

7. Obstetric History • G3P3 (3003)

8. 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

9. History of Present Illness (+) 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 7 days PTA 3 days PTA (+) Recurrence of RLQ pain (+) Associated with minimal vaginal bleeding with passage of blood clots

10. History of Present Illness (+) 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 2 days PTA Few hours PTA • (+) 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

11. 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

12. 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

13. 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

14. 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)

15. 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

16. 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: adynamicprecordium, normal rate and regular rhythm, apex beat at 5th L ICS-MCL, no heaves, no thrills, no murmurs.

17. 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

18. 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

19. 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

20. differentials • Abortion • Ovarian Cyst • Pelvic Inflammatory Disease • Subchorionic Hemorrhage • Ectopic Pregnancy

21. 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)

22. Ectopic pregnancy

23. 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

24. Risk factors: Classification • Mechanical • Functional • Assisted reproduction • Failed contraception

25. 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

26. Mechanical factors • Reduced ciliation 2o to infection: PID (Chlamydia trachomatis), Salpingitis • Developmental tubal abnormalities (diverticula, accessory ostia, hypoplasia)

27. 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

28. Assisted reproduction • Increased incidence with gamete intra-fallopian transfer (GIFT) and in-vitro fertilization (IVF) techniques (atypical implantations more common)

29. 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.

30. Risk factors • Multiple sexual partners • Prior Caesarian section

31. 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

32. Pathophysiology

33. 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%)

34. Normal anatomy of fallopian tube

36. 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 (60-80%) • Abdominal and pelvic tenderness (75%) on palpation with or without palpable pelvic mass (20%) • Vasomotor disturbance (vertigo/syncope) with signs of hemodynamic compromise (20%)

37. Clinical presentation • First trimester uterine changes (25%) • Cervical motion tenderness • Bulging of posterior fornix • CLASSIC CLINICAL TRIAD: Pain, amenorrhea, vaginal bleeding

38. Ectopic pregnancy: DIAGNOSIS • Complete history and physical examination • Urinary pregnancy tests: positive in 50% to 95%

39. 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

40. 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

41. Ectopic pregnancy: diagnosis • Novel serum markers under investigation: vascular endothelial growth factor (VEGF), cancer antigen 125 (CA125), creatine kinase, fetal fibronectin, and mass spectrometry-based proteomics

42. Diagnosis: ultrasonography • Abdominal sonography • 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 • Uterine pregnancy 1 week after missed menses with B-hCG >1500 mIU/ml • Identification of fetal pole within the uterus with FHT

44. 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

45. 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

47. Ectopic pregnancy: diagnosis • Culdocentesis • Laparoscopy

48. 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

49. Ectopic pregnancy: MANAGEMENT • Medical management • Expectant management • Surgical management

50. 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