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NBME 4 Block 3 Q46 - vitf
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07-17-2008, 06:45 AM
ECTOPIC PREGNENECY..Strongest predisposing factor..
a.adolescent age b.congenital anomaly of uterus. c.h/o abortion d. h/o gonorrhoea e. use of depot medroxyprogesterone.
07-17-2008, 06:53 AM
d. h/o gonorrhoea.......................Pelvic inflammatory disease
Ectopic Pregnancy Key Features Essentials of Diagnosis Amenorrhea or irregular bleeding and spotting “ Pelvic pain, usually adnexal “ Adnexal mass by clinical examination or ultrasound “ Failure of serum level of human chorionic gonadotropin (hCG) to double every 48 h No intrauterine pregnancy on transvaginal ultrasound with serum hCG of 2000 mU/mL General Considerations Occurs in about 1 of 150 live births, with 98% of cases being tubal pregnancies Implantation may also occur in the peritoneum or abdominal viscera, the ovary, and the cervix Undiagnosed or undetected ectopic pregnancy is the most common cause of first-trimester maternal death in the United States Demographics Conditions that prevent or retard migration of the fertilized ovum can predispose to ectopic implantation Specific risk factors “ History of infertility “ Pelvic inflammatory disease “ Ruptured appendix “ Prior tubal surgery Clinical Findings Symptoms and Signs 40% of cases are acute “ Sudden onset of severe, nonradiating, intermittent lancinating lower quadrant pain “ Backache present during attacks “ Shock in about 10%, often after pelvic examination “ At least two-thirds of patients give a history of abnormal menstruation 60% of cases are chronic “ Blood leaks from the tubal ampulla over days “ Persistent vaginal spotting is reported “ A pelvic mass is palpable “ Abdominal distention and mild paralytic ileus are often present Differential Diagnosis Acute appendicitis Intrauterine pregnancy (threatened abortion) Pelvic inflammatory disease Ruptured corpus luteum cyst or ovarian follicle Urinary calculi Tuboovarian abscess Gestational trophoblastic neoplasia, eg, hydatidiform mole Shock or sepsis due to other causes See also DDx: Ectopic pregnancy Diagnosis Laboratory Tests Complete blood cell count may show anemia and slight leukocytosis Serum hCG levels are lower than expected for a normal pregnancy of the same gestational age Serum hCG levels may rise slowly or plateau rather than double every 48 h as in viable early pregnancy or fall as in spontaneous abortion Imaging Studies Endovaginal ultrasound may identify the ectopic pregnancy An empty uterine cavity demonstrated by abdominal ultrasound with an hCG of 6500 mU/mL is virtually diagnostic Diagnostic Procedures Culdocentesis is rarely used in evaluation Treatment Medications Methotrexate (50 mg/m2) IM is acceptable for early ectopic pregnancies < 3.5 cm and unruptured, without active bleeding Iron supplementation may be necessary for anemia during convalescence All Rh-negative patients should receive Rho(D) Ig (300 mcg) Surgery Laparoscopy is the surgical procedure of choice to both confirm and permit removal of an ectopic pregnancy without need for an exploratory laparotomy Salpingostomy with removal of the ectopic or partial salpingectomy can usually be performed laparoscopically Injection of indigo carmine into the uterine cavity with flow through the contralateral tube can demonstrate its patency Outcome Complications Tubal infertility Prognosis Repeat tubal pregnancy occurs in 12% Early ultrasound confirmation of intrauterine gestation with next pregnancy When to Refer For suggestive symptoms, laboratory tests, and especially ultrasound findings that support the diagnosis When to Admit All suspected cases of ruptured ectopic pregnancy |
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