Imam Nafi_CHALLENGES IN DIAGNOSING RUPTURED ECTOPIC PREGNANCY.pptx

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1. CHALLENGES IN DIAGNOSING RUPTURED ECTOPIC PREGNANCY dr. Imam Nafi Yana Saputra Resource person dr. Beni Samsul Amri, Sp.OG DEPARTMENT OF OBSTETRICS & GYNECOLOGY FACULTY OF MEDICINE UNIVERSITAS PADJADJARAN MARGONO SOEKARJO HOSPITAL PURWOKERTO SOOCA V - Gynecology (English Case)

2. INTRODUCTION Definition Ruptured ectopic pregnancy occurs when an embryo develops outside the uterus, commonly in the fallopian tube Medical Significance Ruptured ectopic pregnancy requires immediate medical intervention due to the risk of life-threatening complications Epidemiology Ruptured ectopic pregnancy is a leading cause of morbidity and mortality in the first trimester of pregnancy Global incidence: Approximately 1 in 250 pregnancies. In the United States: accounts for about 20% of all pregnancies. In Indonesia: Prevalence ranges from 5 to 6 per 1,000 pregnancies, with around 60,000 cases annually (0.03% of the total population). Trends in Indonesia Significant increase in ruptured ectopic pregnancy incidence; at Arifin Achmad Hospital, cases rise from 4.6% in 2010 to 5.7% in 2012

3. INTRODUCTION Symptoms Lower abdominal pain Amenorrhea Irregular vaginal bleeding Diagnosis Challenging due to non-specific symptoms that can mimic normal pregnancy Common location: Nearly 98% of ectopic pregnancies occur in the fallopian tube Diagnosis involves a thorough medical history, physical examination, and tests such as ultrasonography and β-hCG level assessment. Challenges in Indonesia Limited access to health facilities Lack of public awareness about Ruptured ectopic pregnancy Delays in early detection Importance of Awareness A comprehensive understanding of ruptured ectopic pregnancy’s epidemiology, incidence, and symptoms is crucial for improving early detection and management, thereby reducing morbidity and mortality associated with the condition.

4. CASE PRESENTATION Patient Demographics Mrs. YD , (G2P0A1) 25 year old Chief Complaint Vaginal bleeding for eight days (approximately half a pad of blood daily) Abdominal pain worsening over the last two days Associated Symptoms: Denies any tissue discharge Experience of nausea Vomiting once daily No history of abdominal trauma No respiratory symptoms (cough, shortness of breath, fever)

5. CASE PRESENTATION Pregnancy History Positive pregnancy test on May 18, 2024 Ultrasound examinations suggest ectopic pregnancy Previous Medical History History of ectopic pregnancy Left salpingectomy performed on November 1, 2023, at Goeteng Hospital History of monoplegia post-salpingectomy and undergoing therapy

6. CASE PRESENTATION General condition Compos mentis Vital signs Blood pressure: 124/79 mmHg Pulse: 80 beats per minute Respiratory rate: 20 breaths per minute Body temperature: 36.5°C Oxygen saturation: 99% on room air Weight: 49 kg (increased from 48 kg before pregnancy) Height: 158 cm BMI: 19.2 kg/m² (within normal range) : Abdominal examination Flat and soft abdomen Tenderness (+), defense muscular (-) Shifting dullness (-) Uterine fundus not palpable Laboratory Results (May 30, 2024, from Margono Hospital) Hb/ Ht /Leu/ Tro 13.2/40.1/13430/351000 PT/ aPTT 14.6/32.7 Albumin 4.91 RBG 96.8 Na/K/Ca/Cl 143/4.3/9.8/107 SGOT/SGPT 19/24 Ur/Cr 14.2/0.6 HbsAg non reactive Urinalysis Bacteria 11-21/HPF Leucocyte 2-4/HPF Nitrite negative Protein urine +1/25

7. CASE PRESENTATION Transabdominal ultrasonography : Imaging Results Ultrasound findings: Filled bladder Anteflexed uterus with inhomogeneous density (size: 7.9 x 3.51 x 4.96 cm) Endometrial thickness: 21.04 mm Extrauterine gestational sac visible without fetal pole (size: 2.17 x 2.09 cm in the right tube) Minimal free fluid in the Douglas cavity DIAGNOSIS Suspected ectopic pregnancy in the right fallopian tube

8. CASE PRESENTATION MANAGEMENT PLAN Surgical Procedure: Emergency exploratory laparotomy. Prophylactic Medication: Cefazolin 2 grams IV administered. Pain Management: Ketorolac 30 mg IV administered three times. Blood Transfusion: Two units of Packed Red Cells (PRC) transfused. Intraoperative Findings 50 cc of blood in the peritoneal cavity. Uterus appeared normal Adhesions between the tube and peritoneum; adhesiolysis performed. Enlarged right tube (pars ampullaris) measuring 3x2x1 cm. Scar on the left tube due to previous salpingectomy. Both right and left ovaries within normal limits. Right salpingectomy performed without active bleeding; intraoperative blood loss estimated at 100 cc. Surgical Outcome

9. DISCUSSION Challenges in Diagnosis Ruptured ectopic pregnancy is complex to diagnose due to non-specific clinical symptoms and limitations in transabdominal ultrasound and laboratory values Common Symptoms Abdominal pain Vaginal bleeding Signs of pregnancy (e.g., nausea and vomiting). Physical Examination Cervical motion tenderness may indicate rupture ectoppic pregnancy Absence of adnexal mass can also support suspicion of ruptured ectopic pregnancy Laboratory Findings Hb doesn’t show any impairment Leukocytosis observed (e.g., leukocyte count of 13,430/µL) suggests an inflammatory or infectious process associated with ruptured ectopic pregnancy

10. DISCUSSION hCG Levels Imaging In ectopic pregnancies, hCG levels are typically lower than in normal pregnancies and do not rise as expected (doubling every 48-72 hours). Normal early pregnancy hCG > 25 mIU/ml; ectopic pregnancies may show less than 66% increase in 48 hours or a decrease of no more than 13%. Transabdominal ultrasound may not be sensitive enough for early for detection Ultrasound may show a suspected ectopic pregnancy but not provide clear location information Transvaginal ultrasound is preferred for better resolution and clearer images in identifying ectopic pregnancies. Need for Comprehensive Evaluation Diagnosis can requires careful consideration of clinical symptoms, laboratory findings, and imaging studies to rule out other conditions

11. DISCUSSION Diagnostic Modalities Transvaginal ultrasound: Provides clearer images of ectopic pregnancy location Diagnostic laparoscopy: Allows direct visualization and confirmation if imaging is inadequate Management and Treatment Options for Ruptured Ectopic Pregnancy Medical Approach: Methotrexate : Effective in treating unruptured ectopic pregnancies by stopping the growth of ectopic cells Surgical approach in severe bleeding or unstable hemodynamics cases: laparoscopy / laparotomy

12. DISCUSSION In this case, the patient underwent emergency exploratory laparotomy and right salpingectomy due to an ectopic pregnancy in the right fallopian tube. This procedure aligns with the guidelines for managing Ruptured Ectopic Pregnancy (REP), which recommend surgical intervention in cases with unstable clinical conditions or tubal rupture

13. DISCUSSION Primary Mechanism Ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity Impaired Transport Factors that hinder the normal transport of the fertilized egg through the fallopian tube contribute to abnormal implantation Pelvic Inflammatory Disease (PID) A history of PID or other infections can cause scarring and damage to the fallopian tubes, leading to ectopic pregnancy Surgical History Previous pelvic or abdominal surgeries, including surgeries for ectopic pregnancies, can create adhesions and alter tubal anatomy, increasing risk Smoking Smoking negatively impacts ciliary function in the fallopian tubes, hindering egg transport and potentially creating a favorable environment for ectopic implantation Pathophysiology of Risk Factor for

14. DISCUSSION Age Pathophysiology of Risk Factor for ruptured ectopic pregnancy Women over 35 face a higher risk of ectopic pregnancy, potentially due to age-related changes in tubal function and hormonal balance Assisted Reproductive Technologies Procedures like in vitro fertilization (IVF) can increase the risk due to embryo manipulation and changes in the tubal environment Contraceptive Failures Ectopic pregnancies can occur following failures of contraceptive methods, especially with intrauterine devices (IUDs) or after tubal ligation if fertilization takes place

15. DISCUSSION Pathophyisiolgy of Risk Factor Ectopic Pregnancy Growth As the ectopic pregnancy grows, it may cause distension and rupture of the fallopian tube or implantation site The risk increases with gestational age as the embryo surpasses the ectopic site’s capacity The ampullary region of the fallopian tube is the most common implantation site (80% of cases). Other less common sites include the isthmus, fimbria, and interstitial portions. Rupture occurs due to mechanical stress from the growing gestational sac which causes tissue damage and breach of the tubal wall The rupture process often leads to local inflammation and increased vascularity, contributing to severe bleeding and potential life-threatening internal hemorrhage.

16. CONCLUSION Ruptured Ectopic Pregnancy is a serious medical condition that requires immediate treatment to prevent life-threatening complications This case involved a 25-year-old woman with a history of previous ectopic pregnancy. The diagnosis was established through ultrasonography The patient underwent exploratory laparotomy and right salpingectomy Prompt and appropriate management is crucial to reduce the morbidity and mortality associated with rupturen ectopic pregnancy This case highlights the importance of early detection and proper treatment to prevent serious complications

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18. Evaluasi dan Penegakan Diagnosa Hemorrhagic Luteum Cyst pada Kehamilan Trimester I DEPARTEMENT OF OBSTETRICS & GYNECOLOGY FACULTY OF MEDICINE PADJADJARAN UNIVERSITY HASAN SADIKIN GENERAL HOSPITAL BANDUNG 2024 SOOCA V – Gynecology Case 12 August 2024 Presented by : dr. Nasrudin Resource Person: dr. Herman Sumawan , Sp.OG , Subsp . K.Fm ., M.Sc