case ket.ppt
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ECTOPIC PREGNANCY
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Introduction Ectopic pregnancy Pregnancy develops outside of endometrial of intrauterine cavityCould be emergency situation! The incidens increasing every years Leading cause of maternal death in first trimester
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ECTOPIC PREGNANCY RISK FACTORCLINICAL TRIAD OF ECTOPIC PREGNANCYDIAGNOSTIC PROCEDUREMANAGEMENT
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CasePatient, I, 40 years entered in VK IRD RSUD AA Pekanbaru wednesday, February 22nd 2007 at 05.28 PM, with :
Chief complainConsciousness deficit 15 minute before entered in IRD RSUD AA Pekanbaru.
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Present illness15 minute before entered in IRD RSUD AA Pekanbaru. Patient down of consciousness and falled down, stomatache (+), nausea and vomitus (+) and fell cold.
4 hour before came to the hospital, weakness (+), headache (+), dizziness (+). 3 weeks ago, bleeding from vagina, some time, brownies, no pain
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Amenore (+). The first day last menstruation : 28-12-2006.Febris (-).Feel pain and burn at pelvic area (-).She didnt have ektopic pregnancy before.Patient havent be operate in pelvic area beforeComplain about urinary (-).Complain about leukorrhoe (-).Smoker (-).
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Physical ExaminationA. General StateGeneral condition: weak and paleConsencious : ComposmentisVital sign: Blood pressure : 60/pulse Heart rate : Soft and quick Respiratory rate: 24 x/bpm Temperature : 37,5C
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Conjungtiva : anemiaLips, tongue and skin : PaleEar, nose, throats: NormalyHaight: 154 cmWeight : 51 kg Nutrition : GoodThoraks: NormalyEkstremities: Normaly
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B. Ginecological stateFace: Kloasma gravidarum (-)Mammae: NormalyAksila: Normaly Abdomen Inspeksi: plate,umbilical normaly, sikatrick (-), striae (-) Palpasi: Push pain (+) Hepar, lien and renal difficult to measure Perkusi : redup Auskultasi: peristaltik (+)
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Genitalia Inspeksi : vulva and vagina normalyInspekulo: portio : Livide (+), blood from OUE (-), erosi (-), mass (-)
VT bimanual: Pain portio, uterus ante fleksi, measure of uteri more bigger than normal uteri, pain at left and right adneksa(+), douglass crise (+).
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Laboratory evaluationPlano test: (+)Hb: 9,1 gr%Leukocit: 20.500/mm3Trombocit: 145.000/mm3BT: 2CT : 4Ht: 29 vol%Ureum : 42 mg%Creatinin : 1,4 mg%
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Working diagnose
Shock hipovolemik + acute abdomen e.c suspect rupture ectopic pregnancy G4P3A0L3 (gravid 8-10 Weeks)
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TherapyRepair general conditionIVFD NaCl 0,9% give 4 flash in one hourO2 10 liter/minutePrepare Whole Blood transfusion 1000 ccDauer Catheter urine (-)General Observe and vital signUSG
Plaining :Laparatomy cito
PROGNOSIS : Bonam
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FOLLOW UP22nd February 2007 at 7.30 PMS: Abdominal pain (+), bleeding from vagina(-), all of ekstremity ColdO: Conscious composmentis Blood presure : 90/60 mmhg, pulse : 110 prm soft and regular, RR: 22 prm, temperature : 36C.IVFD NaCl 5 kolf Dauer Catheter: 50 cc, Transfusion (-)
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USG uterus > normally, gravid ekstra uterine fluid in cavum Douglasi and cavum abdomenConclution Rupture Ektopic pregnancyA :Shock handled.Acut abdomen e.c Rupture Ectopic pregnancy + G4P3A0L3 (gravid 8-10 weeks)P : Laparatomy cito
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08.00 PMSalpingektomy by Laparotomi surgery with general anastesi Durante operasionum:Insisi linea mediana 7 cmAbdominal cavity fill with blood Look for the source of bleeding salping dekstraSalpingectomy dekstra Bleeding control Subcuticular and cuticular suture
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Therapi post op:Fasting until bowel peristaltik (+)IVFD RL : D5% + 2 Vials syntocinon 30 gtt/minuteAmbacin 3 x 1Kalnex 3 x 1Pronalges supp 2 x 1Transfusion until Hb 10gr%Pkl : 21.00 Operation done
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23 th February 2007 07.00AM
S: nausea and vomit (+), head ace (+), fever (-), flatus (+),Bowel (-), O: General Condition : awake.Conscious : composmentisVital sign : Blood pressure: 110/80 mmHg Heart rate : 88 prm RR : 18 prm Temperature : 36,5C
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Conjungtiva : anemiaDauer catheter : 600 cc (10 hours)Transfusion Whole blood 500 ccA: Post Laparatomy indication Rupture ectopic pregnancy Ist dayP: Cek Hb post operation Blendered meal Th/ Goes
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24th February 2007 07.00 AM
S: nausea (+), head ace (+), fever (-), flatus (+), bowel (-), O: General condition goodConscious : composmentisVital sign : Blood pressure: 110/80 mmHg HR : 80 prm RR: 16 prm Temperature: 36,5C
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Konjungtiva : anemisDauer catheter : 1000 cc (10 hours)Transfusi Whole blood 250 ccHb : 8,0 gr%A: Post laparatomy indication rupture ectopic pregnancy 2nd dayP: oral therapy diet high calory high protein
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25th February 2007 02.00 PM
S: nausea (+), head ace (-), fever (-), flatus (+), bowel (-), cought (+)O: General condition goodConscious : composmentisVital sign : Blood pressure: 110/70 mmHg HR : 84 prm RR : 16 prm Temperature: 36,9C
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Conjungtiva : anemisDauer catheter : affTransfusi Whole blood 250 ccHb : 8,0 gr%A: Post laparatomy 3th dayindication rupture ectopic pregnancyP: Oral therapy Diet High calory high protein Changes verband
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26th February 2007 07.00 AM
S: nausea (+), head ace (-), fever (-), flatus (+), bowel (-), cought (-)O: General condition goodConscious : composmentisVital sign : Blood pressure: 110/70 mmHg HR : 88 prm RR : 18 prm Temperature : 36,7C
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Konjungtiva : anemisDauer catheter : affHb : 8,0 gr%A: P3A1L3 post laparatomy 4th day indication rupture ectopic pregnancy P: oral therapy diet High calory high proteinHome care
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ECTOPIC PREGNANCYDefenitionAn ectopic pregnancy is a pregnancy that develops outside of endometrial of intrauterine cavity.
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80%12%2%1,4%5%0,2%0,2%
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EpidemiologyCenters for Disease Control (CDC) USA 1970 - 1984 : 4-fold Fatality rate decrease 90%Maternal death in USA 12%In Cipto Mangunkusumo Hospital 1987 1 in 26 . 20 40 years old.
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EtiologyRISK FACTORSHigh RiskModerate RiskSlight RiskTubal connective surgery- Tubal sterilizationPrevious ectopic pregnancy- In utero DES exposureDocumented tubalpathologyInfertilityPrevious genital infMultiple partners- Previous pelvic or abdominal surgery- Smoking- Intercourse before 18 years old
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Patophysiology
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Clinical ManifestationsClinical Triad of Ectopic PregnancyVaginal BleedingPainAmenorea
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Supporting ExaminationsRoutine Blood ExamB-HCG LevelProgesteron concentrateAbdominal USGTransvaginal USGColor flow Doppler USCuldocentesisUterine CurretageLaparoscopy
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Expectant ManagementMedical TherapySurgical TherapyManagementSalpingostomySalpingectomy
MTXNo Intervension
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Complication
Ruptur of TubaLaparatomy ComplicationMassive BleedingShockDICBleedingInfectionsDestruction of surrounding organ
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PrognosisRecurrent Ectopic Pregnancy Risk
After First 5-12%After Second32%
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DiscussionDiagnoseEtiologyManagement
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Thanks for the Atention