Transcript DYSTOCIA
Dystocia
Dr.A Danesh MD
After an ectopic pregnancy, there is a 7-
to 13-fold increase in the risk of a
subsequent ectopic pregnancy. The
chance that asubsequent pregnancy will
be intrauterine is 50% to 80%, and the
chance thatthe pregnancy will be tubal is
10% to 25%; the remaining patients will be
infertile
Chlamydia is an important pathogen
causing tubal damage and bsequenttubal
pregnancy. Because many cases of
chlamydia salpingitis are indolent, cases
maynot be recognized or, if recognized,
may be treated on an outpatient basis.
Chlamydia
has been cultured from 7% to 30% of
patients with tubal pregnancy
Women who conceive with an IUD in
place, however, are 0.4 to 0.8 timesmore
likely to have a tubal pregnancy than
those not using contraceptives.
BecauseIUDs prevent implantation more
effectively in the uterus than in the tube,
awoman conceiving with an IUD is 6 to 10
times more likely to have a tubal
pregnancythan if she conceives without
using contraception
Duration of IUD use does not increase the
absolute risk for tubal pregnancy (1.2 per
1,000 years of exposure), but with
increasing use, there is an increase in the
percentage of pregnancies that are tubal
Progesterone-only contraceptives, including
oral contraceptives (minipill) and subdermal implants
(Norplant), protect against both
intrauterine and ectopic pregnancy when compared
with no contraceptive use. If a pregnancy
does occur, however, the chance of the pregnancy
being ectopic is 4% to 10% for the
minipill (34,35) and up to 30% if pregnancy occurs
while implants are in place
Past use of oral contraceptives does not
increase
the subsequent risk for ectopic pregnancy
Condom and diaphragm use protects against
both intrauterine and ectopic pregnancy, and
there
is no increased incidence of ectopic
pregnancy
The greatest risk of pregnancy, including
ectopic pregnancy, occurs in the first 2
years after sterilization
The risk of tubal pregnancy after any
sterilization procedure is 5% to 16% (
Although it is clear that tubal surgery
is associated with an increased risk for
ectopic pregnancy, it is unclear whether
the increased risk results from the
surgical procedure or from the underlying
problem
After either tubal removal or conservation,
the rates for intrauterine pregnancy (40%)
and ectopic pregnancy (12%) have been
found to be identical
ovarian cystectomy or wedge resection
increases therisk for ectopic pregnancy,
presumably because of peritubal scarring
There is no established association
between ectopic pregnancy and
spontaneous abortion
Although the incidence of ectopic
pregnancy increases with age and parity,
there also is a significant increase in
nulliparous women undergoing infertility
treatment (
Hormonal alterations characteristic of
clomiphene citrate and gonadotropin
ovulation-induction cycles may
predispose tubal implantation. About
1.1% to 4.6%
of conceptions associated with ovulation
induction are ectopic pregnancies
Salpingitis isthmica nodosa (SIN) is a
noninflammatory pathologic condition of
the tube
in which tubal epithelium extends into the
myosalpinx and forms a true diverticulum.
. This condition is found more
often in the tubes of women with an
ectopic pregnancy than in nonpregnant
women (
Endometriosis or leiomyomas can cause
tubal obstruction
In DES-exposed women, the risk for ectopic
pregnancy was 13% in
those who had uterine abnormalities
compared with 4% in those who had a normal
uterus.
No specific type of defect was related to the
risk for ectopic pregnancy.
Current cigarette smoking is associated
with a more than twofold increased risk
for tubal pregnancy (
Chorionic villi, usually found in the lumen,
are pathognomic findings of tubal
pregnancy. Gross or microscopic
evidence of an embryo is seen in two
thirds of cases
Hemoperitoneum is nearly always present
but is confined to the cul-de-sac
unless tubal rupture has occurred. The
natural progression of tubal pregnancy is
either expulsion from the fimbriated end
(tubal abortion), involution of the
conceptus,
or rupture, usually around the eighth
gestational week.
The Arias-Sella reaction is a nonspecific
finding that can
be seen in patients with intrauterine
pregnancies
Figure 18.2 The Arias-Stella reaction of
the endometrium. The glands are closely
packed and
hypersecretory with large, hyperchromatic
nuclei suggesting malignancy
The classic symptom triad of ectopic pregnancy
is pain, amenorrhea, and vaginal
bleeding. This symptom group is present in only
about 50% of patients, however, and
is most typical in patients in whom an ectopic
pregnancy has ruptured. Abdominal
P.610
pain is the most common presenting symptom,
but the severity and nature of the
pain vary widely. There is no pathognomonic
pain that is diagnostic of ectopic
pregnancy
An adnexal mass may
be palpable in up to 50% of cases, but the
mass varies markedly in size,
consistency,
and tenderness. A palpable mass may be
the corpus luteum and not the
ectopic pregnancy
Quantitative β-hCG measurements are the
diagnostic cornerstone for ectopic
pregnancy. The hCG enzyme
immunoassay, with a sensitivity of 25
mIU/mL, is an accurate screening test for
detection of ectopic pregnancy. The assay
is positive in virtually all documented
ectopic pregnancies.
as phantom hCG, in which the presence of
heterophile antibodies or proteolytic
enzymes causes a false-positive hCG result.
Because the antibodies are large
glycoproteins, significant quantities of the antibody
are not excreted in the urine. Thus, in
the patient with hCG levels less than 1,000
mIU/mL, a urine pregnancy test should
be performed and confirmatory positive results
obtained before instituting
treatment
The hCG doubling time can help to differentiate
an ectopic pregnancy from an
intrauterine pregnancy—a 66% rise in the hCG
level over 48 hours (85% confidence
level) represents the lower limit of normal values
for viable intrauterine pregnancies
(82). About 15% of patients with viable
intrauterine pregnancies have less than a
66% rise in hCG level over 48 hours, and a
similar percentage with an ectopic
pregnancy have more than a 66% rise
The hCG pattern that is
most predictive of an ectopic pregnancy is one
that has reached a plateau (a
doubling time of more than 7 days). For falling
levels, a half-life of less than 1.4 days
is rarely associated with an ectopic pregnancy,
whereas a half-life of more than 7 days
is most predictive of ectopic pregnancy.
Serial hCG levels are usually required when the results of
the initial
ultrasonography examination are indeterminate (i.e., when
there is no evidence of
an intrauterine gestation or extrauterine cardiac activity
consistent with an
ectopic pregnancy). When the hCG level is less than 2,000,
doubling time helps to
predict viable intrauterine gestation (normal rise) versus
nonviability (subnormal
rise). With normally rising levels, a second ultrasonography
examination is
performed when the level is expected (by extrapolation) to
reach 2,000 mIU/
mL. Abnormally rising levels (less than 2,000 mIU/mL and
less than 50% rise over
48 hours) indicate a nonviable pregnancy
If the hCG level is more than 300 mIU/mL on
day 16 to 18 after artificial insemination, there
is an 88% chance of a live birth (84). If the
hCG level is less than 300 mIU/mL, the
chance of a live birth is only 22%
serum progesterone levels higher than 25
ng/mL, whereas only 1.5% of patients with
ectopic pregnancies have serum
progesterone levels higher than 25 ng/mL,
and most of these pregnancies exhibit
cardiac activity
A serum progesterone level of less than 5
ng/mL is highly suggestive of an abnormal
pregnancy, but it is not 100% predictive. The
risk of a normal pregnancy with a
serum progesterone level of less than 5
ng/mL is about 1 in 1,500
Estradiolcreatine kinaseSchwangerschafts
protein 1 (SP1), C (PAPP-C) or pregnancyspecific β glycoprotein (PSBS),
RelaxinCA125(AFP) C-reactive protein
C-reactive protein
The earliest ultrasonographic finding of an intrauterine pregnancy
is a small fluid
space and the gestational sac, surrounded by a thick echogenic
ring, located
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eccentrically within the endometrial cavity. The earliest normal
gestational sac is seen
at 5 weeks of gestation with transabdominal ultrasonography and
at 4 weeks of
gestation with transvaginal ultrasonography (112). As the
gestational sac grows, a
yolk sac is seen within it, followed by an embryo with cardiac
activity.
Morphologically, identification of the double
decidual sac sign (DDSS) is the best
method of ultrasonographically
differentiating true sacs from pseudosacs
The appearance of a yolk sac within the
gestational sac is superior to the DDSS
in confirming intrauterine pregnancy
The presence of an adnexal gestational
sac with a fetal pole and cardiac activity is
the most specific but least sensitive sign
of ectopic pregnancy, occurring in only
10%
to 17% of cases
Complex or solid adnexal masses are
frequently associated with ectopic
pregnancy (1,3,19); however, the mass
may represent a corpus luteum,
endometrioma, hydrosalpinx, ovarian
neoplasm (e.g., dermoid cyst), or
pedunculated fibroid
Accurate interpretation of ultrasonography findings requires correlation with the
hCG level (discriminatory zone) (114,119,122,124). All viable intrauterine pregnancies
can be visualized by transabdominal ultrasonography for serum hCG levels higher
than 6,500 mIU/mL; none can be seen at 6,000 mIU/mL. The inability to detect
an intrauterine gestation with serum hCG levels higher than 6,500 mIU/mL indicates
the presence of an abnormal (failed intrauterine or ectopic) pregnancy. Intrauterine
sacs seen at hCG levels below the discriminatory zone are abnormal and represent
either failed intrauterine pregnancies or the pseudogestational sacs of ectopic
pregnancy. If there is no definite sign of an intrauterine gestation (the empty uterus
sign) and the hCG level is below the discriminatory zone, the differential
diagnosis includes the following considerations:
Normal intrauterine pregnancy too early for
visualization
Abnormal intrauterine gestation
Recent abortion
Ectopic pregnancy
Nonpregnant patient
Discriminatory zones for transvaginal
ultrasonography have
been reported at levels from 1,000 to 2,000 mIU/mL
(114,119,122,124). Discriminatory
zones vary according to the expertise of the
examiner and capability of the equipment.
Although the discriminatory zone for intrauterine
pregnancy is well established, there
is no such zone for ectopic pregnancy.
high-velocity, low-resistance signal is
localized to the area of developing
placentation This pattern, seen near the
endometrium, is associated with normal
and abnormal intrauterine pregnancies and is
termed peritrophoblastic flow.
Uterine curettage is performed when the
pregnancy has been confirmed to be
nonviable and the location of the pregnancy
cannot be determined by
ultrasonography.
Laparoscopy is the gold standard for the
diagnosis of ectopic pregnancy.
An algorithm for the diagnosis
of ectopic pregnancy without laparoscopy
proved to be 100% accurate in a
randomized clinical trial
Suction curettage is used to differentiate nonviable intrauterine
pregnancies from
ectopic gestations (less than 50% rise in hCG level over 48
hours, an hCG level of
less than 2,000 mIU/mL, and indeterminate ultrasonography
findings). Performance
of this procedure avoids unnecessary use of methotrexate in
patients with
abnormal intrauterine pregnancy that can be diagnosed only by
evacuating the uterus.
An unlikely potential problem with suction curettage is missing
either an early
nonviable intrauterine pregnancy or combined intrauterine and
extrauterine pregnancies.
Linear salpingostomy is currently the
procedure of choice when the patient has
an unruptured ectopic pregnancy and wishes
to retain her potential for future fertility.
The products of conception are removed
through an incision made into the tube on
Laparotomy
is indicated when the patient becomes
hemodynamically unstable, whereas
laparoscopy
is reserved for patients who are
hemodynamically stable. A ruptured ectopic
pregnancy does not necessarily require
laparotomy.
Pregnancy rates are similar in patients treated by either
laparoscopy or laparotomy. Tubal patency on the ipsilateral side
after
conservative laparoscopic management is about 84%.
In a study of 143 patients followed after undergoing laparoscopic
procedures for
ectopic pregnancy, the overall intrauterine pregnancy rates for
laparoscopic salpingostomy (60%) and laparoscopic
salpingectomy (54%) were
not significantly different
Commonly reported side effects include
leukopenia, thrombocytopenia, bone marrow
aplasia, ulcerative stomatitis, diarrhea,
and hemorrhagic enteritis. Other reported side
effects include alopecia, dermatitis, elevated
liver enzyme levels, and pneumonitis (146).
However, no significant side effects have
been reported at the low doses used for ectopic
pregnancy treatment. Minor side
effects have been reported with multiple doses;
Single-dose Methotrexate Protocol for Ectopic Pregnancy
a
Day
Therapy
D & C, hCG 0
CBC, SGOT, BUN, creatinine, blood type and Rh 1
2
4
Methotrexate 50 mg/m
IM
hCG 7
D & C, dilation and curettage; hCG, human chorionic gonadotropin; CBC, complete blood
count; SGOT, serum glutamic-oxaloacetic transaminase; BUN, blood urea nitrogen; IM,
intramuscularly.
a
If less than a 15% decline in hCG level between days 4 and 7, give second dose of
2
methotrexate, 50 mg/m
on day 7. ,
If more than a 15% decline in hCG level between days 4 and 7, follow weekly until hCG is
below 10 mIU/mL.
In patients not requiring D & C (hCG > 2,000 mIU/mL and no gestational sac on
transvaginal ultrasonography), days 0 and 1 are combined.
Physician Checklist
Obtain hCG level.
Perform transvaginal ultrasound within 48 hours.
Perform endometrial curettage if hCG level is less than 2,000 mIU/mL.
Obtain normal liver function (SGOT), normal renal function (BUN, creatinine), and a
normal CBC (WBC < 2,000/mL and platelet count > 100,000)
Administer RhoGAM if patient is Rh-negative.
Identify unruptured ectopic pregnancy smaller than 3.5 cm.
Obtain informed consent.
Prescribe FeSO
mg PO bid if hematocrit is less than 30%. 325
4
Schedule follow-up appointment on days 4, 6, and 7.
Patient Instructions
Refrain from alcohol use, multivitamins containing folic acid, and sexual intercourse
until hCG level is negative.
Call your physician if:
You experience prolonged or heavy vaginal bleeding.
The pain is prolonged or severe (lower abdomen and pelvic pain is normal during the
first 10 14 days of treatment).
You use oral contraception or barrier contraceptive methods.
About 4% 5% of women experience unsuccessful methotrexate treatment and require
surgery.
hCG, human chorionic gonadotropin; SGOT, serum glutamic-oxaloacetic transaminase;
BUN, blood urea nitrogen; CBC, complete blood count; WBC, white blood cell; PO, by
mouth; bid, twice daily.
After intramuscular administration of
methotrexate, patients are monitored on
an outpatient basis. Patients who report
severe pain or pain that is prolonged
are evaluated by measuring hematocrit levels
and performing
transvaginal ultrasonography.
To maximize the safety of treatment and to
eliminate the possibility of treating in
the presence of a nonviable or early viable
intrauterine pregnancy, patients
considered candidates for methotrexate
treatment should include those to whom
the following factors apply:
An hCG level is present after salpingostomy or
salpingotomy.
?
The hCG level is rising or reached a plateau at least
12 to 24 hours after suction curettage.
?
No intrauterine gestational sac or fluid collection is
detected by transvaginal ultrasonography,
the hCG level is greater than 2,000 mIU/mL, the
hCG level is rising, and an ectopic pregnancy
mass of 4.0 cm or less without cardiac activity or 3.5
cm or less with cardiac activity is visualized.
Ultrasonography findings should be
interpreted with caution because most
unruptured ectopic pregnancies will be
accompanied by fluid in the cul-de-sac.
When
using the single-dose intramuscular regimen, the
incidence of side effects is less than
and the failure rate is comparable to that of ,%1
conservative laparoscopic surgery.
One problem that remains puzzling is the inability to
predict treatment failures with
the use of methotrexate. However, the same is true
with conservative
surgical procedures; thus, the need to monitor hCG
levels after salpingostomy
or methotrexate remains
Comparison of laparoscopically treated
patients with
methotrexate-treated patients suggests that
the two methods have similar
reproductive outcomes.
Salpingocentesis is a technique in which agents
such as KCl, methotrexate, prostaglandins,
and hyperosmolar glucose are injected into the
ectopic pregnancy transvaginally
using ultrasonographic guidance, transcervical tubal
cannulization, or laparoscopy. Agents
injected under ultrasonographic guidance have
included methotrexate The
KCl, combined methotrexate and KCl, and
prostaglandin E
Some ectopic pregnancies resolve by
resorption or by tubal abortion, obviating the
need for medical or surgical therapy
Persistent ectopic pregnancy occurs when a
patient has undergone conservative
surgery (e.g., salpingostomy, fimbrial
expression) and viable trophoblastic tissue
remains.
A slower decline of serum hCG levels has
been seen in patients
treated by salpingostomy compared with
patients treated by salpingectomy. The
incidence of persistence after laparoscopic
linear salpingostomy ranges from 3% to
20%
Persistent ectopic pregnancy can be treated
surgically or medically; surgical
therapy consists of either repeat salpingostomy or,
more commonly,
salpingectomy. Methotrexate offers an alternative to
patients who are
hemodynamically stable at the time of diagnosis.
Methotrexate may be the treatment
of choice because the persistent trophoblastic tissue
may not be confined to the tube
and, therefore, not readily identifiable during repeat
surgical exploration (191,192,193).
Chronic ectopic pregnancy is a condition in
which the pregnancy does not
completely resorb during expectant
management
The incidence of cervical pregnancy in the
United States ranges from 1 in 2,400 to 1
in 50,000 pregnancies
Ultrasound Criteria for Cervical Pregnancy
Echo-free uterine cavity or the presence of a .1
false gestational sac only
Decidual transformation of the endometrium with .2
dense echo structure
Diffuse uterine wall structure .3
Hourglass uterine shape .4
Ballooned cervical canal .5
Gestational sac in the endocervix .6
Placental tissue in the cervical canal .7
Closed internal os .8
When a cervical pregnancy is diagnosed
before surgery, the preoperative
preparation should include blood typing and
cross-matching, establishment of
intravenous access, and detailed informed
consent. This consent should include
the possibility of hemorrhage that may
require transfusion or hysterectomy.
Various techniques that can be used to control
bleeding include uterine packing, lateral cervical suture
placement to ligate the
lateral cervical vessels, placement of a cerclage, and insertion of
an intracervical 30mL Foley catheter in an attempt to tamponade the bleeding.
Alternatively,
angiographic artery embolization can be used. If laparotomy is
required, an attempt
can be made to ligate the uterine or internal iliac arteries
(202,203,204). When none
of these methods is successful, hysterectomy is required.
A pregnancy confined to the ovary represents
0.5% to 1% of all ectopic pregnancies
and is the most common type of nontubal /
ectopic pregnancy
Table 18.6 Criteria for Ovarian Pregnancy Diagnosis
The fallopian tube on the affected side must be .1
intact.
The fetal sac must occupy the position of the .2
ovary.
The ovary must be connected to the uterus by .3
the ovarian ligament.
Ovarian tissue must be located in the sac wall. .4
ovarian cystectomy has become the
preferred treatment
Abdominal pregnancy
is associated with high morbidity and
mortality, with the risk for death 7 to 8
times greater than from tubal ectopic
pregnancy and 90 times greater than
from intrauterine pregnancy.
Diagnosis of Primary
Abdominal Pregnancy
Presence of normal tubes and ovaries .1
with no evidence of recent or past pregnancy
No evidence of uteroplacental fistula .2
The presence of a pregnancy related .3
exclusively to the peritoneal surface and
early
enough to eliminate the possibility of
secondary implantation after primary tubal
nidation
surgical intervention is recommended when
an
abdominal pregnancy is diagnosed.
Interstitial pregnancies represent about 1% of
ectopic pregnancies
Interligamentous pregnancy is a rare form of
ectopic pregnancy that occurs in about 1
in every 300 ectopic pregnancies
Heterotropic pregnancy occurs when
intrauterine and ectopic pregnancies coexist.
The reported incidence varies widely from 1
in 100 to 1 in 30,000 pregnancies
Twin or multiple ectopic gestations occur less
frequently than heterotropic gestations
and may appear in a variety of locations and
combinations.
Complex or solid adnexal masses are
frequently associated with ectopic
pregnancy (1,3,19); however, the mass
may represent a corpus luteum,
endometrioma, hydrosalpinx, ovarian
neoplasm (e.g., dermoid cyst), or
pedunculated fibroid
DYSTOCIA
uterine contractility
maternal pelvimetry
position and size of the fetus
Primary Dysfunctional Labor
Inadequate uterine contractility to maintain
appropriate progress in labor
Four concerted synchronous contractions every 10
minutes (Gap junctions)
uterine embryologic abnormalities such as a
didelphic uterus or bicornuate uterus
Cephalopelvic Disproportion
Fetal birth weight
Fetal head
Maternal pelvic inlet
Abnormal Position of the Fetal
Head
0ccipital posterior (OP)
Deep transverse arrest
Deflexion abnormalities such as face and brow
presentations
Asynclitism
The sagittal suture of the head is either
deviated posteriorly or anteriorly in relation to
the maternal outlet
Second stage of labor is often prolonged and
arrest of descent
Fetal Abnormalities
Fetuses with neuromuscular disease,
Utero demise
hydrocephalus
hydrops fetalis
tumors of the head or sacrum can lead to
mechanical obstruction
Lie of fetous
Breech
Trasvers
oblique
Prolonged Latent Phase
In nulliparous women uterine activity without
cervical change for more than 20 hours
Multiparas this time period is 14 hours
Arrest of Dilation
occurs when there is no cervical change after
2 hours in the active phase of labor despite
uterine activity
Arrest of Descent
If the patient does not gain station of 1 cm
after an hour of adequate pushing efforts, an
arrest of descent is diagnosed
Precipitate labor disorders
Precipitate labor
Delivery in less than 3 hours from onset of
contraction
Precipitate dilatation 5cm or more per hour in
primipara or10cm 0r more per hour in
multipara
Protracted Active Phase
In nulliparous patients, cervical change is less
than 1.2 cm per hour
In multiparous patients cervical change is
.occurring at less than 1.5 cm per hour
Prolonged Second Stage
prolonged second stage is diagnosed when the
fetal head descends less than 1 cm per hour.
A second stage lasting longer than 2 hours has
traditionally been considered abnormal
longer than 2 hours in nulliparas or 1 hour in
multiparas or 3 and3 hour for conduction
anesthesia