In an ectopic implantation at a location other than the Endometriumepithel the uterine cavity, z is carried out. B. in the fallopian tube into the uterus horns, in the cervix, the ovary or in the abdominal or pelvic cavity. Ectopic pregnancies can not be settled by the deadline, may rupture or perish. Early symptoms and signs include lower abdominal pain, vaginal bleeding and vaginal portion sliding pain. With a rupture may lead to syncope and hemorrhagic shock. The diagnosis involves the determination of ?-hCG (human chorionic gonadotropin) and ultrasound. The treatment consists in a laparoscopic or open surgical removal or administration of methotrexate in the i.m.
The incidence of ectopic pregnancy is about 2 100 diagnosed pregnancies.
In an ectopic implantation at a location other than the Endometriumepithel the uterine cavity, z is carried out. B. in the fallopian tube into the uterus horns, in the cervix, the ovary or in the abdominal or pelvic cavity. Ectopic pregnancies can not be settled by the deadline, may rupture or perish. Early symptoms and signs include lower abdominal pain, vaginal bleeding and vaginal portion sliding pain. With a rupture may lead to syncope and hemorrhagic shock. The diagnosis involves the determination of ?-hCG (human chorionic gonadotropin) and ultrasound. The treatment consists in a laparoscopic or open surgical removal or administration of methotrexate in the i.m. The incidence of ectopic pregnancy is about 2 100 diagnosed pregnancies. Etiology Tubal lesions increase the risk. Factors that particularly increase the risk are: Preceding ectopic pregnancy (risk of recurrence 10-25%) Earlier inflammatory disease in the area of ??the pelvis (pelvic inflammatory disease, PID) (in particular by Chlamydia trachomatis) Preceding surgery on the abdomen or in particular to the fallopian tubes including tubal ligation Other specific risk factors are: use of an intrauterine device infertility Multiple sex partners cigarette smoking exposure to diethylstilbestrol Former induced abortion under proper lying intrauterine device of the occurrence of a pregnancy is unlikely, but still about 5% of such pregnancies develop ectopic. Pathophysiology The most common location of ectopic nidation is the tube, followed by the intramural (uterine horns) localization. Pregnancies in the cervix at a cesarean scar in an ovary, in the abdomen or in the interstitial space of the tubes are rare. Heterotopic pregnancy (simultaneous existence of an ectopic and intrauterine pregnancy) only occurs in 1 / 10,000 to 1 / 30,000 of all pregnancies, but may be more common in women who have ovulation induction or a method of assisted reproduction techniques such as in vitro fertilization and have undergone embryo transfer into the fallopian tube (gamete intrafallopian tube transfer, GIFT); in these women strength of a 1% rate reported ectopic pregnancies. The structure containing the fetus, ruptured usually about after the 6th-16th SSW. The rupture leads to bleeding, which can only be easy, but also strong enough to cause a hemorrhagic shock. Abdominal befindliches blood irritates the peritoneum. carried the later the rupture, the faster the blood loss and the higher the risk of mortality. Symptoms and signs Symptoms vary and are often lacking to rupture. Most patients suffer – sometimes spasmodic – pelvic pain of vaginal bleeding or both. The menses may, but need not be delayed or fail to materialize, and the patients may not know they are pregnant. Rupture can announce by sudden, severe pain, followed by syncope or other symptoms and signs of hemorrhagic shock or peritonitis. A violent hemorrhage is more likely to rupture at a intramural pregnancy. Portio sliding pain, unilateral or bilateral adnexal tenderness or resistance in the adnexal region may be present. The uterus may be slightly enlarged (but often less than would be expected from the date of the last menstrual period). Diagnosis Quantitative determination of the ?-subunit of human chorionic gonadotropin (?-hCG) Beck sonography Occasionally Laparoscopy An ectopic pregnancy is suspected in a woman of reproductive age with pelvic pain, vaginal bleeding or unexplained syncope or hemorrhagic shock, regardless of their sexual, contraceptive and menstrual history. Findings on physical examination (including the lower abdomen) are neither sensitive nor specific. Tips and Risks An ectopic pregnancy is suspected in a woman of reproductive age with pelvic pain, vaginal bleeding or unexplained syncope or hemorrhagic shock, regardless of their sexual, contraceptive and menstrual history and the examination findings. First, a urine pregnancy test is made of about 99% sensitive for pregnancy (ectopic and others). If the ?-hCG in the urine is negative and if the clinical findings do not clearly speak for an ectopic pregnancy, further clarification is unnecessary unless symptoms recur or worsen. When the ?-hCG in the urine is positive or the clinical examination findings make a ectopic likely quantitative determination of the ?-hCG in serum and a pelvic ultrasonography are indicated. At a quantitative ?-hCG in the serum of <5 mI.E./ml an ectopic pregnancy is excluded. Is sonographically an intrauterine gestational sac found an ectopic pregnancy is very unlikely except in women who have a method of assisted reproduction (which increase the risk of ectopic pregnancy) have applied. However, intramural or intra-abdominal pregnancies can appear as an intrauterine pregnancy. (Seen in 16-32%) to the sonographic findings suggestive of ectopic pregnancy include complex (mixed solid and cystic) masses, especially in the appendages, and free fluid in the pouch of Douglas. If the ?-hCG in serum over a certain value (referred to as discriminatory zone) should be appreciated a gestational sac by ultrasound in patients with ectopic pregnancy. This value is usually at about 2000 mI.E./ml. If the ?-hCG value above the discriminatory zone and can no intrauterine gestational sac can be identified, an ectopic pregnancy is likely. The use of transvaginal sonography and color Doppler can increase diagnostic confidence. If the ?-hCG-value below the discriminatory zone and sonography is inconspicuous, an early intrauterine pregnancy or an ectopic pregnancy may be present. If, at the clinical examination suspected ectopic (z. B. signs of significant bleeding or peritoneal irritation), to confirm a diagnostic laparoscopy may be necessary. If an ectopic pregnancy unlikely and the patient is stable, the serum levels of ?-hCG can also be controlled at regular intervals on an outpatient basis (typically every 2 days). In a normal pregnancy, the mirror all day 1.4-2.1 double up to 41 days. In an ectopic pregnancy (and abortion), the mirrors are usually lower than would be expected by date, and they do not double up so fast. Take the ?-hCG levels not be as expected or take them off again should the diagnosis of spontaneous abortion or ectopic pregnancy will be considered. Prognosis Ectopic pregnancy is fatal to the fetus; Mother's death is rare, unless the treatment is carried out before a possible rupture. In the US, probably 9% of all pregnancy-related maternal deaths an ectopic pregnancy are due. Treatment Surgical resection (usually) methotrexate in some small, unruptured ectopic pregnancies Surgical resection in hemodynamically unstable patients is an immediate laparotomy and treatment of hemorrhagic shock required (shock: hemorrhagic shock). Circulation stable patients are usually operated on laparoscopically, in some cases, however, a laparotomy must be performed. If possible, to obtain the tube a salpingotomy using an electric cautery, high-frequency (harmonic) ultrasound devices or a laser is carried out and empties the product pregnancy. A salpingectomy is indicated in the following cases: If ectopic pregnancies occur again or have a size> 5 cm, if the tubes are severely damaged, if family planning is complete, to maximize the chance that fertility is regained at a reconstruction of the tube, should only irreversibly damaged portion of the tube to be removed. The tube can possibly be reconstructed. In an intramural pregnancy tube and ovary on the affected side are usually saved. Sometimes a reconstruction is, however, excluded, which macht.Methotrexat If not ruptured tubal pregnancy is a hysterectomy necessary <3 cm in diameter, can be seen no fetal heart activity and the ?-hCG level ideally <5000 mIU / mL, but <15 000 mI. is E./ml, the pregnant woman can be a single dose methotrexate 50 mg / m2 (body surface) in receive. ?-hCG-determination is repeated on day 4 and day. 7 If the ?-hCG-levels do not fall by 15%, a second dose methotrexate or surgical intervention is required. Alternatively, other protocols can be used. For example, the ?-hCG-value on Day 1 and 7 can be determined and a second dose of methotrexate may be given, if the mirror is not covered by 25%. Approximately 15-20% of women treated with methotrexate, need a second dose. The ?-hCG level is determined as long as a week, until it is no longer detectable. The success rates with methotrexate are at 87%; thereby serious complications occur (eg. as a rupture) in 7% of patients. Surgery is indicated when methotrexate is ineffective. Summary The most common site for an ectopic pregnancy are the tubes. Symptoms may include pelvic pain, vaginal bleeding and / or absent menses; but symptoms can up to a rupture missing, sometimes with fatal consequences. An ectopic pregnancy is suspected in a woman of reproductive age with pelvic pain, vaginal bleeding or unexplained syncope or hemorrhagic shock, regardless of their medical history and examination findings. If a urine pregnancy test is positive or have the clinical examination findings suggest an ectopic pregnancy, a quantitative determination of ?-hCG in serum and pelvic ultrasonography should be performed. Treatment consists of resection.