Tài liệu Thai ngoài tử cung chưa vỡ docx

Siêu âm Bs T Hùng= U nang buồng trứng T có vách, còn phổ mạch máu... • positive urinary pregnancy test 50%• b-HCG does not rise >66% within 48 hours lower levels + slower rise and declin

Thai ngoài tử cung chưa vỡ

NGUYỄN THIỆN HÙNG KHOA SIÊU ÂM MEDIC

Nữ, 45 tuổi, Kampuchea.

Không trễ kinh hoặc đau bụng

Khám bệnh vì mệt mỏi, ăn kém

BS lâm sàng gửi MEDIC khám siêu âm kiểm tra

Mổ nội soi lấy túi thai cùng ngày tại BV

Triều An (BS Trương ngọc Thanh)

Túi thai có phôi, CRL=13,7mm, khỏang 7 tuần

Tubal Ring sign(+)

Nữ, 22tuổi, Q Phú nhuận, trễ kinh hơn 30 ngày, đau bụng 3 ngày, Hct=24%, Quickstick(+), chọc ổ bụng không rút được dịch (BS T Tâm + BS Tùng)

Bv Saigon gửi khám siêu âm cấp cứu = Xuất huyết nội + U nang buồng trứng T xoắn ?

Lúc khám, bệnh nhân tỉnh, tiếp xúc tốt, da niêm

không tái, bớt đau bụng

Ít dịch tụ ở hố chậu P

Dạng phôi bên P tử cung

Siêu âm (Bs T Hùng)= U nang buồng trứng T có

vách, còn phổ mạch máu Dạng phôi bên P tử cung, CRL=, 11mm, khỏang 7 w, không nhịp tim, túi thai không rõ, dịch tụ hố chậu P ít

TVS (BS T Thi)= Túi thai bên P tử cung, dịch túi

cùng ít + u nang buồng trứng T có vách

U nang buồng trứng T có vách, còn phổ mạch máu

Risk of recurrence: 10%

Cause: delayed transit of the fertilized zygote

secondary to abnormal angulation of oviduct /

adhesions from inflammation / slowed tubal transit

+ If the pregnancy cannot be documented as

intrauterine, the patient should be considered at risk!Time of manifestation: usually by 7th week of MA

• positive urinary pregnancy test (50%)

• b-HCG does not rise >66% within 48 hours (lower levels + slower rise and decline compared with IUP)

+ Most ectopic pregnancies do not exhibit a b-HCG of >6500 mIU/mL (1st IRP) prior to symptomatology!

+ A b-HCG level above the discriminatory zone with absence of IUP

suggests ectopic pregnancy!

Discriminatory zone of b-HCG (at which a normal IUP should be

visualized):

(a) by transabdominal scan:

³6500 mIU/mL (1st IRP) with 100% sensitivity + 96% specificity

(b) by endovaginal scan:

³2000 to 3000 mIU/mL (1st IRP)

Type 2: early embryonic demise without

rupture / embryonic structures / heartbeat

Type 3: ruptured ectopic with blood in pelvis Type 4: no sonographic signs of ectopic

Transvesical US (usually less sensitive than transvaginal):

* absence of intrauterine pregnancy (beyond 6 weeks MA / with HCG level >1,000 - 2,000 mIU/mL [IRP])

(a) no IUP by transvesical US = ectopic pregnancy in 43 - 46% (b) no IUP by endovaginal US = ectopic pregnancy in 67%

* decidual cast = hyperechoic endometrial thickening (50%)

* pseudogestational sac = parietal decidual reaction + anechoic fluid center from bleeding (10 - 20%)

* echogenic adnexal mass (42%) with small anechoic center =

gestational sac ± embryo ± heartbeat

* live embryo in adnexa (6 - 17%) = only specific sonographic

Transvaginal US (5 - 26% false-negative rate):

* extrauterine mass of any type (84%)

* solid / complex adnexal mass = clotted blood free in

peritoneal cavity / hematosalpinx (36%)

* extrauterine gestational sac without live embryo / yolk sac (35%)

* embryonic heartbeat (12 - 28%)

* free fluid (40 - 83%): echogenic / particulate fluid

(= hemoperitoneum) has 93% positive predictive value for ectopic pregnancy (small amount of anechoic fluid found in 10 - 27% of IUP)

* decidual cast (21%)

* decidual cyst = 1- to 5-mm cyst in endometrium remote from endometrial canal (14%)

Doppler-US (low diagnostic impact):

* high-velocity low-impedance flow around extrauterine

gestation in 54% (up to 4 kHz shift with 3 MHz transducer, 0.38

corpus luteum cyst, tuboovarian abscess, fibroid

Probability of ectopic pregnancy in absence of IUP + clinical

symptoms of an ectopic pregnancy:

5% normal scan / simple cyst in adnexa

92% complex adnexal mass

95% tubal ring

100% live embryo outside uterus

Interstitial (cornual) ectopic (2 - 4%)

+ Often rupture late because of greater myometrial distensibility

compared with other parts of tube!

+ High likelihood of catastrophic hemorrhage + death due to abundant blood supply by both ovarian + uterine arteries!

Increased risk: previous ipsilateral salpingectomy

* eccentric heterogeneous mass in cornual region (66%)

* eccentrically placed gestational sac (25%)

* thinning of myometrial mantle to <5 mm (33%)

* interstitial line sign = thin echogenic line extending directly up to the center of ectopic pregnancy

(= endometrial canal / interstitial portion of Fallopian tube) in 92%

* large vascular channels with peritrophoblastic flow

•absence of double decidual sign

Prognosis:

massive bleeding from erosion of uterine arteries + veins (pregnancy survives only 12 - 16 weeks GA);

2-fold mortality compared with other tubal ectopics

DDx: pregnancy within horn of bicornuate uterus; hydatidiform mole;

Abdominal ectopic (1:6000)

• bloating, abdominal pain (fetal movement / peritoneal irritation due to adhesions)

• bleeding, hypotension, shock

* extrauterine location of fetus + placenta

* uterus compressed with visible endometrial cavity line

* absence of uterine wall between gestation + bladder / abdominal wall

* anhydramnios

Cx: bowel obstruction / perforation; erosion of

pregnancy through abdominal wall

Lithopedion

= "stone child" = very rare obstetric complication

consisting of a dehydrated + calcified demised fetus in

an extrauterine pregnancy existing for >3 months

without infection

Types:

(1) Lithokelyphosis = fetal membranes calcified

(2) Lithokelyphopedion = fetus + membranes

calcified

(3) True lithopedion = only fetus calcified

Maternal age at discovery: 23 - 100 years of age;

within 4 - 20 years of fetal demise

Vôi hóa buồng trứng P, bnh nữ 70 tuổi

Vôi hóa buồng trứng P, bnh nữ 70 tuổi

most common in adnexae

* large densely calcified mass in lower abdomen / upper pelvis

* CT scan reveals fetal skeleton

DDx:

uterine fibroid, calcified ovarian malignancy / cyst, sarcoma

Dx: (1) Laparoscopy (almost 100% accurate)

(2) Culdocentesis (high probability for ectopic with aspiration of nonclotting blood with a hematocrit >15) Cx: maternal death in 1:1,000; tubal rupture (10 -

15%)

DDx: (1) Hemorrhagic corpus luteum / hematoma

(2) Adnexal mass: hydrosalpinx, endometrioma, ovarian cyst

(3) Fluid-containing small bowel loop

(4) Eccentrically placed GS in bicornuate /

retroflexed / fibroid uterus