Ectopic pregnancy 02

EVALUATION OF WOMEN WITH SUSPECTED ECTOPIC PREGNANCY Overview — The main goals and steps of the evaluation of a woman with a suspected ectopic pregnancy (nghi ngờ thai tử cung) are: ●Confirm that the patient is pregnant ● Determine the site of the ectopic pregnancy ●Determine whether the structure in which the pregnancy is implanted (most commonly, the fallopian tube) has ruptured and whether the patient is hemodynamically stable Failure to diagnose ectopic pregnancy (chẩn đoán trễ thai tử cung) before tubal rupture limits the treatment options and increases maternal morbidity (tỷ lệ mắc bệnh mẹ) and mortality (tỷ lệ tử vong) ●Perform additional testing to guide further management History (Bệnh sử) — A menstrual history should be taken and the estimated gestational age (đánh giá tuổi thai) should be calculated The history should focus on the presence and characteristics of vaginal bleeding and abdominal pain Risk factors (những yếu tố nguy cơ) for ectopic pregnancy should be elicited, including prior ectopic pregnancy, current use of an intrauterine device (dụng cụ tử cung- IUD), prior tubal ligation, and in vitro fertilization (thụ tin ống nghiệm) (IVF) However, over 50 percent of women are asymptomatic before tubal rupture and not have an identifiable risk factor for ectopic pregnancy A population-based French study identified four factors that increased the risk of rupture when an ectopic pregnancy was suspected: (1) never having used contraception (phương pháp tránh thai), (2) history of tubal damage and infertility (vô sinh), (3) induction of ovulation (kích thích buồng trứng), and (4) high level of human chorionic gonadotropin (hCG, at least 10,000 IU/L) The overall rate of tubal rupture in this series was 18 percent The medical and surgical history should be reviewed, since this may impact treatment Physical examination (khám lâm sàng) — Vital signs should be measured and hemodynamic stability assessed In young, healthy patients with blood loss, assessing the vital signs should include an evaluation for postural change However, vital signs, including postural changes, may be normal early in the course of significant bleeding due to compensatory mechanisms Women with hemodynamic instability and suspected ectopic pregnancy require emergency surgery The abdominal examination is often unremarkable or may reveal lower abdominal tenderness (ấn đau vùng hạ vị) If rupture with significant bleeding has occurred, the abdomen may be distended and diffuse or localized tenderness to palpation and/or rebound tenderness (phản ứng phúc mạc) may be found on examination A complete pelvic examination should be performed The speculum examination (khám mỏ vịt) is used to confirm that the uterus is the source of bleeding (máu chảy từ lòng tử cung) (rather than a cervical or vaginal lesion) and to assess the volume of bleeding by noting the quantity of blood in the vagina and presence or absence of active bleeding from the cervix A bimanual pelvic examination (khám âm đạo tay) is performed; the examination is often unremarkable in a woman with a small, unruptured ectopic pregnancy (thai chưa vỡ) Palpation of the adnexa should be performed with only a small degree of pressure, since excessive pressure may rupture an ectopic pregnancy Findings on examination may include cervical motion (đau lắc cổ tử cung), adnexal, and/or abdominal tenderness An adnexal mass is noted in some women The uterus may be somewhat enlarged, but will likely be smaller than appropriate for gestational age Uterine enlargement in women with ectopic pregnancy may be due to endocrine changes of pregnancy, rare cases of heterotopic pregnancy (1 thai tử cung thai tử cung), or incidental uterine pathology (most commonly, uterine fibroids) Diagnostic testing — The tests used to diagnose an ectopic pregnancy are a combination of serum quantitative hCG level and transvaginal ultrasound (TVUS) Transvaginal ultrasound — TVUS is the most useful imaging test for determining the location of a pregnancy TVUS should be performed as part of the initial evaluation and may need to be repeated, depending upon the hCG level or a suspicion of rupture The ultrasound should be performed by a clinician with expertise in gynecologic ultrasound and with the evaluation of ectopic pregnancy, whenever possible TVUS alone (without measurement of hCG)(siêu âm đầu dò âm đạo kết hợp với giá trị β hCG) can exclude or diagnose an ectopic pregnancy only if one of the following findings is present: ●Findings diagnostic of an intrauterine pregnancy (IUP, gestational sac with a yolk sac (túi noãn hoàng) or embryo (phôi)) ●Findings diagnostic of a pregnancy at an ectopic site (gestational sac with a yolk sac or embryo) In either case, a gestational sac alone is not sufficient for diagnosis In some ectopic gestations, a pseudosac (túi thai giả) is formed that may appear to be a gestational sac Cardiac activity may or may not be present In the great majority of cases, either two findings above excludes or diagnoses an ectopic gestation The rare exceptions are heterotopic pregnancies and misdiagnoses of an IUP (ie, interstitial pregnancy or rudimentary horn pregnancy) In a review of 568 cases of rudimentary uterine horn pregnancies from 1900 to 1999, a rupture rate of 50 percent was found with 80 percent occurring before the third trimester ... small, unruptured ectopic pregnancy (thai chưa vỡ) Palpation of the adnexa should be performed with only a small degree of pressure, since excessive pressure may rupture an ectopic pregnancy Findings... gestational age Uterine enlargement in women with ectopic pregnancy may be due to endocrine changes of pregnancy, rare cases of heterotopic pregnancy (1 thai tử cung thai tử cung), or incidental... the evaluation of ectopic pregnancy, whenever possible TVUS alone (without measurement of hCG)(siêu âm đầu dò âm đạo kết hợp với giá trị β hCG) can exclude or diagnose an ectopic pregnancy only