Thai ngoài tử cung chưa vỡ

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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)

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Nội dung Text: Thai ngoài tử cung chưa vỡ

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
ECTOPIC PREGNANCY = implantation outside the endometrial cavity Incidence: 1.4% of all pregnancies (increasing); 9.9:10,000 women annually; 73,700 cases in 1986 in United States; 4 15% of maternal deaths (decreasing); coexistent with intrauterine pregnancy in 1:6,800 30,000 pregnancies (higher number of coexisting ectopic with ovulation induction) Risk of recurrence: 10% Cause: delayed transit of the fertilized zygote secondary to abnormal angulation of oviduct / adhesions from inflammation / slowed tubal transit
Risk factors: (1) Previous tubal surgery / ligation (2) Previous PID (30 50%) (3) Ovulation induction (4) Endometriosis (5) Previous ectopic pregnancy (10fold increase in risk, 25% chance of recurrence) (6) IUD in place + If the pregnancy cannot be documented as intrauterine, the patient should be considered at risk! Time of manifestation: usually by 7th week of MA
CLASSIC TRIAD (66% within 48 hours (lower levels + slower rise and decline compared with IUP) + Most ectopic pregnancies do not exhibit a bHCG of >6500 mIU/mL (1st IRP) prior to symptomatology! + A bHCG level above the discriminatory zone with absence of IUP suggests ectopic pregnancy! Discriminatory zone of bHCG (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)
Location: (a) tubal (95%): (1) Ampullary ectopic (2) Isthmic ectopic (92%) (3) Interstitial ectopic (3%) (b) other (5%): (1) Abdominal ectopic (2) Ovarian ectopic (3) Interligamentary ectopic (4) Cervical ectopic (very rare)
Spectrum: Type 1: unruptured live ectopic + heartbeat 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 b 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 finding * free abdominal fluid / hyperechoic clot in culdesac * hydro/ hematosalpinx * corpus luteum within ovary in >50% on side of ectopic pregnancy
Transvaginal US (5 26% falsenegative 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 5mm cyst in endometrium remote from endometrial canal (14%)
DopplerUS (low diagnostic impact): * highvelocity lowimpedance flow around extrauterine gestation in 54% (up to 4 kHz shift with 3 MHz transducer, 0.38 ± 0.2 Pourcelot index) * absence of peritrophoblastic flow after 36 days (
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
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