Ectopic PregnancyEctopic Pregnancy
 An ectopic pregnancy is a gestationAn ectopic pregnancy is a gestation
that implants outside of thethat implants outside...
 More than 95% of ectopic pregnanciesMore than 95% of ectopic pregnancies
implant in various anatomic segments ofimplant ...
Fig. 1. Possible locations of ectopic pregnancyFig. 1. Possible locations of ectopic pregnancy
EpidemiologyEpidemiology
 Since the early 1970s, the incidence ofSince the early 1970s, the incidence of
ectopic pregnanc...
 Improved technology, which has allowedImproved technology, which has allowed
for earlier and more complete diagnosisfor ...
 The use of intrauterine contraceptiveThe use of intrauterine contraceptive
devices (IUDs). Women with IUDs aredevices (I...
The overall incidence ofThe overall incidence of
ectopic pregnancy is estimatedectopic pregnancy is estimated
to be at le...
EtiologyEtiology
 Probably as many as 50% of cases result fromProbably as many as 50% of cases result from
alteration of ...
EvolutionEvolution
 Tubal pregnancies rapidly invade theTubal pregnancies rapidly invade the
mucosa, feeding from the tub...
 The pregnancy is unable to survive owingThe pregnancy is unable to survive owing
to its poor blood supply, thus resultin...
 In rare instances, a tubal pregnancy willIn rare instances, a tubal pregnancy will
be expelled from the tube and seed on...
Symptoms and Clinical DiagnosisSymptoms and Clinical Diagnosis
 High risk factors can beHigh risk factors can be
summariz...
 A history of tubal infection (ectopic rateA history of tubal infection (ectopic rate
of 1 in 24, as opposed to 1 in 200 ...
 History of tubal reconstructive surgeryHistory of tubal reconstructive surgery
(tuboplasty or end-to-end reanastomosis(t...
 More than one therapeutic abortionMore than one therapeutic abortion
(controversial)(controversial)
 Pregnancy resultin...
The classic symptom triadThe classic symptom triad
amenorrhea,amenorrhea,
vaginal bleeding,vaginal bleeding,
abdominal pa...
 Abdominal pain, usually in the lower abdomenAbdominal pain, usually in the lower abdomen
in early cases, or generalized ...
 Making the diagnosis of an acutelyMaking the diagnosis of an acutely
ruptured ectopic pregnancy is fairlyruptured ectopi...
 Physical examination in patients with an unrupturedPhysical examination in patients with an unruptured
ectopic pregnancy...
Differential DiagnosisDifferential Diagnosis
 Many gynecologic andMany gynecologic and
nongynecologic disorders havenongy...
 Threatened or incomplete abortion (alsoThreatened or incomplete abortion (also
presenting with pain, bleeding, and apres...
 Acute pelvic inflammatory disease withAcute pelvic inflammatory disease with
fever, abdominal pain, leukocytosis, and,fe...
 The key to the successful management ofThe key to the successful management of
ectopic pregnancy is early diagnosis. Alt...
β-hCG testingβ-hCG testing
 Human chorionic gonadotropin is consisting ofHuman chorionic gonadotropin is consisting of
tw...
 The sensitivity of the current methods forThe sensitivity of the current methods for
detection of β-hCG in the maternal ...
UltrasonographyUltrasonography
 This field has shown rapid technologicalThis field has shown rapid technological
improvem...
 If the sac is not visualized at the uterineIf the sac is not visualized at the uterine
cavity, special attention is need...
CuldocentesisCuldocentesis
 Culdocentesis is the technique by which a needle,Culdocentesis is the technique by which a ne...
Fig. 2. Technique for culdocentesisFig. 2. Technique for culdocentesis
ManagementManagement
 Emergency treatmentEmergency treatment
 Surgical treatmentSurgical treatment
LaparotomyLaparotomy
...
Emergency treatmentEmergency treatment
 Immediate surgery is indicated when theImmediate surgery is indicated when the
di...
Surgical treatmentSurgical treatment
 Rapid entry into the abdomen should beRapid entry into the abdomen should be
accomp...
 The type of procedure performed by eitherThe type of procedure performed by either
laparoscopy or laparotomy will be dic...
Medical treatmentMedical treatment
Unruptured ectopic pregnancyUnruptured ectopic pregnancy
can be treated withcan be tre...
IndicationsIndications
 no contraidications to MTXno contraidications to MTX
 type of unruptured or abortiontype of unru...
Expectant managementExpectant management
 As many as 80% of ectopic pregnancies withAs many as 80% of ectopic pregnancies...
Treatment of Uncommon Types ofTreatment of Uncommon Types of
Ectopic PregnanciesEctopic Pregnancies
 Ectopic pregnancy an...
 Cervical pregnancy usually presents with profuseCervical pregnancy usually presents with profuse
vaginal bleeding, and a...
All of the following therapeutic procedures areAll of the following therapeutic procedures are
recommended for ectopic pre...
Likely reasons for the establishment of an ectopicLikely reasons for the establishment of an ectopic
tubal pregnancy inclu...
15b ectopicpregnancy-090507104012-phpapp02
15b ectopicpregnancy-090507104012-phpapp02
15b ectopicpregnancy-090507104012-phpapp02
15b ectopicpregnancy-090507104012-phpapp02
15b ectopicpregnancy-090507104012-phpapp02
15b ectopicpregnancy-090507104012-phpapp02
15b ectopicpregnancy-090507104012-phpapp02
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  1. 1. Ectopic PregnancyEctopic Pregnancy
  2. 2.  An ectopic pregnancy is a gestationAn ectopic pregnancy is a gestation that implants outside of thethat implants outside of the endomitrial cavity. It represents aendomitrial cavity. It represents a serious hazard to a woman’s healthserious hazard to a woman’s health and reproductive potential, requiringand reproductive potential, requiring prompt recognition and earlyprompt recognition and early aggressive intervention.aggressive intervention.
  3. 3.  More than 95% of ectopic pregnanciesMore than 95% of ectopic pregnancies implant in various anatomic segments ofimplant in various anatomic segments of the fallopian tube, including thethe fallopian tube, including the interstitial (1%), isthmic (5%), ampullaryinterstitial (1%), isthmic (5%), ampullary (85%), and infundibular portions (9%).(85%), and infundibular portions (9%). Other less common sites of ectopicOther less common sites of ectopic implantation are the uterine cervix, ovary,implantation are the uterine cervix, ovary, and the peritoneal cavity (Fig. 1).and the peritoneal cavity (Fig. 1).
  4. 4. Fig. 1. Possible locations of ectopic pregnancyFig. 1. Possible locations of ectopic pregnancy
  5. 5. EpidemiologyEpidemiology  Since the early 1970s, the incidence ofSince the early 1970s, the incidence of ectopic pregnancy has tripled, andectopic pregnancy has tripled, and currently this condition represents thecurrently this condition represents the fourth leading cause of maternal mortalityfourth leading cause of maternal mortality overall (4%) and the most common causeoverall (4%) and the most common cause of maternal mortality in the firstof maternal mortality in the first trimester. Several factors have beentrimester. Several factors have been implicated as contributing to thisimplicated as contributing to this increased incidence:increased incidence:
  6. 6.  Improved technology, which has allowedImproved technology, which has allowed for earlier and more complete diagnosisfor earlier and more complete diagnosis of some patients whose condition wentof some patients whose condition went undetected in the past.undetected in the past.  The rising incidence of acute and chronicThe rising incidence of acute and chronic salpingitis, induced abortion, tubalsalpingitis, induced abortion, tubal ligation, tubal reconstructive surgery, andligation, tubal reconstructive surgery, and conservative management of tubalconservative management of tubal pregnancy, all of which result inpregnancy, all of which result in histologic and structural damage to thehistologic and structural damage to the tubes.tubes.
  7. 7.  The use of intrauterine contraceptiveThe use of intrauterine contraceptive devices (IUDs). Women with IUDs aredevices (IUDs). Women with IUDs are four times more likely to suffer from anfour times more likely to suffer from an ectopic pregnancy. This effect is due toectopic pregnancy. This effect is due to the better protection afforded by IUDsthe better protection afforded by IUDs against intrauterine compared withagainst intrauterine compared with extrauterine pregnancy and the higherextrauterine pregnancy and the higher incidence of pelvic inflammatory diseaseincidence of pelvic inflammatory disease among IUD users.among IUD users.
  8. 8. The overall incidence ofThe overall incidence of ectopic pregnancy is estimatedectopic pregnancy is estimated to be at least one in every 200to be at least one in every 200 pregnancies.pregnancies.
  9. 9. EtiologyEtiology  Probably as many as 50% of cases result fromProbably as many as 50% of cases result from alteration of tubal transport mechanismsalteration of tubal transport mechanisms secondary to damage to the ciliated surface ofsecondary to damage to the ciliated surface of the endosalpinx caused by infections such asthe endosalpinx caused by infections such as Chlamydia and gonorrhea. Others are theChlamydia and gonorrhea. Others are the result of intrinsic abnormalities of theresult of intrinsic abnormalities of the fertilized ovum and possibly transmigration offertilized ovum and possibly transmigration of the oocyte to the contralateral tube, withthe oocyte to the contralateral tube, with resulting delays in passage.resulting delays in passage.
  10. 10. EvolutionEvolution  Tubal pregnancies rapidly invade theTubal pregnancies rapidly invade the mucosa, feeding from the tubal vessels,mucosa, feeding from the tubal vessels, which become enlarged and engorged.which become enlarged and engorged. The segment of the affected tube isThe segment of the affected tube is distended as the pregnancy grows.distended as the pregnancy grows. Possible outcomes of such abnormalPossible outcomes of such abnormal gestations are as follows:gestations are as follows:
  11. 11.  The pregnancy is unable to survive owingThe pregnancy is unable to survive owing to its poor blood supply, thus resulting into its poor blood supply, thus resulting in a tubala tubal abortionabortion andand resorptionresorption, or it is, or it is expelled from the fimbriated end into theexpelled from the fimbriated end into the abdominal cavity.abdominal cavity.  The pregnancy continues to grow untilThe pregnancy continues to grow until the overdistended tubethe overdistended tube ruptureruptures, withs, with resulting profuse intraperitoneal bleeding.resulting profuse intraperitoneal bleeding.
  12. 12.  In rare instances, a tubal pregnancy willIn rare instances, a tubal pregnancy will be expelled from the tube and seed ontobe expelled from the tube and seed onto sites in the abdominal cavity (e.g. thesites in the abdominal cavity (e.g. the omentum, the small or large bowel, or theomentum, the small or large bowel, or the parietal peritoneum), and gives rise to aparietal peritoneum), and gives rise to a viableviable abdominal pregnancyabdominal pregnancy..
  13. 13. Symptoms and Clinical DiagnosisSymptoms and Clinical Diagnosis  High risk factors can beHigh risk factors can be summarized as follows:summarized as follows:
  14. 14.  A history of tubal infection (ectopic rateA history of tubal infection (ectopic rate of 1 in 24, as opposed to 1 in 200 inof 1 in 24, as opposed to 1 in 200 in noninfected patients)noninfected patients)  Prior ectopic pregnancy (15% to 50%Prior ectopic pregnancy (15% to 50% increase in incidence of ectopic gestationincrease in incidence of ectopic gestation in subsequent pregnancies)in subsequent pregnancies)  History of tubal sterilization within theHistory of tubal sterilization within the past 1 to 2 years (higher incidence ifpast 1 to 2 years (higher incidence if cauterization was used)cauterization was used)
  15. 15.  History of tubal reconstructive surgeryHistory of tubal reconstructive surgery (tuboplasty or end-to-end reanastomosis(tuboplasty or end-to-end reanastomosis for sterilization reversal)for sterilization reversal)  Pregnancy with an IUD in place or aPregnancy with an IUD in place or a history of IUD use.history of IUD use.  Infertility.Infertility.
  16. 16.  More than one therapeutic abortionMore than one therapeutic abortion (controversial)(controversial)  Pregnancy resulting from failed postcoitalPregnancy resulting from failed postcoital contraception (probably associated withcontraception (probably associated with abnormal tubal transport)abnormal tubal transport)
  17. 17. The classic symptom triadThe classic symptom triad amenorrhea,amenorrhea, vaginal bleeding,vaginal bleeding, abdominal pain.abdominal pain.
  18. 18.  Abdominal pain, usually in the lower abdomenAbdominal pain, usually in the lower abdomen in early cases, or generalized in rupturedin early cases, or generalized in ruptured ectopics with a hemoperitoneum. Amenorrheaectopics with a hemoperitoneum. Amenorrhea or a history of an abnormal last menstrualor a history of an abnormal last menstrual period is found in 75% to 90% of ectopicperiod is found in 75% to 90% of ectopic pregnancies. Vaginal bleeding, from spottingpregnancies. Vaginal bleeding, from spotting to the equivalent of a menstrual period, resultsto the equivalent of a menstrual period, results from a low human chorionic gonadotropinfrom a low human chorionic gonadotropin (hCG) production by the ectopic trophoblast(hCG) production by the ectopic trophoblast and is seen in 50% to 80% of patients.and is seen in 50% to 80% of patients.
  19. 19.  Making the diagnosis of an acutelyMaking the diagnosis of an acutely ruptured ectopic pregnancy is fairlyruptured ectopic pregnancy is fairly straightforward. The patient presents withstraightforward. The patient presents with symptoms of increasing abdominal pain,symptoms of increasing abdominal pain, abdominal distention, and hypovolemia.abdominal distention, and hypovolemia. The entire abdomen is acutely tender withThe entire abdomen is acutely tender with guarding and rebound tenderness.guarding and rebound tenderness.
  20. 20.  Physical examination in patients with an unrupturedPhysical examination in patients with an unruptured ectopic pregnancy may be extremely variable. Ninetyectopic pregnancy may be extremely variable. Ninety percent have abdominal tenderness, but only 45%percent have abdominal tenderness, but only 45% have positive rebound tenderness, and only 50 %have positive rebound tenderness, and only 50 % have an adnexal mass on pelvic examination. In halfhave an adnexal mass on pelvic examination. In half the cases, the mass is contralateral to the ectopicthe cases, the mass is contralateral to the ectopic pregnancy and represents the corpus luteum. Twentypregnancy and represents the corpus luteum. Twenty percent present with bilateral adnexal masses owingpercent present with bilateral adnexal masses owing to the presence of a contralateral coupus luteum cyst.to the presence of a contralateral coupus luteum cyst. The uterus is soft and either of normal size or slightlyThe uterus is soft and either of normal size or slightly enlarged.enlarged.
  21. 21. Differential DiagnosisDifferential Diagnosis  Many gynecologic andMany gynecologic and nongynecologic disorders havenongynecologic disorders have symptoms in common with ectopicsymptoms in common with ectopic pregnancy. Gynecologic disorders topregnancy. Gynecologic disorders to be considered includebe considered include::
  22. 22.  Threatened or incomplete abortion (alsoThreatened or incomplete abortion (also presenting with pain, bleeding, and apresenting with pain, bleeding, and a positive pregnancy test)positive pregnancy test)  A ruptured corpus luteum cystA ruptured corpus luteum cyst (abdominal pain, moderate to severe, at(abdominal pain, moderate to severe, at times coexisting with a history oftimes coexisting with a history of amenorrhea, vaginal spotting, andamenorrhea, vaginal spotting, and presence or absence of pregnancy, andpresence or absence of pregnancy, and evidence of hemoperitoneum)evidence of hemoperitoneum)
  23. 23.  Acute pelvic inflammatory disease withAcute pelvic inflammatory disease with fever, abdominal pain, leukocytosis, and,fever, abdominal pain, leukocytosis, and, at times, adnexal masses.at times, adnexal masses.  Adnexal torsionAdnexal torsion  Degenerating leiomyoma (common inDegenerating leiomyoma (common in pregnancy)pregnancy)
  24. 24.  The key to the successful management ofThe key to the successful management of ectopic pregnancy is early diagnosis. Althoughectopic pregnancy is early diagnosis. Although the number of new cases has increasedthe number of new cases has increased threefold, fewer are arriving at the hospitalthreefold, fewer are arriving at the hospital ruptured, with the patient already inruptured, with the patient already in hemorrhagic shock. This decrease is evidencehemorrhagic shock. This decrease is evidence that a high index of suspicion and vigorousthat a high index of suspicion and vigorous efforts at early diagnosis are effective.efforts at early diagnosis are effective.
  25. 25. β-hCG testingβ-hCG testing  Human chorionic gonadotropin is consisting ofHuman chorionic gonadotropin is consisting of two linked subunits, αandβ. β-hCG is secretedtwo linked subunits, αandβ. β-hCG is secreted by both the cytotrophoblast and theby both the cytotrophoblast and the syncytiotrophoblast and has the sole functionsyncytiotrophoblast and has the sole function of supporting the corpus luteum. Abnormalβ-of supporting the corpus luteum. Abnormalβ- hCG can not provide information on thehCG can not provide information on the location of the pregnancy. Ultrasonographylocation of the pregnancy. Ultrasonography must be used to locate the gestation.must be used to locate the gestation.
  26. 26.  The sensitivity of the current methods forThe sensitivity of the current methods for detection of β-hCG in the maternal serumdetection of β-hCG in the maternal serum allows the confirmation of pregnancyallows the confirmation of pregnancy even before a missed period.even before a missed period.
  27. 27. UltrasonographyUltrasonography  This field has shown rapid technologicalThis field has shown rapid technological improvements in recent years, and itsimprovements in recent years, and its application to the diagnosis of ectopicapplication to the diagnosis of ectopic pregnancy, alone and in combination withpregnancy, alone and in combination with hCG testing, is now the standard of care.hCG testing, is now the standard of care. Transvaginal ultrasonography has allowed theTransvaginal ultrasonography has allowed the detection of an intrauterine gestational sac atdetection of an intrauterine gestational sac at as early as 5 weeks of amenorrhea (2 mmas early as 5 weeks of amenorrhea (2 mm diameter).diameter).
  28. 28.  If the sac is not visualized at the uterineIf the sac is not visualized at the uterine cavity, special attention is needed tocavity, special attention is needed to differentiate between a true sac and adifferentiate between a true sac and a pseudosac, which is a ring-like structurepseudosac, which is a ring-like structure produced on ultrasound by a prominentproduced on ultrasound by a prominent decidual echo. Evidence ofdecidual echo. Evidence of hemoperitoneum may be inferred by thehemoperitoneum may be inferred by the sonographic description of “free fluid insonographic description of “free fluid in the cul-de-sac.”the cul-de-sac.”
  29. 29. CuldocentesisCuldocentesis  Culdocentesis is the technique by which a needle,Culdocentesis is the technique by which a needle, attached to a syringe, is inserted transvaginallyattached to a syringe, is inserted transvaginally through the posterior vaginal fornix into the pouch ofthrough the posterior vaginal fornix into the pouch of Douglas to detect any fluid within the peritonealDouglas to detect any fluid within the peritoneal cavity (Fig. 2). Although the procedure is simple,cavity (Fig. 2). Although the procedure is simple, inexpensive, and rapid, it is quite uncomfortable forinexpensive, and rapid, it is quite uncomfortable for the patient and is of limited use in an unrupturedthe patient and is of limited use in an unruptured ectopic pregnancy. It is unnecessary when theectopic pregnancy. It is unnecessary when the diagnosis is obvious and has a high false-negativediagnosis is obvious and has a high false-negative rate.rate.
  30. 30. Fig. 2. Technique for culdocentesisFig. 2. Technique for culdocentesis
  31. 31. ManagementManagement  Emergency treatmentEmergency treatment  Surgical treatmentSurgical treatment LaparotomyLaparotomy laparoscopylaparoscopy  Medical treatmentMedical treatment  Expectant managementExpectant management
  32. 32. Emergency treatmentEmergency treatment  Immediate surgery is indicated when theImmediate surgery is indicated when the diagnosis of ectopic pregnancy withdiagnosis of ectopic pregnancy with hemorrhage is made. Transfusion withhemorrhage is made. Transfusion with whole blood or an appropriate bloodwhole blood or an appropriate blood component therapy as soon possible iscomponent therapy as soon possible is indicated when the patient is in shock.indicated when the patient is in shock.
  33. 33. Surgical treatmentSurgical treatment  Rapid entry into the abdomen should beRapid entry into the abdomen should be accomplished, as control of hemorrhage can beaccomplished, as control of hemorrhage can be lifesaving. Careful, fast exploration of thelifesaving. Careful, fast exploration of the abdominal cavity should be done at once.abdominal cavity should be done at once. Remove products of conception, clots, and freeRemove products of conception, clots, and free blood. At operation the damaged tube isblood. At operation the damaged tube is usually removed. This procedure is the mostusually removed. This procedure is the most common for ectopic pregnancy.common for ectopic pregnancy.
  34. 34.  The type of procedure performed by eitherThe type of procedure performed by either laparoscopy or laparotomy will be dictated bylaparoscopy or laparotomy will be dictated by local findings at the time of surgery and thelocal findings at the time of surgery and the desire of the woman for future fertility. Indesire of the woman for future fertility. In patients who with to conserve fertility, a linearpatients who with to conserve fertility, a linear salpingostomysalpingostomy is the treatment of choice inis the treatment of choice in unruptured ampullary pregnancies. In ampullaryunruptured ampullary pregnancies. In ampullary pregnancies that have already ruptured, apregnancies that have already ruptured, a segmantal resection orsegmantal resection or partial salpingectomypartial salpingectomy cancan be offered, which implies the removal of onlybe offered, which implies the removal of only the affected segment of tube, leaving the restthe affected segment of tube, leaving the rest intact.intact.
  35. 35. Medical treatmentMedical treatment Unruptured ectopic pregnancyUnruptured ectopic pregnancy can be treated withcan be treated with Methotrexate (MTX).Methotrexate (MTX).
  36. 36. IndicationsIndications  no contraidications to MTXno contraidications to MTX  type of unruptured or abortiontype of unruptured or abortion  unruptued mass <4 cm at its greastestunruptued mass <4 cm at its greastest dimensiondimension  β-hCG level <2000mIU/mlβ-hCG level <2000mIU/ml  without signs of hemoperitoneumwithout signs of hemoperitoneum
  37. 37. Expectant managementExpectant management  As many as 80% of ectopic pregnancies withAs many as 80% of ectopic pregnancies with hCG levels of 1000mIU/ml or less will nothCG levels of 1000mIU/ml or less will not ruture spontaneously or bleed profusely butruture spontaneously or bleed profusely but will undergo spontaneous resolution.will undergo spontaneous resolution. Expectant management is generally reservedExpectant management is generally reserved for reliable, relatively asymptomatic patientsfor reliable, relatively asymptomatic patients in whom the hCG titers are <200mIU/mlin whom the hCG titers are <200mIU/ml and delining.and delining.
  38. 38. Treatment of Uncommon Types ofTreatment of Uncommon Types of Ectopic PregnanciesEctopic Pregnancies  Ectopic pregnancy and tubal pregnancy areEctopic pregnancy and tubal pregnancy are terms used interchangeably because other sitesterms used interchangeably because other sites of ectopic implantation are rare. A pregnancyof ectopic implantation are rare. A pregnancy can implant on the surface of the ovary. Thecan implant on the surface of the ovary. The treatment is aimed at removing the pregnancytreatment is aimed at removing the pregnancy and sacrificing as little as possible of the ovarianand sacrificing as little as possible of the ovarian tissue.tissue.
  39. 39.  Cervical pregnancy usually presents with profuseCervical pregnancy usually presents with profuse vaginal bleeding, and attempts at removal of thevaginal bleeding, and attempts at removal of the pregnancy are often unsuccessful. Hysterectomypregnancy are often unsuccessful. Hysterectomy is frequently indicated and is usually quiteis frequently indicated and is usually quite difficult. In more recent years, methotrexate anddifficult. In more recent years, methotrexate and arterial embolization have been used to managearterial embolization have been used to manage cervical pregnancy.cervical pregnancy.
  40. 40. All of the following therapeutic procedures areAll of the following therapeutic procedures are recommended for ectopic pregnancy EXCEPT:recommended for ectopic pregnancy EXCEPT: A salpingectomyA salpingectomy B salpingo-oophorectomyB salpingo-oophorectomy C partial salpingectomyC partial salpingectomy D salpingostomyD salpingostomy
  41. 41. Likely reasons for the establishment of an ectopicLikely reasons for the establishment of an ectopic tubal pregnancy include all of the followingtubal pregnancy include all of the following EXCEPT:EXCEPT:  A pelvic infectionA pelvic infection  B peritubal adhesionsB peritubal adhesions  C transmigration of fertilized ovumC transmigration of fertilized ovum  D uterine myomaD uterine myoma

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