Ectopic pregnancy PBL

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  • Macroscopic examination of the slide shows a rounded collection of material with a variegated appearance. There is an intimate admixture of pink and red tissue.Examination of this material under the microscope shows blood (red) and fibrin (pink) admixed with white blood cells and platelets (1), (2). Scattered through this blood clot are small numbers of immature chorionic villi (1), (2). These villi are rounded structures covered by two layers of cells. The inner cuboidal layer is the cytotrophoblast (2) and the outer syncitial layer is the syncitiotrophoblast (2). No foetal tissue is seen on this slide.การตรวจสอบด้วยตาเปล่าของภาพนิ่งที่แสดงให้เห็นคอลเลกชันที่โค้งมนของวัสดุที่มีลักษณะแตกต่างกัน มีส่วนผสมใกล้ชิดของเนื้อเยื่อสีชมพูและสีแดงเป็นการตรวจสอบของวัสดุนี้ภายใต้กล้องจุลทรรศน์ที่แสดงให้เห็นเลือด (สีแดง) และไฟบริน (สีชมพู) admixed ด้วยเซลล์เม็ดเลือดขาวและเกล็ดเลือด (1), (​​2) กระจัดกระจายอยู่ทั่วลิ่มเลือดนี้เป็นตัวเลขขนาดเล็กของ chorionic villi การอ่อน (1), (​​2) villi เหล่านี้เป็นโครงสร้างกลมปกคลุมด้วยสองชั้นของเซลล์ชั้น cuboidal ภายในเป็น cytotrophoblast (2) และชั้น syncitialด้านนอกเป็น syncitiotrophoblast (2) ไม่มีเนื้อเยื่อของทารกในครรภ์มีให้เห็นบนภาพนิ่งนี้
  • Placentation in the boto, Iniageoffrensis. The glandular endometrium forms trabeculae lined with uterine epithelium. Branched chorionic villi are inserted into the crypts. The spaces between the trophoblast and uterine epithelium are likely shrinkage artefacts. H.E. Scale bar = 1000 μm.
  • primary villiSyncytiotrophoblasts with a core of cytotrophoblasts. The syncytiotrophoblasts open lacunae and maternal capillaries expand to form sinusoids which anastomose with the trophoblastic lacunaesecondary villiMesoderm invades within the cytoblasts and syncytiotrophoblaststertiarary villivessels formPrimary villiWeek 2 - first stage of chorionic villi development, trophoblastic shell cells (syncitiotrophoblasts and cytotrophoblasts) form finger-like extensions into maternal decidua.Secondary villiWeek 3 - second stage of chorionic villi development, extraembryonic mesoderm grows into villi, covers entire surface of chorionic sac.Basal region will form chorionic plate.Tertiary villiWeek 4 - third stage of chorionic villi development, mesenchyme differentiates into blood vessels and cells, forms arteriocapillary network, fuse with placental vessels, developing in connecting stalk.
  • These villi are rounded structures covered by two layers of cells. The inner cuboidal layer is the cytotrophoblast (2) and the outer syncitial layer is the syncitiotrophoblast (2). No foetal tissue is seen on this slide.
  • A positive pregnancy test (presence of human chorionic gonadotropin), ultrasound, and culdocentesis with presence of blood are helpful in making the diagnosis of ectopic pregnancy. Seen here is tubal epithelium at the right, with rupture site and chorionic villi at the lower left.
  • Diagnosis decidualizedstroma and atrophy due to intrauterine deviceDescription Inactive gland on the right lying in decidualstroma. Dilated blood vessels. Superficial erosion of the endometrium.
  • Decidua fragment with widespread necrosis.
  • Ectopic pregnancy PBL

    1. 1. Ectopic pregnan cy
    2. 2. Case 1 • 22 1 , 6  1 PTA
    3. 3. Case 1   LMP 28 6, PMP 28 2556 -    
    4. 4. Case 1 Mild pale, no jaundice, not dehydrate BP 80/50, PR 120/min, RR 25/min, Temp. 37.0º c Abdomen: Mild distension, hypoactive bowel sound, no hepatosplenomegaly, no palpable mass Moderate tender at suprapubic area with guarding & rebound tenderness Shifting dullness negative. Both costovertebral angle not tender Physical examination
    5. 5. Case 1 Pelvic exam:NIUB : Normal, no urethral discharge Vagina : Normal mucosa, scanty old blood at posterior fornix Cervix : Os closed, old clot blood per os, no lesion, marked tender Uterus : Normal size, anteversion, marked tenderness Adnexa : Marked tender at both sides, Rt > Lt . Mass can’t be evaluate due to involuntary guarding Cul-de-sac : bulging Physical examination
    6. 6. Case 1 Urine pregnancy test: positive CBC : Hb 7.0 g/dL, Hct 22.2 Vol% MCV 59 fl, MCH 18 pg, MCHC 31.5 g/dl WBC 15,000 cells/mm3 N 85 % L 10 % M 5 %Platelet 393,000 cells/mm3 U/A : Color p.yellow Sp.Gr. 1.015 pH 6.5 Protein, Suger – ve WBC 3-5 /HF RBC 0-1 /HF Bacteria 1+ Transvaginal ultrasound: (gestational sac) 4 complex mass moderate free fluid Cul- Investigations:
    7. 7. Case 1
    8. 8. Case 1
    9. 9. Case 1
    10. 10. Case 1
    11. 11. Case 1
    12. 12. Case 1
    13. 13. Case 1
    14. 14. 1.
    15. 15. Differential Diagnosis 22 chief complaint : 1 - Reproductive system Gastrointestinal system Kidney Ureter Bladder system
    16. 16. Differential Diagnosis chief complaint : 1 Organ : - Ceacum - Appendix - Uterus - Ovary - Fallopian tube - Ureter
    17. 17. Differential Diagnosis chief complaint : 1 Gastrointestinal system : - Appendicitis - Constipation - Gastroenterit is      Appendicitis :    Mc Burney point
    18. 18. Differential Diagnosis chief complaint : 1      Nephrolithiasis : colicky intermittent Kidney Ureter Bladder system : - Nephrolithiasis - Cystitis - Pyelonephritis
    19. 19. Differential Diagnosis 22 chief complaint : 1 - Reproductive system Gastrointestinal system Kidney Ureter Bladder system      
    20. 20. Differential Diagnosis chief complaint : 1     Reproductive system : - Ectopic pregnancy - Adnexal torsion - Pelvic inflammatory disease - Ovarian cyst rupture - Abortion   
    21. 21. Differential DiagnosisReproductive system : - Ectopic pregnancy - Abortion - Adnexal torsion - Pelvic inflammatory disease - Ovarian cyst rupture Abdomen: Moderate tender at suprapubic area with guarding & rebound tenderness Pelvic exam:NIUB : no urethral discharge Vagina : scanty old blood at posterior fornix Cervix : Os closed, old clot blood per os, marked tender Uterus : marked tenderness Adnexa : Marked tender at both sides, Rt > Lt . Mass can’t be evaluate due to involuntary guarding Cul-de-sac : bulging Physical examination Urine pregnancy test: positive
    22. 22.   decidual basalis  Abortion Differential Diagnosis
    23. 23. Differential Diagnosis Adnexal torsion      CT,MRI
    24. 24. Pelvic inflammatory disease   Chlamydia trachomatis, Neisseria gonorrhoeae Differential Diagnosis minimal criteria) 1. lower abdominal tenderness) 2. (adnexal tenderness) 3. (cervical
    25. 25. Pelvic inflammatory disease Differential Diagnosis additional criteria)  º C  discharge mucopurulent )  Erythrocyte sedimentation rate (ESR)  C-reactive protein  Neisseria gonorrhoeae Chlamydia tra chomatis
    26. 26. Pelvic inflammatory disease Differential Diagnosis specific criteria)  endometrial biopsy endometritis)  (MRI) free pelvic fluid tubo- ovarian complex) 
    27. 27. Ovarian cyst rupture Differential Diagnosis    (MRI) complex cystic mass diffuse homogenous echo pattern
    28. 28. Differential Diagnosis Ectopic pregnancy  3 :    Ultrasound MRI
    29. 29. Differential Diagnosis Hb 7.0 g/dL Hct 22.2 % MCV 59 fl MCH 18 pg WBC 15,000 cells/mm3 N 85 % CBC   Mild pale  Vagina : scanty old blood at posterior fornix  Cervix : Os closed, old clot blood per os  Cul-de-sac : bulging
    30. 30. Differential DiagnosisReproductive system : - √ Ectopic pregnancy - Abortion - Adnexal torsion - Pelvic inflammatory disease - Ovarian cyst rupture Abdomen: Moderate tender at suprapubic area with guarding & rebound tenderness Vagina : scanty old blood at posterior fornix Cervix : Os closed, old clot blood per os Adnexa : Marked tender at both sides, Rt > Lt Mass can’t be evaluate due to involuntary guarding Cul-de-sac : bulgingUrine pregnancy test: positive Transvaginal ultrasound: (gestational sac) 4 complex mass moderate free fluid Cul-de-sac
    31. 31. Differential Diagnosis Transvaginal ultrasound: (gestational sac) 4 complex mass moderate free fluid Cul-de-sac
    32. 32. Differential Diagnosis
    33. 33. Differential Diagnosis Ectopic pregnancy
    34. 34. Macroscopic Microscopic finding
    35. 35. Macroscopic finding
    36. 36. Macroscopic finding
    37. 37. Macroscopic finding
    38. 38. Microscopic finding
    39. 39. Chorionic Villi of the Placenta http://www.webmd.com/baby/chorionic-villi- of-the-placenta http://www.rbej.com/conten
    40. 40. http://www.studyblue.com/notes/note/n/
    41. 41. Villi development Immature chorionic villi Mature chorionic villi http://embryology.med.unsw.edu.au/embryology/index.php?title=BGDA_Prac
    42. 42. Microscopic finding
    43. 43. Normal Fallopian tube http://legacy.owensboro.kctcs.edu/gcaplan/anat2/notes/APIINotes2%20fe
    44. 44. Microscopic finding rupture site and chorionic villi tubal epithelium Muscularis Tubal ectopic pregnancy
    45. 45. The Decidua Endometrium Decidua http://www.fetalultrasound.com/online Decidua basalis = beneath the implanted embryo Decidua capsularis = covers the rest of the chorionic sac Decidua parietalis (vera) = endometrial reaction which lines the uterine cavity and is not involved in implantation
    46. 46. http://www.studyblue.com/notes/note/n/keywords- The Decidua
    47. 47. Decidua of Ectopic pregnancy VS Abortion Ectopic pregnancy Abortion uterine decidua decidual cast) decidual basalis decidual necrosis decidual blood vessel thrombi, neutrophilic infiltrate, (old/recent hemorrhage) decidual basalis : 3 - ; : 2551.
    48. 48. Decidua of Ectopic pregnancy VS Abortion Ectopic pregnancy http://en.wikipedia.org/wi ki/Endometrium http://alf3.urz.unibas.ch/pathopic/e/ge
    49. 49. Abortion necrotic decidua Decidua of Ectopic pregnancy VS Abortion http://alf3.urz.unibas.ch/pathopic/e/ge tpic-fra.cfm?id=4676 decidual blood vessel thr http://placentation.ucsd.e du/oran.html
    50. 50. Overview
    51. 51. Anatomy of uterus and adnexa Saladin KS. Anatomy & Physiology: The Unity of Form and Function. 3rd Edition.
    52. 52. Ectopic pregnancy • Ectopic pregnancy is the result of a flaw in human reproductive physiology that allows the conceptus to implant and mature outside the endometrial cavity, which ultimately ends in the death of the fetus • Without timely diagnosis and treatment, ectopic pregnancy can become Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    53. 53. Ectopic pregnancy • Ectopic pregnancy refers to the implantation of a fertilized egg in a location outside of the uterine cavity –Fallopian tubes (approximately 97.7%) –Cervix –Ovary –Cornual region of the uterus –Abdominal cavity Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    54. 54. Ectopic pregnancy http://library.med.utah.edu/WebPat Ectopic pregnancies occur when the fertilized ovum implants outside of the uterine fundus. About 1 in 150 pregnancies results in ectopic implantation. Most cannot be sustained at extrauterine sites. However, a tubal ectopic pregnancy, as diagrammed here, may proceed for several weeks, but the enlargement can rupture the tube and lead to acute, life-threatening bleeding, often about 6 weeks after a previous menstrual period.
    55. 55. Ectopic pregnancy Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited: Ampullary, 80% Cervical, 0.2% Isthmic, 12% Fimbrial, 5% Cornual Intersti tial, 2% Abdominal, 1 .4% Ovarian, 0. 2% • Of tubal pregnancies, – Ampulla (80%) – Isthmus (12%) – Fimbria (5%) – Cornua (2%) – Interstitia (2- 3%)
    56. 56. Signs and symptoms • The classic clinical triad of ectopic pregnancy is as follows: –Abdominal pain –Amenorrhea –Vaginal bleeding Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    57. 57. Signs and symptoms • The following symptoms have also been reported: – Painful fetal movements (in the case of advanced abdominal pregnancy) – Dizziness or weakness – Fever – Flulike symptoms – Vomiting – Syncope Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    58. 58. Signs and symptoms • The presence of the following signs suggests a surgical emergency: – Abdominal rigidity – Involuntary guarding – Severe tenderness – Evidence of hypovolemic shock (eg, orthostatic blood pressure changes, tachycardia) Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    59. 59. Signs and symptoms • Findings on pelvic examination may include the following: – The uterus may be slightly enlarged and soft – Uterine or cervical motion tenderness may suggest peritoneal inflammation – An adnexal mass may be palpated – Uterine contents may be present in the vagina, due to shedding of endometrial lining stimulated by an ectopic pregnancy Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    60. 60. Diagnosis • Serum β-HCG levels • Ultrasonography • Laparoscopy Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    61. 61. Etiology • An ectopic pregnancy requires the occurrence of 2 events: –Fertilization of the ovum –Abnormal implantation Sepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    62. 62. Etiology • The following risk factors have been linked to ectopic pregnancy: –Tubal damage –History of previous ectopic pregnancy –Smoking –Altered tubal motility –History of 2 or more years of infertility –History of multiple sexual partnersSepilian PV. Ectopic pregnancy. Medscape. Updated May 6, 2013. Sited:
    63. 63. 5.
    64. 64. • Tubal damage • History of previous ectopic pregnancy • Smoking • Altered tubal motility • History of 2 or more years of infertility • History of multiple sexual partners • Maternal age 22 SI
    65. 65. Pelvic inflammatory disease may be
    66. 66. Altered tubal motility may be
    67. 67. 2. u/s
    68. 68. Ultrasonography   Transabdominal ultrasonography, TAS)  Transvaginal ultrasonography, TVS) 
    69. 69. Ultrasonography – – – - - - yolk sac) chorionic cavity - –
    70. 70. Ultrasonography – – - vitelline duct – - Crown Rump Length) – rhombencephalon amniotic membrane amniotic cavity chorionic cavity
    71. 71. Ultrasonography – - Crown Rump Length) – forebrain, midbrain hindbrain amniotic cavity vittelline duct
    72. 72. Ultrasonography ( : http://www.advancedfertility.com/ultraso4.htm)
    73. 73. 3.
    74. 74.    Treatment -
    75. 75. Treatment -    
    76. 76.  beta-hCG   u/s  3.5 cm Treatment -
    77. 77.  methotrexate systemic methotrexate 2 Single dose multiple dose Treatment -
    78. 78.     F/U 2-4 hCG 5 mlU/mL  4 cm   hCG 5,000 mlU/mL    methotrexate methotrexat Treatment -
    79. 79.  linear salpingostomy antemesosalpinx Treatment
    80. 80. Treatment
    81. 81. Treatment salpingectomy partial salpingectomy total salpingectomy   cm   
    82. 82. Treatment Partial salpingectomy Total salpingectomy
    83. 83. 1. ACOG practice bulletin. Management of recurrent pregnancy loss. Number 24, February 2001. (Replaces Technical Bulletin Number 212, September 1995). American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet2002 2. Cnattingius S, Ekbom A, Granath F, Rane A. Caffeine intake and the risk of spontaneous abortion. Food Chem Toxicol2003 3. Saladin KS. Anatomy & Physiology: The Unity of Form and Function. 3rd Edition. New York: McGraw-Hill Companies, Inc.; 2010. 4. Schorge O J, Schaffer I J, Halvorson M L, Hoffman L B, Bradshaw D K, Cunningham G F. Williams Gynecology. New York. The McGraw-Hill Companies; 2008. 5. Sepilian PV. Ectopic pregnancy. Medscape. Updated: May 6, 2013. Sited:http://emedicine.medscape.com/article/2041923 6. Tubal ectopic pregnancy [Internet]. Pathologyoutlines [ 19 . 2556] http://www.pathologyoutlines.com/topic/placentaspontaneousab.html 7. ; 2551 8. 3 : 2548. 9. - 10. 1 : 2548 References

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