CHAPTER I

PREFACE
Ectopic pregnancy is a implantation of a fertilized ovum outside the uterus is a
major health problem for women of reproductive age and is the leading cause of
pregnancy- related death during the first 20 weeks of pregnancy. Accurate
diagnosis and treatment of ectopic pregnancy decreases the risk of death and
optimizes subsequent fertility.(Ezeddin HP, 2008, Hoover KW, Tao G, 2010)
The blastocyst normally implants in the endometrial lining of the uterine cavity.
Implantation anywhere else is considered an ectopic pregnancy. It is derived from
the Greek ektoposout of place. According to the American College of
Obstetricians and Gynecologists (2008), 2 percent of all first-trimester pregnancies
in the United States are ectopic, and these account for 6 percent of all pregnancyrelated deaths. The risk of death from an extrauterine pregnancy is greater than
that for pregnancy that either results in a live birth or is intentionally terminated.
Moreover, the chance for a subsequent successful pregnancy is reduced after an
ectopic pregnancy. With earlier diagnosis, however, both maternal survival and
conservation of reproductive capacity are enhanced. (Cunningham FG et al, 2010)
The diagnosis of an ectopic pregnancy is usually unexpected and is often
emotionally traumatic. Many women may have only recently discovered they were
pregnant when they receive the diagnosis. Some women diagnosed with an
ectopic pregnancy do not even know they are pregnant and suddenly must think
about the possibility of major surgery or medical treatment. (Cunningham FG et al,
2010)
Ectopic pregnancy, in which the gestational sac is outside the uterus, is the
most common lifethreatening emergency in early pregnancy. The incidence in the
United States has increased greatly in the last few decades, from 4.5 per 1000
pregnancies in 1970 to an estimated 19.7 per 1000 pregnancies in 1992.1,2
Although spontaneous resolution of ectopic pregnancy can occur, patients are at
risk of tubal rupture and catastrophic hemorrhage.3,4 Ectopic pregnancy remains

an important cause of maternal death, accounting for about 4% of the

approximately 20 annual pregnancy-related deaths in Canada. Despite the
relatively high frequency of this serious condition, early detection can be
challenging. In up to half of all women with ectopic pregnancy presenting to an
emergency department, the condition is not identified at the initial medical
assessment.6 Although the incidence of ectopic pregnancy in the general
population is about 2%, the prevalence among pregnant patients presenting to an
emergency department with first-trimester bleeding or pain, or both, is 6% to
16%.714 Thus, greater suspicion and a lower threshold for investigation are
justified. (Cunningham FG et al, 2010)

CHAPTER 2
CASE REPORT
IDENTITY

Name :
Age :
MRNo :
Date :
Adress :

Miss. N
24 years old
86 72 03
Mei, 3rd 2014
Belimbing, Padang

CHIEF COMPLAIN
A 24 years old patient was admitted to the Delivery Room of Dr. M. Djamil Central
General Hospital on Mei 3rd, 2014 at 10.30 am referred by Private hospital with
diagnose Ectopic pregnancy
PRESENT ILLNESS HISTORY
Lower right abdominal pain a little bit since 1 days ago.
This morning around 07.00 increasing pain during activity and perceived
continuously, no pain radiating to the back and do not feel congested
Blood staining from vagina since 1 day ago, staining a piece of panty, black
redish colored and the patient went to the private hospital and said to be
pregnant outside the uterine, patient are referred to hospital M. Djamil with
attached catheter and infusion
Meat-like tissue out from the vagina was (-)
Fish bubbles like tissue out from the vagina was (-)
Amenorrhea since 2 month ago.
First date of last menstrual period March, patients did not know she was
pregnant
This was the second pregnancy
History of frequent whitish discharge from the vagina since 5 months ago.
No complaint in urinary and bowel system
History of fever (-)

 Menstrual History : menarche at 12 years old, no regular cycle, every 28 days

which last for about 4-5 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain
PREVIOUS ILLNESS HISTORY
There wasnt previous history of heart, lung, liver, kidney, DM, hypertension and
allergic history.
FAMILY ILLNESS HISTORY
There wasnt history of hereditary disease, contagious and physicological illness in
the family.
Marriage history

: once in 2010

History of pregnancy/abortion/delivery : 2/ 0 / 1
1. 2011, male, 3100 gr, term pregnancy, Spontan, midwife, alive
2. Present
History of family planning

: contraceptio injection every mounth

History of immunization

: (-)

History of education

: senior high school

History of occupation

: house wife

History of habitual

: smoking, alcohol and drug abuse were absent

Physical Examination :
General Appearance

: Moderate

Consiousness

: Composmentis cooperative

Blood Pressure

: 110/70 mmHg

Pulse rate

: 88 x/mnt

Respiration rate

: 26x/mnt

Temperature

: 37C

Body height

: 156 cm

Body weight before pregnancy : 51 kg

4

Body weight

: 52 kg

Upper arm circumference : 25 cm

BMI

: 20,95 (normoweight)
Eyes
: Conjunctiva anemic, Sclera wasnt icteric
Neck
: JVP 5-2 cmH2O
Chest
: H/L normal
Abdoment: OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obstetric Record:
Abdoment
Inspection

: Abdomen didnt seem enlarge, cicatrix (-)

Palpation

: Uterine fundal was hard to palpate, abdominal tenderness (+),

defence muscular (-)

Percution

: Tympani

Auscultaion

: Peristaltic sound was dicress

Genitalia
Inspection

V/U normal, Bleeding pervaginam (+)

Inspeculo
Vagina : tumor (-), laceration (-), fluxus (+) black redish blood
seemed to accumulate in the posterior fornix, chadwig
sign (+)
Portio: multiparous, size equal to 1st digiti of plantar pedis,
tumor (-), laceration (-), fluxus (+) There was black
redish

blood oozing from cervical canal, EUO was

close
VT binamual
Vagina : tumour (-)\

Portio: multiparous, size equal to 1st digiti of plantar pedis, tumor

(-), motion pain of the servix (+), EUO was close
CUT

: hard to examine

AP

: hard to examine

Douglas pouch: bulging

Laboratory finding :
No Parameter
1
Haemoglobin

Result
9,3 gr/dl

Haematocryte

29 %

Leucocyte

16.100/mm3

Trombocyte

284.000/mm3

PT

11,4 seconds

APTT

34,7 seconds

USG

Diagnose
Acute abdomen due to ruptured ectopic pregnancy in G2P1A0L1 gravid 6-8 weeks
+ mild anemia (Hb: 9,3 gr%)

Advice:
Control GA, VS
Pre-operation room

 Consult to anasthesiologist and operative room

Prepare blood for transfusion
Informed consent
Plan:
Cito laparotomy
11.00 am
- laparatomy was performed
After opening the peritoneum in the blood and blood clot looked 1000 cc.
Exploration was the source of bleeding coming from the right tubal rupture pars
ampularis. Size 3x2x1,5 cm
Impression: right fallopian tube rupture pars ampularis.
Plan : Right Salfingektomy
Uterine shape and size larger than normal, the left fallopian tube and ovary
both shape and size within normal limits
Salfingektomy was performed
D/ Post right salfingectomy on indication rupture of right tube pars ampularis
Follow - up
May, 4th 2014
A/ Fever (-),
Bleding from
vagina (-),
Urine (+)
with catetter

Physical Examination :
GA

Cons

BP

HR

RR

Mdt

CMC

120/80

82

21

36,8

Obstetric Record:
Abdoment
Inspection

: Abdomen didnt seem enlarge. Incicion of laparatomy was good

Palpation

:Uterine fundal was hard to palpate, abdominal tenderness (-),

defense muskular (-), rebound tenderness (-)

Percution

: Tympani

Auscultaion

: Peristaltic sound was normal

Genitalia
Inspection

V/U normal, Bleeding pervaginam (-)

Diagnose :
Post right salfingectomy on indication rupture of right tube pars ampularis
Advice:
Control GA, VS
gradual mobilization
High protein and carbohidrat in diet
Theraphy :

Aff IVFD

Ceftriaxone 2 x 500 mg

Mefenamic acid 3x500 mg

Vit C 1x1

SF 1x1

Follow - up May, 5th 2014

A/ Fever (-), Bleding from vagina (-), Urine (+)
Physical Examination :

GA

Cons

BP

HR

RR

Mdt

CMC

120/80

85

24

36,8

Obstetric Record:
Abdoment
Inspection

: Abdomen didnt seem enlarge. Incicion of laparatomy was good

Palpation

:Uterine fundal was hard to palpate, abdominal tenderness (-),

defense muskular (-), rebound tenderness (-)

Percution

: Tympani

Auscultaion

: Peristaltic sound was normal

Genitalia
Inspection

V/U normal, Bleeding pervaginam (-)

Diagnose :
Post right salfingectomy on indication rupture of right tube pars ampularis
Advice:
Control GA, VS
gradual mobilization
High protein and carbohidrat in diet
Theraphy :

Ceftxime 2 x 100 mg

Mefenamic acid 3x500 mg

Vit C 1x1

SF 1x1

Follow - up May, 6th 2014

A/ Fever (-), Bleding from vagina (-), Urine (+)
Physical Examination :

10

GA

Cons

BP

HR

RR

Mdt

CMC

120/80

87

23

36,8

Obstetric Record:
Abdoment
Inspection

: Abdomen didnt seem enlarge. Incicion of laparatomy was good

Palpation

:Uterine fundal was hard to palpate, abdominal tenderness (-),

defense muskular (-), rebound tenderness (-)

Percution

: Tympani

Auscultaion

: Peristaltic sound was normal

Genitalia
Inspection

V/U normal, Bleeding pervaginam (-)

Diagnose :
Post right salfingectomy on indication rupture of right tube pars ampularis
Advice:
Control GA, VS
gradual mobilization
High protein and carbohidrat in diet
Theraphy :

Ceftxime 2 x 100 mg

Mefenamic acid 3x500 mg

Vit C 1x1

SF 1x1
CHAPTER 3
Ectopic Pregnancy

A.

DEFINITIONS
Ectopic pregnancies account for 1% to 2% of all conceptions. An ectopic

pregnancy is an early embryo (fertilized egg) that has implanted outside of the

11

uterus (womb), the normal site for implantation. In normal conception, the egg is
fertilized by the sperm inside the fallopian tube. The resulting embryo travels
through the tube and reaches the uterus 3 to 4 days later. However, if the fallopian
tube is blocked or damaged and unable to transport the embryo to the uterus, the
embryo may implant in the lining of the tube, resulting in an ectopic pregnancy. The
fallopian tube cannot support the growing embryo. After several weeks the tube
can rupture and bleed, resulting in a potentially serious situation.(Cunningham FG
et al, 2010)
Ninety-five percent of ectopic pregnancies implant in the fallopian tube, but
they also can occur in the cervix, ovary or even within the abdomen (abdominal
pregnancy). Abdominal pregnancies are extremely rare and can progress quite late
into the pregnancy before they are discovered. Fetuses that grow in the abdomen
who could survive after birth have been delivered, on rare occasions, by
laparotomy (abdominal surgery).(Cunningham FG et al, 2010)
Women who have ectopic pregnancies, particularly if they have been
attempting to conceive for a long period of time, often ask whether the pregnancy
can be removed from the tube and then transplanted into the uterus where it might
grow normally. Unfortunately, this is not possible with present medical science.
(Dart RG, Dyne PL, 2004)
B.

EPIDEMIOLOGY
According to the Centers for Disease Control and Prevention (1995), the rate

of ectopic pregnancies continued to increase in the United States through the

1990s . Thereafter, because of the increasing use of medical outpatient treatment,
reliable data on the actual number of ectopic pregnancies are not available after
1990. That said, the 1.9-percent rate in 1992 is similar to that of 2.1 percent in
more than 125,000 pregnancies reported from Kaiser Permanente of North
California from 1997 to 2000. (Barnhart KT, 2009)
Ruptured ectopic pregnancy is a major cause of death during early
pregnancy. Diagnosis and the latest treatment protocols decrease case fatality rate
over the last 35 years. Women who are not white have a 3.4 times greater risk than

12

women who were white. Access to health care affect the mortality. (Durfe RB, 2003)
The incidence of ectopic pregnancy increased in all women, especially in
those aged 20 to 40 years with an average age of 30 years. Ectopic pregnancy
occurs most often in the fallopian tube area (98%), despite that ectopic
pregnancies can also occur in the ovary (ovarian), abdominal cavity (stomach), or
cervix (neck of the womb). (Hoover KW, Tao G, Kent CK, 2010)
C.

ETIOLOGY AND RISK FACTORS

The cause of ectopic pregnancy largely unknown. Most hypotheses that try

to explain the occurrence of all types of ectopic pregnancy was unable to obtain
sufficient data support. A more realistic approach is to recognize the factors
predisposing to ectopic pregnancy. Various abnormalities and damage to tubal
ectopic pregnancy is instrumental in. (Cunningham FG et al, 2010, Hoover KW,
Tao G, Kent CK, 2010, Rachimhadhi T, 1999)
1.

Factors - factors that prevent or inhibit mechanical trip fertilized ovum into the

uterine cavity
Salfingitis, especially endosalfingitis, which cause agglutination tubal mucosal
folds and can narrow the lumen of the tube and forming pockets - pockets of
dead-end. Infection can also reduce mucosal cilia-cilia that cause tubal
implantation of the zygote into the fallopian mucosa. Incidence of 12.8% after
one infection, 35.5% after two infections and 75% after three or more
infections.
Peritubal adhesions after infection post abortion or puerperal infection,
appendicitis or endometriosis which causes tertekuknya tube and narrowing
lumenya.
Tube growth abnormalities, especially diverticulum, accessory ostium and
hypoplasia. The anatomical abnormalities associated with exposure to
diethylstilbestrol (DES) while in utero.
Previous ectopic pregnancy. With a previous ectopic pregnancies treated with
linear salfingostomi, the possibility of an ectopic pregnancy is 15-20%. After

13

two ectopic pregnancies, the risk for subsequent ectopic pregnancy increased
to 32%.
History of previous tubal surgery, either to repair tubal patency and tubal
sterilization failure.
A history of recurrent miscarriage induction. This is related to the occurrence
salfingitis.
Tumors are pushing tubes, such as myoma uteri and adnexal mass
2.

Functional Factors that slow the fertilized ovum to the uterine cavity, such
as:

Migrating external ova. The risk of ectopic pregnancy slightly increased in

women with a tubal if ovulation occurs on the contralateral ovary.
Reflux menstruation. Fertilization of the ovum by the slowness of menstrual
bleeding to prevent the entry of ova into the uterus or has it turned back ova
into tube.
Changes in mortality tube. Mortilitas tuba influenced by estrogen and
progesterone levels in serum. Estrogen will increase the activity of smooth
muscle of the uterus and fallopian while progesterone lowers Tonos smooth
muscle. This mechanism also explains the increased incidence of ectopic
pregnancy in the use of birth control pills containing only progestin. Mortality
changes also occur in the fallopian intrauterine exposure to DES are reported
to increase the incidence of ectopic pregnancy 4% -13%.
Smoking habits at the time of conception. Coste et al (1991) through a casecontrol study concluded that there is a relationship between the number of
cigarettes per stick consumption with the risk of ectopic pregnancy, ie if
smoking more than 20 cigarettes per day increased 2.5-fold and 1.3-fold when
smoked 1 - 10 cigarettes per day.
3.

Increased mucosal tubal receptivity to the fertilized ovum, this found in

endometriosis in the tube.

4.

Assisted reproduction. The increased incidence of ectopic pregnancy in

induction of ovulation, gamete intrafallopian transfer (GIFT), in vitro
14

fertilization (IVF) and ovum transfer.

5.

Failure of contraception. There is an increased incidence of ectopic

pregnancy after tubal sterilization. The risk is higher in electrocoagulation
types of sterilizatio.

6.

Ectopic pregnancy can occur even after a hysterectomy, because trapping

the fertilized ovum in the fallopian cut the time of hysterectomy.

Tabel 1 : Risk factor of ectopic pregnancy (Dart RG, Dyne PL, 2004)

15

D.

CLASIFICATION

Nearly 95% of ectopic pregnancies implant in the fallopian tubes, ovaries

3.2%, and 1.3% in the abdomen. Bilateral ectopic pregnancy is rare, the
prevalence is 1 in 200,000 pregnancies. (Barnhart KT, 2009, Breen JL., 1970,
Cunningham FG et al, 2010
Figure 1. Location of Ectopic Pregnancy (Barnhart KT, 2009)

16

1.

Tubal Pregnancy
The fertilized ovum may lodge in any portion of the oviduct, giving rise to

ampullary, isthmic, and interstitial tubal pregnancies. In rare instances, the fertilized
ovum may implant in the fimbriated extremity. The ampulla is the most frequent
site, followed by the isthmus. Interstitial pregnancy accounts for only about 2
percent. From these primary types, secondary forms of tubo-abdominal, tuboovarian, and broad-ligament pregnancies occasionally develop. (Ezeddin HP,
2008, Hoover KW, Tao G, Kent CK, 2010)
Because the tube lacks a submucosal layer, the fertilized ovum promptly
burrows through the epithelium, and the zygote comes to lie near or within the
muscularis. The rapidly proliferating trophoblast may invade the subjacent
muscularis, however, half of ampullary ectopic pregnancies stay within the tubal
lumen with preservation of the muscularis layer in 85 percent (Senterman and
associates, 1988). The embryo or fetus in an ectopic pregnancy is often absent or
stunted.(Jafri SZ et all, 1987)
The findings of ectopic pregnancy include intrauterine normal endometrium,
pseudogestasional sac, trilaminar endometrium, decidua thin-walled cysts.
Decidual reaction Psudogestasional sac is surrounded by a thick intrauterine fluid.
Ten percent of patients with ectopic pregnancy is accompanied by a picture
pseudogestasional sac. (Hammond CB, et al, 1994)
2.

Interstitial pregnancy
Interstitial ectopic pregnancy (sometimes called pregnancy kornual) is also

important to recognize. This pregnancy is 2-4% of all ectopic pregnancies and is

located in the interstitial tube, partially surrounded by myometrium. Interstitial
ectopic pregnancy have a higher morbidity than mortality due to tubal ectopic other
great potential bleeding. (Jafri SZ et al, 1987) In this location, the myometrium
surrounding the gestational sac portion of the expansion, which allows for
enlarging painless for a relatively long time. Consider the diagnosis of intrauterine
pregnancy seen in the fundus of the myometrium thickness of 5 mm. Specificity
threshold of 5 mm unexplored. (Fleischer AC, Pennell RG, 1990)

17

3.

Ovarian pregnancy
Ovarian pregnancy occurs when the fertilized ovum in the ovary and stuck.

Ovarian pregnancy occurs 3% of ectopic pregnancies, sometimes manifested by

heterotopic pregnancy. Ovarian pregnancy is strongly associated with the use of
intrauterine devices and tubal pregnancy are often at the same time. The presence
of gestational sac, chorionic villi, or atypical cysts with ring hiperekhoik on the
ovaries, fallopian tubes normal to convince us that an ovarian pregnancy. (Dart
RG, Dyne PL, 2004, Durfe RB, 2008)
4.

Cervical pregnancy
Cervical pregnancy occurs when implantation blastokist are at endoservikalis

canal. It is also rare (<1% of ectopic pregnancies) and is often associated with in
vitro fertilization and a history of previous curettage. The diagnosis was made by
ultrasonography. In uterine cervical pregnancy hourglass-shaped or shaped 8
because the fetus expansion into the cervix. If the gestational sac in the cervix
looks, subtle manipulation to be done unruk distinguish cervical pregnancy with
abortion in progress. If there is a sliding sign (at the time of manipulating the
transducer probe gestational sac), this suggests that the gestational sac was not
attached to the cervix (cervical pregnancy get rid of), and indicates the ongoing
abortion.7,8
5.

Scar Pregnancy
Pregnancy in cesarean section scars are also rare, about 1% of all

pregnancies. Implantation in the previous cesarean section scars, separate the

uterine cavity. In the scar blastokist surrounded by myometrium and fibrous tissue.
Mechanisms which may lead to pregnancy is the channel that connects the
endometrium and myometrium, thus facilitating the implantation of the scar.
Patients may complain of vaginal bleeding in pregnancy fastest 5-6 weeks up to 16
weeks. Scarring can also rupture and cause severe bleeding and hemodynamic
collapse. At this scar pregnancy, gestational sac visible in the inferior part of the

18

anterior wall of the uterus. Due to compression by the gestational sac, also
increasingly thin myometrium anteriorly. Thinning of the myometrium is prediposisi
uterine rupture. (Barnhart KT, 2009, Cunningham FG et al, 2010)
6.

Intra-abdominal pregnancy
Implantation occurs in the intraperitoneal cavity, excluding tubes, ovaries,

and the location of intra ligaments. It is a rare cause of ectopic pregnancy, but often
occurs in patients receiving assisted reproductive technology, and a 1.4%
incidence of ectopic pregnancy. Significant bleeding and maternal mortality is
closely related to intra-abdominal pregnancy, which is 7.7 times higher than other
ectopic pregnancies. (Barnhart KT, 2009, Cunningham FG et al, 2010)
7.

Heterotopic pregnancy
Heterotopic pregnancy occurs when the intrauterine and extrauterine

pregnancies occur simultaneously. Knowledge of heterotopic pregnancy is

becoming increasingly important as more and more women who perform assisted
reproductive techniques, especially ovulation induction. The prevalence of
heterotopic pregnancy in women who undergo assisted reproduction techniques is
1-3%. Heterotopic pregnancy is a challenge of the future and always be
remembered in women with assisted reproductive techniques experiencing pelvic
pain. Ultrasound picture shows the extra and intrauterine pregnancy. (Breen JL,
1970, Durfe RB, 2003)
E.

PATHOLOGY OF ECTOPIC PREGNANCY

Fertilized ovum can grow on any part of the fallopian tubes so that

pregnancy can occur ampulla, isthmus, interstitial and fimbriae. From this primary
implantation can occur secondary forms such as tubo-abdominal pregnancy, tuboovarian and broad ligament pregnancy. (Cunningham FG et al, 2010, Fleischer AC,
Pennell RG, 1990)
Fertilized ovum (zygote) embed themselves with tubal epithelium to
penetrate, thus directly located in the muscular wall of the tube because it does not

19

have the submucosal structures. All around the zygote contained capsule that
consists of rapidly proliferating trophoblasts invade the tunica muscularis and tubes
underneath. At the same time, maternal blood vessels open and blood to
accumulate in the trophoblast or in between the trophoblast and the surrounding
tissue. Walls of the tube in direct contact with the zygote not hold trophoblast
invasion, because it could not form a normal decidua as well as endometrial tissue.
Villi are the findings patognomonis korialis for tubal pregnancy, while the embryo is
just visible on the evidence of two thirds of cases. (Hammond CB, et al, 1994)
Products of conception suffered death at 6-8 weeks of pregnancy, due to
tubal mucosa is not a good medium for the growth of the blastocyst and uterine
bleeding that occurs is regarded as menstruation that came too late. Abortion can
occur in tubal ectopic pregnancy is usually implant in ampulla.6, 7 bleeding that
occurs due to tubal pregnancy is extraluminal or luminal (hematosalfing) and out
through the tip of the fimbriae into the peritoneal cavity and accumulate dikavum
hematokel retrouterina of Douglas form. (Hoover KW, Tao G,, 2010)
Rupture can occur in any part of the tube where the implantation of the
zygote. When it occurs in the early weeks of pregnancy, most likely implantation in
the isthmus. Rupture occurs largely spontaneously, but can also by trauma such as
coitus or bimanual examination. In ectopic pregnancy, the uterus also experienced
changes resemble a normal pregnancy, the softening of the cervix and uterine
isthmus and enlargement. The endometrium undergoes changes to form the
decidua in varying degrees. Arias-Stella (1954) describe the changes in the
endometrium, namely: epithelial cells are enlarged, hypertrophic essence,
hyperchromatic, and irregular lobular. Polarity disappeared and abnormal nuclei of
cells occupying the luminal direction. Experience and foamy cytoplasm
vacuolization, sometimes encountered mitosis. This description is not specific to
ectopic pregnancy. So that all the changes in the uterus does not rule out the
possibility of an ectopic pregnancy. (Jafri SZ, Loginsky SJ, 1987, Barnhart KT.,
2009)
F.

ECTOPIC PREGNANCY DIAGNOSE

20

1.

ANAMNESA
In ectopic pregnancy are not disturbed normal pregnancy symptoms such as

amenorrhoea, nausea, and slight pain in the lower abdomen that is not so
perceived. (Cunningham FG et al, 2010)
Patients ectopic pregnancy will usually present with the classic form of
abdominal pain, amenorrhoea and bleeding pervaginan. Abdominal pain is the
main complaint in disturbed ectopic pregnancy. Pain may be unilateral or bilateral
and can also be felt in the belly of the bottom or top. After the rupture, can be
painful shoulder, neck or waist. This indicates intraperitoneal hemorrhage has
occurred. (Cunningham FG et al, 2010, Dart RG, Dyne PL, 2004)
Complaints amenorrhoea may vary, depending on the life of the fetus. Most
patients do not experience amenorrhea as a dead fetus before the next
menstruation. Bleeding happens pervaginan shows fetal death, and derived from
the uterine cavity due to the release of the decidua. Usually the bleeding is not
much but it can last long and blackish colored blood. (Cunningham FG et al, 2010,
Dart RG, Dyne PL, 2004)
2.

PHYSICAL EXAMINATION
Physical

examination

performed

include

vital

signs

measurements,

abdominal and pelvic examination. Prior to the rupture of a physical examination

that were found are not specific with normal vital signs. When you rupture can
occur with rapid pulse shock symptoms, acral cold, pale and hypotension.
(Cunningham FG et al, 2010, Dart RG, Dyne PL, 2004)
In an ectopic pregnancy is not interrupted signs were found to resemble a
normal pregnancy. When it is disturbed and will rupture found tenderness and
rebound tenderness on palpation of the abdomen for peritoneal stimuli and shifting
dullness to percussion which indicates the presence of intraperitoneal bleeding. In
further bleeding can be found Cullen's sign, which is a bluish color around the
umbilicus due to the absorption of blood in the peritoneal cavity by lymphatic

21

system (Cunningham FG et al, 2010, Dart RG, Dyne PL, 2004)

On vaginal examination the vagina and cervix will be found that is bluish
and soft with pain in one iliac fossa when the cervix is moved. Can also be found
adnexal mass tenderness and protrusion of the pouch of Douglas when a rupture
has occurred. (Cunningham FG et al, 2010, Dart RG, Dyne PL, 2004)
3.

Examination of serial quantitative -hCG

Examination through urine pregnancy test has a sensitivity that is normally

done between 1500-3500 mIU / ml serum. With technological advancement

examination -hCG levels can radioimunoassay which had a sensitivity of 5-10
mIU / ml serum. In this way means that the test was positive 9 or 10 days after
ovulation. -hCG levels are used to differentiate an ectopic pregnancy with a
normal intrauterine pregnancy is based on the doubling time (doubling time) within
48 hours of -hCG levels will increase by more than 66% of normal pregnancy
whereas ectopic pregnancy is less than 66%. (Durfe RB., 2003)
4.

Ultrasonography (USG)
Ultrasound is an invaluable tool in the early diagnosis of ectopic pregnancy.

The existence of a positive pregnancy test in early pregnancy as well as the

discovery of the pregnancy signs on examination not provide assurance whether
occurring intrauterine pregnancy or pregnancy ektopik.12 Robinson et al (1988)
suggest that the positive pregnancy test, ultrasound did not show any signs of
intrauterine pregnancy, there free fluid in the pouch of Douglas and pelvic mass of
abnormal, almost certainly an ectopic pregnancy. (Barnhart KT. 2009)
This casts doubt on the findings of ectopic pregnancy ultrasound is a
pseudo sac which actually is a picture of the decidua in ectopic pregnancy, this can
be regarded as intrauterine pregnancy. (Barnhart KT. 2009)
Transvaginal ultrasound has an accuracy of 1 week earlier than ultrasound
trasabdominal. Abdominal ultrasound can detect the presence of an intrauterine
gestational sac is better when the levels of -hCG> 6500 mIU / ml or 5-6 weeks
after the last menstrual period and ultrasound can detect gestational sac

22

trasvaginal when the levels of -hCG> 1500 mIU / ml or 4-5 weeks after the last
menstrual period. If no sign of intrauterine pregnancy on the levels of -hCG
should be suspected presence of an ectopic pregnancy. Examination of -hCG
when combined with the ultrasound diagnostic accuracy approaching 100% of
ectopic pregnancies. (Cunningham FG et al, 2010)
5.

Culdocentesis
Culdocentesis can assist in the diagnostic hemoperitoneum due to rupture

the tube. The sensitivity and specificity in detecting hemoperitoneum Culdocentesis

reported 85-90%. Patients with little or no intra-abdominal bleeding, Culdocentesis
negative, not get rid of pregnancy ektopik.4, 9 Now Culdocentesis is rarely used
because of the presence of other tests have more accurate and non-invasive.
(Cunningham FG et al, 2010)
6.

Dilatation and curettage

In the diagnostic process of ectopic pregnancy, curettage is done to

distinguish between non-viable intrauterine pregnancy with an ectopic pregnancy, if

other diagnostic results are not satisfactory. Results curettage examined to
determine the presence / absence of villi korialis. Ditemukanya decidua without villi
curettaged korialis of preparations showed the presence of an ectopic pregnancy
greatly. (Cunningham FG et al, 2010)
7.

Laparoscopic
Laparoscopy is the gold standard for the diagnosis of ectopic pregnancy, in

which the tube can be visualized and evaluated clearly, although 3-4% of the mass
is very small ectopic pregnancy is not diagnosed. Ectopic pregnancy appears as a
mass that distorts the normal structure of the tube. Laparoscopy is used when a
suspected ectopic pregnancy and there were no signs of intraperitoneal bleeding.
Especially when -hCG levels less than 6500 mIU / ml with increased levels during
48 hours of observation less than 66%. (Cunningham FG et al, 2010)

23

G.

MANAGEMENT OF ECTOPIC PREGNANCY

If the ectopic pregnancy has been established, the patient should be

reevaluated clinically back. Medical or expectant management may be attempted if

the patient is in stable condition. If the patient's condition is not good, an indication
of surgical treatment. Currently there are 3 ways of management of ectopic
pregnancy, namely: (Barnhart KT, 2009)
1.

Expectant (Observation)
Expectant management based on that patients with ectopic pregnancy can

be reabsorbed perfect or the occurrence of spontaneous abortion. Expectant

management is often performed in patients with -hCG levels <1000 mIU / ml,
hemoperitoneum <50 ml with hematosalfing <2 cm. As many as 67% of ectopic
pregnancies that have not bothered with a diameter <30 mm and no active
bleeding can be reabsorbed perfect. Tubal patency rate of approximately 85% and
pregnancy rates as much as 52%. (Barnhart KT, 2009)
Garcia et al (1987) stated that only expectant acts done under strict control
and in asymptomatic patients with -hCG levels continue to fall. The advantage of
this method does not need surgery, costs little and fertility is not compromised.
(Barnhart KT, 2009)
2.

Medikamentosa
Medical treatment often used is Methotrexate (MTX). Methotrexate is a folic

acid antagonist that is metabolized in the liver and excreted through the kidneys.
MTX inhibits purine and pyrimidine synthesis thus interfere with DNA synthesis and
cell multiplication. Cells growing as network tropoblas very susceptible to MTX, so
as to stop the development of an ectopic pregnancy which eventually die and are
absorbed. (Barnhart KT, 2009, Rachimhadhi T, 1999)
MTX can be administered systematically, locally or orally, so that surgery
can be avoided thus tubal adhesions, post-surgical morbidity is reduced and
recovery time shortened, and fertility can be maintained in the future. (Barnhart KT,
2009)

24

Terms of use of MTX in ectopic pregnancy are: (Cunningham FG et al,

2010)
Absolut:
Hemodynamically stable.
USG supports an ectopic pregnancy.
Ability of patients had follow-up.
There are no contraindications to MTX.
Relative:
Ectopic pregnancy is not interrupted with a diameter <3.5 cm.
No fetal heart motion.
-hCG levels <5000 mIU / ml.
Indications for MTX:
Tubal patency to be maintained.
Patients who refuse surgery.
Surgery is risky (pregnancy cervix, cornua and ovaries).
Contraindications to the use of MTX:
Liver disease and kidney disease.
Tubal rupture.
Giving systemic MTX can be done with a double dose or a single dose. Double
dose with administration of MTX 1.0 mg / kg IM days 1,3,5 and 7, with citrovorum
0.1 mg / kg IM days 2,4,6 and 8. Treatment was continued until the levels of -hCG
down> 15% in 48 hours or 4 doses of MTX. (Barnhart KT, 2009)
Giving a single dose of MTX at a dose of 50 mg/m2 IM with the evaluation of hCG titers at days 4 and 7. (Barnhart KT, 2009)
3.

Surgery
Current treatment of ectopic pregnancy has changed from salfingektomi

which was once the gold standard treatment of ectopic pregnancy be a procedure

25

to maintain tubal function. Laparotomy only when laparoscopic equipment is not

available or the patient is hemodynamically unstable due to hemorrhage intra
abdominal. Several surgical techniques are often employed for the management of
ectopic pregnancy. (Hoover KW, Tao G, 2010)

Salfingostomi
This technique is performed to remove the tubal pregnancy is smaller than 2

cm and located in the distal third of the tube. With linear laparoscopic incision
along the 2 cm above the right ectopic pregnancy, so that the concept can go out
alone or slightly reduced from the opposite direction and was appointed to the
dental forceps carefully. Bleeding is controlled with electrocautery or laser, and
wounds without suturing incisions are left open to heal itself. Sherman et al (1982)
reported that salfingostomi provide a higher pregnancy rate than salfingektomi.
(Ezeddin HP, 2008, Hoover KW, Tao G, 2010)
Salfingotomi
The difference between salfingostomi with salfingotomi is made logitudinal
salfingotomi incision and the incision sutured with vicryl former no. 7.0 carefully.
Layers are sewn just muscle and serosa without the mucosal layer, because it may
cause an inflammatory reaction that can cause obstruction. Salfingotomi is the
technique of choice if the diameter of an ectopic pregnancy is greater than 2 cm.
(Ezeddin HP, 2008, Hoover KW, Tao G, 2010)
Salfingektomi
Salfingektomi is the removal of the tube to create a wedge-shaped excision
is not more than a third outer tube interstitial past. It aims to minimize the possibility
of subsequent ectopic pregnancy in the fallopian butts. This technique remains the
top choice in tubal rupture with massive intraperitoneal hemorrhage.
(Ezeddin HP, 2008, Hoover KW, Tao G, 2010)
Segmental resection and anastomosis

26

This technique is performed for tubal ectopic pregnancy at the isthmus. After
tubal segments clearly visible, mesosalfing incision below the tube and the tube
containing the ectopic pregnancy resected. Mesosalfing then stitched back and
both ends of the tube reanastomosis with vikryl 7.0 by stitching one-on-one.
(Ezeddin HP, 2008, Hoover KW, Tao G, 2010)

CHAPTER 4
DISCUSSION

This case report discusses A 24 years old patient was admitted to the Delivery
Room of Dr. M. Djamil Central General Hospital on Mei 3 rd, 2014 at 10.30 am
referred by Private hospital with diagnose Ectopic pregnancy disorder. As a guide
to the discussion on target academically comprehensive scientific then we will
discusss some of the reference questions are as follows :
1. Whether the diagnose of this patient was right ?
2. Whether the management of this patient was appropriate ?
3. What the cause of Ectopic pregnancy disorder in this patiens ?

27

1. Whether the diagnose of this patient was right ?

Discussion based on the questions are : Known by anamnese this patient was
a Lower right abdominal pain a little bit since 1 days ago. Pain feel increasing
during activity and perceived continuously, no pain radiating to the back and do not
feel congested, bleeding from the genitals slightly (+) blackish red underwea On
physical examination, Conjunctiva anemic, Abdomen didnt seem enlarge, Uterine
fundal was hard to palpate, abdominal tenderness (+), defence muskular (-),
Peristaltic sound was dicres. Bleeding from vagina, fluxus from genitalia, motion
pain of the servix, CUT and AP hard to examine, Douglas pouch: bulging
From anamnesis,fisical examination and laboratorium finding the diagnose this
patient is right.
2. Whether the management of this patient was appropriate ?
This patient pregnancy was planned to be terminated by emergency
laparatomy.

This

procedure

is

recomended

by

cunningham

2011

on

recomendations for Ectopic pregnancy.

3. What the cause of ectopic pregnancy in this patiens ?

From the anamesis this patient use contraseption (injection every mounth
and every third mounth), according to Cunningham 2011 and Komar A :
Changes in mortality tube. Mortilitas tuba influenced by estrogen and
progesterone levels in serum. Estrogen will increase the activity of smooth
muscle of the uterus and fallopian while progesterone lowers Tonos smooth
muscle. This mechanism also explains the increased incidence of ectopic
pregnancy in the use of birth control pills containing only progestin. Mortality
changes also occur in the fallopian intrauterine exposure to DES are reported
to increase the incidence of ectopic pregnancy 4% -13%.

Tube growth abnormalities, especially diverticulum, accessory ostium and

hypoplasia. The anatomical abnormalities associated with exposure to
diethylstilbestrol (DES) while in utero.

28

CHAPTER 5
SUMMARY

1. The diagnose in this case was correct

2. The treatment of this case was correct by doing the emergency laparatomy,
regarding its Ectopic pregnancy.
3. We need to investigate the cause ectopic pregnancy in this patien. The patient
has some of risk factor from ectopic pregnancy.

29

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