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    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 subseuent fertility.!Ezeddin "#$ 200%$ "oover &'$ (ao )$ 20*0+

    (he blastocyst normally implants in the endometrial lining of the uterine cavity.

    ,mplantation anywhere else is considered an ectopic pregnancy. ,t is derived from

    the )reek ektoposout of place. According to the American ollege of

    /bstetricians and )ynecologists !200%+$ 2 percent of all first-trimester pregnancies

    in the nited 1tates are ectopic$ and these account for percent of all pregnancy-

    related deaths. (he risk of death from an e3trauterine pregnancy is greater than

    that for pregnancy that either results in a live birth or is intentionally terminated.

    4oreover$ the chance for a subseuent successful pregnancy is reduced after an

    ectopic pregnancy. 'ith earlier diagnosis$ however$ both maternal survival and

    conservation of reproductive capacity are enhanced. !unningham 5) et al$ 20*0+

    (he diagnosis of an ectopic pregnancy is usually une3pected and is oftenemotionally traumatic. 4any women may have only recently discovered they were

    pregnant when they receive the diagnosis. 1ome 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. !unningham 5) et al$

    20*0+

    Ectopic pregnancy$ in which the gestational sac is outside the uterus$ is the

    most common lifethreatening emergency in early pregnancy. (he incidence in the

    nited 1tates has increased greatly in the last few decades$ from 6.7 per *000

    pregnancies in *890 to an estimated *8.9 per *000 pregnancies in *882.*$2

    Although spontaneous resolution of ectopic pregnancy can occur$ patients are at

    risk of tubal rupture and catastrophic hemorrhage.:$6 Ectopic pregnancy remains

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    an important cause of maternal death$ accounting for about 6; of the

    appro3imately 20 annual pregnancy-related deaths in anada.

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    CHAPTER 2

    CASE REPORT

    IDENTITY

    >ame ? 4iss. > Age ? 26 years old

    4@>o ? % 92 0:

    o complaint in urinary and bowel system

    "istory of fever !-+

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    4enstrual "istory ? menarche at *2 years old$ no regular cycle$ every 2% days

    which last for about 6-7 days each cycle with the amount of 2-: times pad

    changeDday without menstrual pain

    PREVIOUS ILLNESS HISTORY

    (here wasnt previous history of heart$ lung$ liver$ kidney$

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    ody weight ? 72 kg

    pper arm circumference ? 27 cm

    4, ? 20$87 !normoweight+

    Eyes ? onjunctiva anemic$ 1clera wasnt icteric

    Ne"- ? GH# 7-2 cm"2/

    Chest ? "DB normal

    A$%o(e!t? /@

    .e!ita&ia ? /@

    E+tre(ity ? Edema -D-$ #hysiological @efle3 IDI$ #athological @efle3 -D-

    O$stetri" Re"or%?

    A$%o(e!t

    ,nspection ? Abdomen didnt seem enlarge$ cicatri3 !-+

    #alpation ? terine fundal was hard to palpate$ abdominal tenderness !I+$

    defence muscular !-+

    #ercution ? (ympani

    Auscultaion ? #eristaltic sound was dicress

    .e!ita&ia

    ,nspection ? HD normal$ leeding pervaginam !I+

    ,nspeculo

    Hagina ? tumor !-+$ laceration !-+$ flu3us !I+ black redish blood

    seemed to accumulate in the posterior forni3$ chadwig

    sign !I+

    #ortio? multiparous$ size eual to *st digiti of plantar pedis$

    tumor !-+$ laceration !-+$ flu3us !I+ (here was black

    redish blood oozing from cervical canal$ E/ was

    close

    H( binamual

    Hagina ? tumour !-+J

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    #ortio? multiparous$ size eual to *st digiti of plantar pedis$ tumor

    !-+$ motion pain of the servi3 !I+$ E/ was close

    ( ? hard to e3amine

    A# ? hard to e3amine

    o #arameter @esult

    *

    2

    :

    6

    7

    "aemoglobin

    "aematocryte

    Beucocyte

    (rombocyte

    #(

    A#((

    8$: grDdl

    28 ;

    *.*00Dmm:

    2%6.000Dmm:

    **$6 seconds

    :6$9 seconds

    1)

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    Diag!ose

    Acute abdomen due to ruptured ectopic pregnancy in )2#*A0B* gravid -% weeks

    I mild anemia !"b? 8$: gr;+

    A%'i"e,

    ontrol )A$ H1

    #re-operation room

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    onsult to anasthesiologist and operative room

    #repare blood for transfusion

    ,nformed consent

    P&a!,

    ito laparotomy

    **.00 am

    - laparatomy was performed

    After opening the peritoneum in the blood and blood clot looked C *000 cc.

    E3ploration was the source of bleeding coming from the right tubal rupture pars

    ampularis. 1ize :323*$7 cm

    ,mpression? right fallopian tube rupture pars ampularis.

    #lan ? @ight 1alfingektomy

    terine shape and size larger than normal$ the left fallopian tube and ovary

    both shape and size within normal limits

    1alfingektomy was performed

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    #hysical E3amination ?

    GA Cons BP HR RR T

    Mdt CMC 120/80 82 21 36,8

    O$stetri" Re"or%?A$%o(e!t

    ,nspection ? Abdomen didnt seem enlarge. ,ncicion of laparatomy was good

    #alpation ?terine fundal was hard to palpate$ abdominal tenderness !-+$

    defense muskular !-+$ rebound tenderness !-+

    #ercution ? (ympani

    Auscultaion ? #eristaltic sound was normal

    .e!ita&ia

    ,nspection ? HD normal$ leeding pervaginam !-+

    Diag!ose?

    #ost right salfingectomy on indication rupture of right tube pars ampularis

    A%'i"e,

    ontrol )A$ H1

    gradual mobilization

    "igh protein and carbohidrat in diet

    Therahy ,

    Aff ,H5inety-five percent of ectopic pregnancies implant in the fallopian tube$ but

    they also can occur in the cervix$ ovaryor even within the abdomen !abdominal

    pregnancy+. Abdominal pregnancies are e3tremely rare and can progress uite late

    into the pregnancy before they are discovered. 5etuses that grow in the abdomen

    who could survive after birth have been delivered$ on rare occasions$ by

    laparotomy !abdominal surgery+.!unningham 5) et al$ 20*0+

    'omen 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. nfortunately$ this is not possible with present medical science.

    !

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    women who were white. Access to health care affect the mortality. !Durfe RB, 2003)

    (he incidence of ectopic pregnancy increased in all women$ especially in

    those aged 20 to 60 years with an average age of :0 years. Ectopic pregnancy

    occurs most often in the fallopian tube area !8%;+$ despite that ectopic

    pregnancies can also occur in the ovary !ovarian+$ abdominal cavity !stomach+$ or

    cervi3 !neck of the womb+. !"oover &'$ (ao )$ &ent &$ 20*0+

    C0 ETIOLO.Y AND RIS FACTORS

    (he cause of ectopic pregnancy largely unknown. 4ost hypotheses that try

    to e3plain 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. Harious abnormalities and damage to tubal

    ectopic pregnancy is instrumental in. !unningham 5) et al$ 20*0$ "oover &'$

    (ao )$ &ent &$ 20*0$ @achimhadhi ($ *888+

    *. 5actors - factors that prevent or inhibit mechanical trip fertilized ovum into the

    uterine cavity

    1alfingitis$ especially endosalfingitis$ which cause agglutination tubal mucosal

    folds and can narrow the lumen of the tube and forming pockets - pockets ofdead-end. ,nfection can also reduce mucosal cilia-cilia that cause tubal

    implantation of the zygote into the fallopian mucosa. ,ncidence of *2.%; after

    one infection$ :7.7; after two infections and 97; after three or more

    infections.

    #eritubal adhesions after infection post abortion or puerperal infection$

    appendicitis or endometriosis which causes tertekuknya tube and narrowing

    lumenya.

    (ube growth abnormalities$ especially diverticulum$ accessory ostium and

    hypoplasia. (he anatomical abnormalities associated with e3posure to

    diethylstilbestrol !

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    two ectopic pregnancies$ the risk for subseuent ectopic pregnancy increased

    to :2;.

    "istory of previous tubal surgery$ either to repair tubal patency and tubal

    sterilization failure.

    A history of recurrent miscarriage induction. (his is related to the occurrence

    salfingitis.

    (umors are pushing tubes$ such as myoma uteri and adne3al mass

    2. 5unctional 5actors that slow the fertilized ovum to the uterine cavity$ such

    as?

    4igrating e3ternal ova. (he risk of ectopic pregnancy slightly increased in

    women with a tubal if ovulation occurs on the contralateral ovary.

    @eflu3 menstruation. 5ertilization 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.

    hanges in mortality tube. 4ortilitas 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 (onos smooth

    muscle. (his mechanism also e3plains the increased incidence of ectopic

    pregnancy in the use of birth control pills containing only progestin. 4ortality

    changes also occur in the fallopian intrauterine e3posure to

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    fertilization !,H5+ and ovum transfer.

    7. 5ailure of contraception. (here is an increased incidence of ectopic

    pregnancy after tubal sterilization. (he risk is higher in electrocoagulation

    types of sterilizatio.

    . Ectopic pregnancy can occur even after a hysterectomy$ because trapping

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

    Tabel 1 : Ri! fa"t#r #f e"t#$i" $re%&a&"' (

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    D0 CLASIFICATION

    >early 87; of ectopic pregnancies implant in the fallopian tubes$ ovaries

    :.2;$ and *.:; in the abdomen. ilateral ectopic pregnancy is rare$ the

    prevalence is * in 200$000 pregnancies. !arnhart &($ 2008$ reen GB.$ *890$

    unningham 5) et al$ 20*0

    5igure *. Bocation of Ectopic #regnancy !arnhart &($ 2008+

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    *. (ubal #regnancy

    (he fertilized ovum may lodge in any portion of the oviduct$ giving rise to

    ampullary$ isthmic$ and interstitial tubal pregnancies. ,n rare instances$ the fertilized

    ovum may implant in the fimbriated e3tremity. (he ampulla is the most freuent

    site$ followed by the isthmus. ,nterstitial pregnancy accounts for only about 2

    percent. 5rom these primary types$ secondary forms of tubo-abdominal$ tubo-

    ovarian$ and broad-ligament pregnancies occasionally develop. !Ezeddin "#$

    200%$ "oover &'$ (ao )$ &ent &$ 20*0+

    ecause 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. (he 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 %7 percent !1enterman and

    associates$ *8%%+. (he embryo or fetus in an ectopic pregnancy is often absent or

    stunted.!Gafri 1K et all$ *8%9+

    (he findings of ectopic pregnancy include intrauterine normal endometrium$

    pseudogestasional sac$ trilaminar endometrium$ decidua thin-walled cysts.

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    :. /varian pregnancy

    /varian pregnancy occurs when the fertilized ovum in the ovary and stuck.

    /varian pregnancy occurs :; of ectopic pregnancies$ sometimes manifested by

    heterotopic pregnancy. /varian pregnancy is strongly associated with the use of

    intrauterine devices and tubal pregnancy are often at the same time. (he 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. !

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    anterior wall of the uterus.

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    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. 'alls 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.

    Hilli are the findings patognomonis korialis for tubal pregnancy$ while the embryo is

    just visible on the evidence of two thirds of cases. !"ammond $ et al$ *886+

    #roducts of conception suffered death at -% 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.$ 9 bleeding that

    occurs due to tubal pregnancy is e3traluminal or luminal !hematosalfing+ and out

    through the tip of the fimbriae into the peritoneal cavity and accumulate dikavum

    hematokel retrouterina of

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    *. A>A4>E1A

    ,n ectopic pregnancy are not disturbed normal pregnancy symptoms such as

    amenorrhoea$ nausea$ and slight pain in the lower abdomen that is not so

    perceived. !unningham 5) et al$ 20*0+

    #atients 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. #ain 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. (his indicates intraperitoneal hemorrhage has

    occurred. !unningham 5) et al$ 20*0$

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    system !unningham 5) et al$ 20*0$

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    trasvaginal when the levels of P-h)R *700 m, D ml or 6-7 weeks after the last

    menstrual period. ,f no sign of intrauterine pregnancy on the levels of P-h)

    should be suspected presence of an ectopic pregnancy. E3amination of P-h)

    when combined with the ultrasound diagnostic accuracy approaching *00; of

    ectopic pregnancies. !unningham 5) et al$ 20*0+

    7. uldocentesis

    uldocentesis can assist in the diagnostic hemoperitoneum due to rupture

    the tube. (he sensitivity and specificity in detecting hemoperitoneum uldocentesis

    reported %7-80;. #atients with little or no intra-abdominal bleeding$ uldocentesis

    negative$ not get rid of pregnancy ektopik.6$ 8 >ow uldocentesis is rarely used

    because of the presence of other tests have more accurate and non-invasive.

    !unningham 5) et al$ 20*0+

    .

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    .0 MANA.EMENT OF ECTOPIC PRE.NANCY

    ,f the ectopic pregnancy has been established$ the patient should be

    reevaluated clinically back. 4edical or e3pectant management may be attempted if

    the patient is in stable condition. ,f the patientOs condition is not good$ an indication

    of surgical treatment. urrently there are : ways of management of ectopic

    pregnancy$ namely? !arnhart &($ 2008+

    *. E3pectant !/bservation+

    E3pectant management based on that patients with ectopic pregnancy can

    be reabsorbed perfect or the occurrence of spontaneous abortion. E3pectant

    management is often performed in patients with P-h) levels L*000 m, D ml$

    hemoperitoneum L70 ml with hematosalfing L2 cm. As many as 9; of ectopic

    pregnancies that have not bothered with a diameter L:0 mm and no active

    bleeding can be reabsorbed perfect. (ubal patency rate of appro3imately %7; and

    pregnancy rates as much as 72;. !arnhart &($ 2008+

    )arcia et al !*8%9+ stated that only e3pectant acts done under strict control

    and in asymptomatic patients with P-h) levels continue to fall. (he advantage of

    this method does not need surgery$ costs little and fertility is not compromised.

    !arnhart &($ 2008+

    2. 4edikamentosa

    4edical treatment often used is 4ethotre3ate !4(N+. 4ethotre3ate is a folic

    acid antagonist that is metabolized in the liver and e3creted through the kidneys.

    4(N inhibits purine and pyrimidine synthesis thus interfere with A synthesis and

    cell multiplication. ells growing as network tropoblas very susceptible to 4(N$ so

    as to stop the development of an ectopic pregnancy which eventually die and are

    absorbed. !arnhart &($ 2008$ @achimhadhi ($ *888+

    4(N 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. !arnhart &($

    2008+

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    Ter(s of )se of MT3 i! e"toi" reg!a!"y are, !unningham 5) et al$

    20*0+

    Absolut:

    "emodynamically stable.

    1) supports an ectopic pregnancy.

    Ability of patients had follow-up.

    (here are no contraindications to 4(N.

    Relative:

    Ectopic pregnancy is not interrupted with a diameter L:.7 cm.

    >o fetal heart motion.

    Q-h) levels L7000 m, D ml.

    Indications for MTX:

    (ubal patency to be maintained.

    #atients who refuse surgery.

    1urgery is risky !pregnancy cervi3$ cornua and ovaries+.

    ontraindications to the use of 4(N?

    Biver disease and kidney disease.

    (ubal rupture.

    )iving systemic 4(N can be done with a double dose or a single dose.

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    to maintain tubal function. Baparotomy only when laparoscopic euipment is not

    available or the patient is hemodynamically unstable due to hemorrhage intra

    abdominal. 1everal surgical techniues are often employed for the management of

    ectopic pregnancy. !"oover &'$ (ao )$ 20*0+

    1alfingostomi

    (his techniue is performed to remove the tubal pregnancy is smaller than 2

    cm and located in the distal third of the tube. 'ith linear laparoscopic incision

    along the C 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. leeding is controlled with electrocautery or laser$ and

    wounds without suturing incisions are left open to heal itself. 1herman et al !*8%2+

    reported that salfingostomi provide a higher pregnancy rate than salfingektomi.

    !Ezeddin "#$ 200%$ "oover &'$ (ao )$ 20*0+

    1alfingotomi

    (he difference between salfingostomi with salfingotomi is made logitudinal

    salfingotomi incision and the incision sutured with vicryl former no. 9.0 carefully.

    Bayers are sewn just muscle and serosa without the mucosal layer$ because it maycause an inflammatory reaction that can cause obstruction. 1alfingotomi is the

    techniue of choice if the diameter of an ectopic pregnancy is greater than 2 cm.

    !Ezeddin "#$ 200%$ "oover &'$ (ao )$ 20*0+

    1alfingektomi

    1alfingektomi is the removal of the tube to create a wedge-shaped e3cision

    is not more than a third outer tube interstitial past. ,t aims to minimize the possibility

    of subseuent ectopic pregnancy in the fallopian butts. (his techniue remains the

    top choice in tubal rupture with massive intraperitoneal hemorrhage.

    !Ezeddin "#$ 200%$ "oover &'$ (ao )$ 20*0+

    1egmental resection and anastomosis

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    (his techniue 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. 4esosalfing then stitched back and

    both ends of the tube reanastomosis with vikryl 9.0 by stitching one-on-one.

    !Ezeddin "#$ 200%$ "oover &'$ (ao )$ 20*0+

    CHAPTER 4DISCUSSION

    (his case report discusses A 26 years old patient was admitted to the

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    *. 'hether the diagnose of this patient was right S

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    CHAPTER 5

    SUMMARY

    *. (he diagnose in this case was correct

    2. (he treatment of this case was correct by doing the emergency laparatomy$

    regarding its Ectopic pregnancy.

    :. 'e need to investigate the cause ectopic pregnancy in this patien. (he patient

    has some of risk factor from ectopic pregnancy.

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    REFERENCES

    arnhart &(. Ectopic #regnancy. ,n ew Mork. 2008

    reen GB. A 2* year survey of 76 ectopic pregnancies. Am G /bstet )ynecol.

    *890

    unningham 5) et al. Ectopic #regnancy. ,n 'illiams /bstetrics 2:rdEdition. 4c

    )raw "ill ompanies$ >ew Mork. 20*0

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    Ezeddin "#. )ambaran &asus &ehamilan Ektopik (erganggu di agian /bstetri

    dan )inekologi @1< Arifin Achmad #ekanbaru #eriode * Ganuari 200:-:*