1. IN THE NAME OF GOD

2. Dystocia
Dr.A Danesh MD

3. After an ectopic pregnancy, there is a 7- to 13-fold increase in the risk of a subsequent ectopic pregnancy. The chance that asubsequent pregnancy will be intrauterine is 50% to 80%, and the chance thatthe pregnancy will be tubal is 10% to 25%; the remaining patients will be infertile

4. Chlamydia is an important pathogen causing tubal damage and bsequenttubal pregnancy. Because many cases of chlamydia salpingitis are indolent, cases maynot be recognized or, if recognized, may be treated on an outpatient basis. Chlamydia
has been cultured from 7% to 30% of patients with tubal pregnancy

5. Women who conceive with an IUD in place, however, are 0. 4 to 0
Women who conceive with an IUD in place, however, are 0.4 to 0.8 timesmore likely to have a tubal pregnancy than those not using contraceptives. BecauseIUDs prevent implantation more effectively in the uterus than in the tube, awoman conceiving with an IUD is 6 to 10 times more likely to have a tubal pregnancythan if she conceives without using contraception

6. Duration of IUD use does not increase the absolute risk for tubal pregnancy (1.2 per
1,000 years of exposure), but with increasing use, there is an increase in the
percentage of pregnancies that are tubal

7. Progesterone-only contraceptives, including
oral contraceptives (minipill) and subdermal implants (Norplant), protect against both
intrauterine and ectopic pregnancy when compared with no contraceptive use. If a pregnancy
does occur, however, the chance of the pregnancy being ectopic is 4% to 10% for the
minipill (34,35) and up to 30% if pregnancy occurs while implants are in place

8. Past use of oral contraceptives does not increase
the subsequent risk for ectopic pregnancy

9. Condom and diaphragm use protects against both intrauterine and ectopic pregnancy, and there
is no increased incidence of ectopic pregnancy

10. The greatest risk of pregnancy, including ectopic pregnancy, occurs in the first 2
years after sterilization

11. The risk of tubal pregnancy after any sterilization procedure is 5% to 16% (

12. Although it is clear that tubal surgery
is associated with an increased risk for ectopic pregnancy, it is unclear whether
the increased risk results from the surgical procedure or from the underlying problem

13. After either tubal removal or conservation, the rates for intrauterine pregnancy (40%)
and ectopic pregnancy (12%) have been found to be identical

14. ovarian cystectomy or wedge resection increases therisk for ectopic pregnancy, presumably because of peritubal scarring

15. There is no established association between ectopic pregnancy and spontaneous abortion

16. Although the incidence of ectopic pregnancy increases with age and parity, there also is a significant increase in nulliparous women undergoing infertility treatment (

17. Hormonal alterations characteristic of clomiphene citrate and gonadotropin
ovulation-induction cycles may predispose tubal implantation. About 1.1% to 4.6%
of conceptions associated with ovulation induction are ectopic pregnancies

18. Salpingitis isthmica nodosa (SIN) is a noninflammatory pathologic condition of the tube
in which tubal epithelium extends into the myosalpinx and forms a true diverticulum.
. This condition is found more
often in the tubes of women with an ectopic pregnancy than in nonpregnant
women (

19. Endometriosis or leiomyomas can cause tubal obstruction

20. In DES-exposed women, the risk for ectopic pregnancy was 13% in
those who had uterine abnormalities compared with 4% in those who had a normal uterus.
No specific type of defect was related to the risk for ectopic pregnancy.

21. Current cigarette smoking is associated with a more than twofold increased risk for tubal pregnancy (

22. Chorionic villi, usually found in the lumen, are pathognomic findings of tubal
pregnancy. Gross or microscopic evidence of an embryo is seen in two thirds of cases

23. Hemoperitoneum is nearly always present but is confined to the cul-de-sac
unless tubal rupture has occurred. The natural progression of tubal pregnancy is
either expulsion from the fimbriated end (tubal abortion), involution of the conceptus,
or rupture, usually around the eighth gestational week.

24. The Arias-Sella reaction is a nonspecific finding that can
be seen in patients with intrauterine pregnancies

25. Figure 18. 2 The Arias-Stella reaction of the endometrium
Figure 18.2 The Arias-Stella reaction of the endometrium. The glands are closely packed and
hypersecretory with large, hyperchromatic nuclei suggesting malignancy

26. The classic symptom triad of ectopic pregnancy is pain, amenorrhea, and vaginal
bleeding. This symptom group is present in only about 50% of patients, however, and
is most typical in patients in whom an ectopic pregnancy has ruptured. Abdominal
P.610
pain is the most common presenting symptom, but the severity and nature of the
pain vary widely. There is no pathognomonic pain that is diagnostic of ectopic
pregnancy

27. An adnexal mass may
be palpable in up to 50% of cases, but the mass varies markedly in size, consistency,
and tenderness. A palpable mass may be the corpus luteum and not the
ectopic pregnancy

28. Quantitative β-hCG measurements are the diagnostic cornerstone for ectopic
pregnancy. The hCG enzyme immunoassay, with a sensitivity of 25 mIU/mL, is an accurate screening test for detection of ectopic pregnancy. The assay is positive in virtually all documented ectopic pregnancies.

29. as phantom hCG, in which the presence of heterophile antibodies or proteolytic
enzymes causes a false-positive hCG result. Because the antibodies are large
glycoproteins, significant quantities of the antibody are not excreted in the urine. Thus, in
the patient with hCG levels less than 1,000 mIU/mL, a urine pregnancy test should
be performed and confirmatory positive results obtained before instituting
treatment

30. The hCG doubling time can help to differentiate an ectopic pregnancy from an
intrauterine pregnancy—a 66% rise in the hCG level over 48 hours (85% confidence
level) represents the lower limit of normal values for viable intrauterine pregnancies
(82). About 15% of patients with viable intrauterine pregnancies have less than a
66% rise in hCG level over 48 hours, and a similar percentage with an ectopic
pregnancy have more than a 66% rise

31. The hCG pattern that is
most predictive of an ectopic pregnancy is one that has reached a plateau (a
doubling time of more than 7 days). For falling levels, a half-life of less than 1.4 days
is rarely associated with an ectopic pregnancy, whereas a half-life of more than 7 days
is most predictive of ectopic pregnancy.

32. Serial hCG levels are usually required when the results of the initial
ultrasonography examination are indeterminate (i.e., when there is no evidence of
an intrauterine gestation or extrauterine cardiac activity consistent with an
ectopic pregnancy). When the hCG level is less than 2,000, doubling time helps to
predict viable intrauterine gestation (normal rise) versus nonviability (subnormal
rise). With normally rising levels, a second ultrasonography examination is
performed when the level is expected (by extrapolation) to reach 2,000 mIU/
mL. Abnormally rising levels (less than 2,000 mIU/mL and less than 50% rise over
48 hours) indicate a nonviable pregnancy

33. If the hCG level is more than 300 mIU/mL on day 16 to 18 after artificial insemination, there is an 88% chance of a live birth (84). If the hCG level is less than 300 mIU/mL, the chance of a live birth is only 22%

34. serum progesterone levels higher than 25
ng/mL, whereas only 1.5% of patients with ectopic pregnancies have serum progesterone levels higher than 25 ng/mL, and most of these pregnancies exhibit cardiac activity

35. A serum progesterone level of less than 5 ng/mL is highly suggestive of an abnormal pregnancy, but it is not 100% predictive. The risk of a normal pregnancy with a
serum progesterone level of less than 5 ng/mL is about 1 in 1,500

36. Estradiolcreatine kinaseSchwangerschafts protein 1 (SP1), C (PAPP-C) or pregnancy-specific β glycoprotein (PSBS), RelaxinCA125(AFP) C-reactive protein

37. C-reactive protein

38. The earliest ultrasonographic finding of an intrauterine pregnancy is a small fluid
space and the gestational sac, surrounded by a thick echogenic ring, located
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Ovid: Berek & Novak's Gynecology
eccentrically within the endometrial cavity. The earliest normal gestational sac is seen
at 5 weeks of gestation with transabdominal ultrasonography and at 4 weeks of
gestation with transvaginal ultrasonography (112). As the gestational sac grows, a
yolk sac is seen within it, followed by an embryo with cardiac activity.

39. Morphologically, identification of the double decidual sac sign (DDSS) is the best
method of ultrasonographically differentiating true sacs from pseudosacs

40. The appearance of a yolk sac within the gestational sac is superior to the DDSS
in confirming intrauterine pregnancy

41. The presence of an adnexal gestational sac with a fetal pole and cardiac activity is
the most specific but least sensitive sign of ectopic pregnancy, occurring in only 10%
to 17% of cases

42. Complex or solid adnexal masses are frequently associated with ectopic
pregnancy (1,3,19); however, the mass may represent a corpus luteum,
endometrioma, hydrosalpinx, ovarian neoplasm (e.g., dermoid cyst), or
pedunculated fibroid

43. Accurate interpretation of ultrasonography findings requires correlation with the
hCG level (discriminatory zone) (114,119,122,124). All viable intrauterine pregnancies
can be visualized by transabdominal ultrasonography for serum hCG levels higher
than 6,500 mIU/mL; none can be seen at 6,000 mIU/mL. The inability to detect
an intrauterine gestation with serum hCG levels higher than 6,500 mIU/mL indicates
the presence of an abnormal (failed intrauterine or ectopic) pregnancy. Intrauterine
sacs seen at hCG levels below the discriminatory zone are abnormal and represent
either failed intrauterine pregnancies or the pseudogestational sacs of ectopic
pregnancy. If there is no definite sign of an intrauterine gestation (the empty uterus
sign) and the hCG level is below the discriminatory zone, the differential
diagnosis includes the following considerations:

44. Normal intrauterine pregnancy too early for visualization
Abnormal intrauterine gestation
Recent abortion
Ectopic pregnancy
Nonpregnant patient

45. Discriminatory zones for transvaginal ultrasonography have
been reported at levels from 1,000 to 2,000 mIU/mL (114,119,122,124). Discriminatory
zones vary according to the expertise of the examiner and capability of the equipment.
Although the discriminatory zone for intrauterine pregnancy is well established, there
is no such zone for ectopic pregnancy.

46. high-velocity, low-resistance signal is localized to the area of developing placentation This pattern, seen near the endometrium, is associated with normal
and abnormal intrauterine pregnancies and is termed peritrophoblastic flow.

47. Uterine curettage is performed when the pregnancy has been confirmed to be
nonviable and the location of the pregnancy cannot be determined by
ultrasonography.

48. Laparoscopy is the gold standard for the diagnosis of ectopic pregnancy.

49. An algorithm for the diagnosis
of ectopic pregnancy without laparoscopy proved to be 100% accurate in a
randomized clinical trial

50. Suction curettage is used to differentiate nonviable intrauterine pregnancies from
ectopic gestations (less than 50% rise in hCG level over 48 hours, an hCG level of
less than 2,000 mIU/mL, and indeterminate ultrasonography findings). Performance
of this procedure avoids unnecessary use of methotrexate in patients with
abnormal intrauterine pregnancy that can be diagnosed only by evacuating the uterus.
An unlikely potential problem with suction curettage is missing either an early
nonviable intrauterine pregnancy or combined intrauterine and extrauterine pregnancies.

51. Linear salpingostomy is currently the procedure of choice when the patient has
an unruptured ectopic pregnancy and wishes to retain her potential for future fertility.
The products of conception are removed through an incision made into the tube on

52. Laparotomy
is indicated when the patient becomes hemodynamically unstable, whereas laparoscopy
is reserved for patients who are hemodynamically stable. A ruptured ectopic pregnancy does not necessarily require laparotomy.

53. Pregnancy rates are similar in patients treated by either
laparoscopy or laparotomy. Tubal patency on the ipsilateral side after
conservative laparoscopic management is about 84%.
In a study of 143 patients followed after undergoing laparoscopic procedures for
ectopic pregnancy, the overall intrauterine pregnancy rates for
laparoscopic salpingostomy (60%) and laparoscopic salpingectomy (54%) were
not significantly different

54. Commonly reported side effects include
leukopenia, thrombocytopenia, bone marrow aplasia, ulcerative stomatitis, diarrhea,
and hemorrhagic enteritis. Other reported side effects include alopecia, dermatitis, elevated
liver enzyme levels, and pneumonitis (146). However, no significant side effects have
been reported at the low doses used for ectopic pregnancy treatment. Minor side
effects have been reported with multiple doses;

55. Single-dose Methotrexate Protocol for Ectopic Pregnancy
Day
Therapy
0 D & C, hCG
1 CBC, SGOT, BUN, creatinine, blood type and Rh 2 4
Methotrexate 50 mg/m IM
7 hCG
D & C, dilation and curettage; hCG, human chorionic gonadotropin; CBC, complete blood
count; SGOT, serum glutamic-oxaloacetic transaminase; BUN, blood urea nitrogen; IM,
intramuscularly.
If less than a 15% decline in hCG level between days 4 and 7, give second dose of
methotrexate, 50 mg/m
, on day 7.
If more than a 15% decline in hCG level between days 4 and 7, follow weekly until hCG is
below 10 mIU/mL.
In patients not requiring D & C (hCG > 2,000 mIU/mL and no gestational sac on
transvaginal ultrasonography), days 0 and 1 are combined.

56. Physician Checklist
Obtain hCG level.
Perform transvaginal ultrasound within 48 hours.
Perform endometrial curettage if hCG level is less than 2,000 mIU/mL.
Obtain normal liver function (SGOT), normal renal function (BUN, creatinine), and a
normal CBC (WBC < 2,000/mL and platelet count > 100,000)
Administer RhoGAM if patient is Rh-negative.
Identify unruptured ectopic pregnancy smaller than 3.5 cm.
Obtain informed consent.
Prescribe FeSO
325 mg PO bid if hematocrit is less than 30%. 4
Schedule follow-up appointment on days 4, 6, and 7.
Patient Instructions
Refrain from alcohol use, multivitamins containing folic acid, and sexual intercourse
until hCG level is negative.
Call your physician if:
You experience prolonged or heavy vaginal bleeding.
The pain is prolonged or severe (lower abdomen and pelvic pain is normal during the
first days of treatment).
You use oral contraception or barrier contraceptive methods.
About 4% 5% of women experience unsuccessful methotrexate treatment and require
surgery.
hCG, human chorionic gonadotropin; SGOT, serum glutamic-oxaloacetic transaminase;
BUN, blood urea nitrogen; CBC, complete blood count; WBC, white blood cell; PO, by
mouth; bid, twice daily.

57. After intramuscular administration of methotrexate, patients are monitored on
an outpatient basis. Patients who report severe pain or pain that is prolonged
are evaluated by measuring hematocrit levels and performing
transvaginal ultrasonography.

58. To maximize the safety of treatment and to eliminate the possibility of treating in
the presence of a nonviable or early viable intrauterine pregnancy, patients
considered candidates for methotrexate treatment should include those to whom
the following factors apply:

59. An hCG level is present after salpingostomy or salpingotomy.?
The hCG level is rising or reached a plateau at least 12 to 24 hours after suction curettage.
No intrauterine gestational sac or fluid collection is detected by transvaginal ultrasonography,
the hCG level is greater than 2,000 mIU/mL, the hCG level is rising, and an ectopic pregnancy
mass of 4.0 cm or less without cardiac activity or 3.5 cm or less with cardiac activity is visualized.

60. Ultrasonography findings should be interpreted with caution because most
unruptured ectopic pregnancies will be accompanied by fluid in the cul-de-sac.

61. When
using the single-dose intramuscular regimen, the incidence of side effects is less than
1%, and the failure rate is comparable to that of conservative laparoscopic surgery.
One problem that remains puzzling is the inability to predict treatment failures with
the use of methotrexate. However, the same is true with conservative
surgical procedures; thus, the need to monitor hCG levels after salpingostomy
or methotrexate remains

62. Comparison of laparoscopically treated patients with
methotrexate-treated patients suggests that the two methods have similar
reproductive outcomes.

63. Salpingocentesis is a technique in which agents such as KCl, methotrexate, prostaglandins,
and hyperosmolar glucose are injected into the ectopic pregnancy transvaginally
using ultrasonographic guidance, transcervical tubal cannulization, or laparoscopy. Agents
injected under ultrasonographic guidance have included methotrexate The
KCl, combined methotrexate and KCl, and prostaglandin E

64. Some ectopic pregnancies resolve by resorption or by tubal abortion, obviating the
need for medical or surgical therapy

65. Persistent ectopic pregnancy occurs when a patient has undergone conservative
surgery (e.g., salpingostomy, fimbrial expression) and viable trophoblastic tissue
remains.

66. A slower decline of serum hCG levels has been seen in patients
treated by salpingostomy compared with patients treated by salpingectomy. The
incidence of persistence after laparoscopic linear salpingostomy ranges from 3% to
20%

67. Persistent ectopic pregnancy can be treated surgically or medically; surgical
therapy consists of either repeat salpingostomy or, more commonly,
salpingectomy. Methotrexate offers an alternative to patients who are
hemodynamically stable at the time of diagnosis. Methotrexate may be the treatment
of choice because the persistent trophoblastic tissue may not be confined to the tube
and, therefore, not readily identifiable during repeat surgical exploration (191,192,193).

68. Chronic ectopic pregnancy is a condition in which the pregnancy does not
completely resorb during expectant management

69. The incidence of cervical pregnancy in the United States ranges from 1 in 2,400 to 1
in 50,000 pregnancies

70. Ultrasound Criteria for Cervical Pregnancy
1. Echo-free uterine cavity or the presence of a false gestational sac only
2. Decidual transformation of the endometrium with dense echo structure
3. Diffuse uterine wall structure
4. Hourglass uterine shape
5. Ballooned cervical canal
6. Gestational sac in the endocervix
7. Placental tissue in the cervical canal
8. Closed internal os

71. When a cervical pregnancy is diagnosed before surgery, the preoperative
preparation should include blood typing and cross-matching, establishment of
intravenous access, and detailed informed consent. This consent should include
the possibility of hemorrhage that may require transfusion or hysterectomy.

72. Various techniques that can be used to control
bleeding include uterine packing, lateral cervical suture placement to ligate the
lateral cervical vessels, placement of a cerclage, and insertion of an intracervical 30-
mL Foley catheter in an attempt to tamponade the bleeding. Alternatively,
angiographic artery embolization can be used. If laparotomy is required, an attempt
can be made to ligate the uterine or internal iliac arteries (202,203,204). When none
of these methods is successful, hysterectomy is required.

73. A pregnancy confined to the ovary represents 0
A pregnancy confined to the ovary represents 0.5% to 1% of all ectopic pregnancies
/and is the most common type of nontubal ectopic pregnancy

74. Table 18.6 Criteria for Ovarian Pregnancy Diagnosis
1. The fallopian tube on the affected side must be intact.
2. The fetal sac must occupy the position of the ovary.
3. The ovary must be connected to the uterus by the ovarian ligament.
4. Ovarian tissue must be located in the sac wall.

75. ovarian cystectomy has become the preferred treatment

76. Abdominal pregnancy
is associated with high morbidity and mortality, with the risk for death 7 to 8
times greater than from tubal ectopic pregnancy and 90 times greater than
from intrauterine pregnancy.

77. Diagnosis of Primary Abdominal Pregnancy
1. Presence of normal tubes and ovaries with no evidence of recent or past pregnancy
2. No evidence of uteroplacental fistula
3. The presence of a pregnancy related exclusively to the peritoneal surface and early
enough to eliminate the possibility of secondary implantation after primary tubal
nidation

78. surgical intervention is recommended when an
abdominal pregnancy is diagnosed.

79. Interstitial pregnancies represent about 1% of ectopic pregnancies

80. Interligamentous pregnancy is a rare form of ectopic pregnancy that occurs in about 1
in every 300 ectopic pregnancies

81. Heterotropic pregnancy occurs when intrauterine and ectopic pregnancies coexist.
The reported incidence varies widely from 1 in 100 to 1 in 30,000 pregnancies

82. Twin or multiple ectopic gestations occur less frequently than heterotropic gestations
and may appear in a variety of locations and combinations.

90. Complex or solid adnexal masses are frequently associated with ectopic
pregnancy (1,3,19); however, the mass may represent a corpus luteum,
endometrioma, hydrosalpinx, ovarian neoplasm (e.g., dermoid cyst), or
pedunculated fibroid

92. DYSTOCIA uterine contractility maternal pelvimetry
position and size of the fetus

93. Primary Dysfunctional Labor
Inadequate uterine contractility to maintain appropriate progress in labor
Four concerted synchronous contractions every 10 minutes (Gap junctions)
uterine embryologic abnormalities such as a didelphic uterus or bicornuate uterus

94. Cephalopelvic Disproportion
Fetal birth weight
Fetal head
Maternal pelvic inlet
                                                                              .

95. Abnormal Position of the Fetal Head
0ccipital posterior (OP)
Deep transverse arrest
Deflexion abnormalities such as face and brow presentations

96. Asynclitism
The sagittal suture of the head is either deviated posteriorly or anteriorly in relation to the maternal outlet
Second stage of labor is often prolonged and arrest of descent

97. Fetal Abnormalities Fetuses with neuromuscular disease, Utero demise
hydrocephalus
hydrops fetalis
tumors of the head or sacrum can lead to mechanical obstruction

98. Lie of fetous
Breech
Trasvers
oblique

99. Prolonged Latent Phase
In nulliparous women uterine activity without cervical change for more than 20 hours
Multiparas this time period is 14 hours

100. Arrest of Dilation
occurs when there is no cervical change after 2 hours in the active phase of labor despite uterine activity

101. Arrest of Descent
If the patient does not gain station of 1 cm after an hour of adequate pushing efforts, an arrest of descent is diagnosed

102. Precipitate labor disorders
Delivery in less than 3 hours from onset of contraction
Precipitate dilatation 5cm or more per hour in primipara or10cm 0r more per hour in multipara

103. Protracted Active Phase
In nulliparous patients, cervical change is less than 1.2 cm per hour
In multiparous patients cervical change is occurring at less than 1.5 cm per hour.

104. Prolonged Second Stage
prolonged second stage is diagnosed when the fetal head descends less than 1 cm per hour.
A second stage lasting longer than 2 hours has traditionally been considered abnormal
longer than 2 hours in nulliparas or 1 hour in multiparas or 3 and3 hour for conduction anesthesia