Case Study #3 - Creighton University

Case Study #3Bekah Bowman9.11.08

OvaryUterine tubeInfundibulum: fimbriae and abdominal ostium Ampulla: widest/longest; fertilization Isthmus: thick walls Uterine part: uterine ostium

Female InternalReproductive Anatomy OvaryUterine tubeInfundibulum: fimbriae and abdominal ostium Ampulla: widest/longest; fertilization Isthmus: thick walls Uterine part: uterine ostium

Anatomy Cont. Uterus(3 Layers) Endometrium: mucous layer Location of normal implantationof blastocyte Myometrium: smooth musclelayer Perimetrium: outer serous layer

Normal Implantation Ovulation Abdominalostium of uterine tubeand ovary become closelyapposed during ovulation Fimbriae sweep ovum into tube Ovum carried down uterine tube Fertilization in ampulla of uterinetube Zygote Morula Blastocyst Day 6-7: Blastocyst implants inendometrium of uterus

Normal Implantation Cont. Endometriumideal Vascularized Growth factorsand metabolitessecreted(uterine glands) Room forgrowthin uterus

What we know. 30 year old Negro female 6th pregnancy 4th pregnancy going full term two previous abortions

Admitted to hospital. increasingly severe lower abdominalpain Syncope (fainting) associated withabdominal pain slight vaginal bleeding: 2 days prior bleeding accompanied by nausea; novomiting last NORMAL menses: 8 weeks prior

PhysicalExam. moderatelydistendedand diffuselytender abdomen tenderness present in cervix, uterus,and right and left adnexa (uterine tubes) Serous (clear fluid) discharge fromvagina A culdocentesis aspirated blood fromthe rectouterine space. (by puncture ofapex of vaginal wall) Pregnancy Test: negative

Prodecureperformed. Laparotomy: incision into abdominalcavity through the vagina Left ovary had corpus luteum ofpregnancy Ampulla of right uterine tubecontained hemorrhagic mass showingactive bleeding. POSSIBLEDIAGNOSIS?

Possible Diagnosis? Ectopic pregnancy-Right Tubal Pregnancy Blastocyst implants at abnormal site outside uterus Sites: Uterine tubes (tubal pregnancy) Ovary (ovarian pregnancy) Abdominal cavity (abdominal pregnancy) Intrauterine portion of uterine tubes (cornual pregnancy)

Ectopic Pregnancy Sites: Uterinetube ( 97% of allectopic pregnancies) Ampulla: 55% Isthmus: 25% Fimbria: 17% Ovary (ovarian preganancy)and Abdominal Cavity(abdominal pregancy): 3%

Where did implantation of theblastocyte occur in this patient? Uterine Tube What risk factors could have attributedto ectopic pregnancy?

Risk Factors Previoustubal surgery (distal tubalsurgery) Previous ectopic pregnancy Gonorrhea – affects mucousmembrane; pus Postabortion Previous intrauterine device use Increasing age infection of uterus during labor

TREATMENT Rightsalpingectomysurgical removal of uterinetube. Clotted and free bloodevacuated

Pathology Report Grossdescription Distal 8 cm of right uterine tubeenlarged Patent fimbriated end Small smooth-lined, clear-filledparatubal cyst Opened cyst contains fetus - 2 cmlength

Pathology Report Cont. Microscopicdescription Proximal portion of right uterine tube Patent lumen Small amt. of inflammatory cellswithin muscularis Distal portion of right uterine tube andplacenta Blood clots found between placentaand epithelial lining of the tube.

Last Menstrual Cycle: 8Weeks

Due to Corpus Luteum, which sustainsthe endometrium.

Blood in pelvic cavity (rectouterinespace)?

Ruptured blood vessels from UterineTube.

Pregnancy Test: Negative?

human chorionic gonadotropin (hCG)produced by trophoblast cells whenimplanted into uterus. EctopicPregnancies produce hCG at slowerrate.

Brauer, Philip R. Human Embryology: The Ultimate USMLEStep 1 Review. Canada: Hanley & Belfus, Inc., 2003. Larsen, William J. Human Embryology, 3 Edition.Philadelphia: Churchill Livingstone, 2001. Lozeau, Anne-Marie., and Beth Potter. “Diagnosis andrd Management of Ectopic Pregnancy.” American FamilyPhysician. Vol. 72, Number 9. November 1, 2005.Moore, Keith L., and Arthur F. Dalley. Clinically OrientedAnatomy. Baltimore: Lippincott Williams and Wilkins, 2006.Sucheston, Martha E., and M. Samuel Cannon. CongenitalMalformations: Case Studies in Developmental Anatomy.Philadelphia: F A Davis, 1973.

Ectopic pregnancy-Right Tubal Pregnancy Blastocyst implants at abnormal site outside uterus Sites: Uterine tubes (tubal pregnancy) Ovary (ovarian pregnancy) Abdominal cavity (abdominal pregnancy) Intrauterine portion of uterine tubes (cornual pregnancy)