Ectopic Pregnancy: Ectopic Pregnancy: Radiological diagnosis and treatment optionsRadiological diagnosis and treatment options

Henry Henry DeluDelu, Jr. , Jr. Harvard Medical School MSIII Harvard Medical School MSIII

Our PatientOur Patient

Chief complaint: 32 Chief complaint: 32 yoyo G10P2G10P2--00--77--22at 6 3/7 weeks gestation by LMP, presents at 6 3/7 weeks gestation by LMP, presents with severe abdominal pain and vaginal with severe abdominal pain and vaginal bleeding for 12 days. bleeding for 12 days.

10 Pregnancies, 2 live births, 0 preterm births, 7 miscarriages,10 Pregnancies, 2 live births, 0 preterm births, 7 miscarriages, 2 living children.2 living children.

Our Patient continuedOur Patient continued

ROS: Denies passage of tissue per vagina, ROS: Denies passage of tissue per vagina, vaginal trauma, or recent intercourse.vaginal trauma, or recent intercourse.

PMH: 7 priorPMH: 7 prior miscarriages.miscarriages.

HCG: 4455HCG: 4455

Differential Diagnosis of Differential Diagnosis of Abdominal Pain:Abdominal Pain:

Ectopic PregnancyEctopic PregnancyAcute Acute salpingitissalpingitisSpontaneous AbortionSpontaneous AbortionRuptured corpus Ruptured corpus luteumluteumAcute AppendicitisAcute AppendicitisDysfunctional uterine bleedingDysfunctional uterine bleedingAdnexalAdnexal TorsionTorsionDegenerating Degenerating LeiomyomataLeiomyomataEndometriosisEndometriosisNephrolithiasisNephrolithiasis

Normal Pelvic AnatomyNormal Pelvic Anatomy

http://www.yoursurgery.com/http://www.yoursurgery.com/procedures/hysteroscopy/images/procedures/hysteroscopy/images/AnteriorNormalUterus.jpgAnteriorNormalUterus.jpg

http://http://www.yoursurgerywww.yoursurgery..com/procedures/hysteroscopy/com/procedures/hysteroscopy/images/images/AnteriorNormalUterusAnteriorNormalUterus..jpgjpg

http://www.advancedfertility.com/pics/singlefollicle12.jpg

Menu of Radiological TestsMenu of Radiological Tests

USUSCTCTMRIMRIXX--ray ray Nuclear MedicineNuclear Medicine

UltrasoundUltrasoundTransabdominalTransabdominal::

1. Easier for the patient1. Easier for the patient2. Requires FULL BLADDER for optimal visualization2. Requires FULL BLADDER for optimal visualization3. Panoramic view of the abdomen and pelvis 3. Panoramic view of the abdomen and pelvis 4. Difficult to detect pregnancies below 6wks gestation4. Difficult to detect pregnancies below 6wks gestation

TransvaginalTransvaginal::1. Invasive/Requires insertion of a probe into the vagina 1. Invasive/Requires insertion of a probe into the vagina 2. Empty bladder necessary2. Empty bladder necessary3. Limited pelvic view but Excellent Resolution/ Better anatomy 3. Limited pelvic view but Excellent Resolution/ Better anatomy 4. Detects earlier pregnancies4. Detects earlier pregnancies

Normal Pelvic Ultrasound Normal Pelvic Ultrasound

Uterus

Normal Ovary

Bladder

Endometrium

http://www.obgyn.net/us/gallery/http://www.obgyn.net/us/gallery/Gyn_Normal_Ovary.jpgGyn_Normal_Ovary.jpg

http://www.obgyn.net/us/gallery/http://www.obgyn.net/us/gallery/Gyn_Normal_Ovary.jpgGyn_Normal_Ovary.jpg

Our PatientOur Patient

Normal OvaryEctopic

Pregnancy

BIDMC PACS

Transvaginal US

Our PatientOur Patient

Ectopic Pregnancy

BIDMC PACS

Sagittal US

Our PatientOur Patient

EctopicPregnancyLess than .5cm

BIDMC PACS

TREATMENT OPTIONSTREATMENT OPTIONS

1. 1. MethotrexateMethotrexate, anti, anti--folic acid drug, if folic acid drug, if less than 3.5/4cm diameter.less than 3.5/4cm diameter.2. Surgical 2. Surgical LaporotomyLaporotomy if more than if more than 3.5/4cm diameter.3.5/4cm diameter.

Treatment of Our PatientTreatment of Our Patient

Laparoscopic left Laparoscopic left salpingectomysalpingectomy, despite , despite less than 4cm. less than 4cm. The ectopic pregnancy and portion of the The ectopic pregnancy and portion of the left fallopian tube were excised with the left fallopian tube were excised with the gyrusgyrus using using electrocauteryelectrocautery and cutting. and cutting.

Companion Patient #1Companion Patient #1CHIEF COMPLAINT: 34 year old womanCHIEF COMPLAINT: 34 year old womanG4P1021 presents withG4P1021 presents with vaginal bleeding xvaginal bleeding x 2 2 WKS, and believes she is having a miscarriage. WKS, and believes she is having a miscarriage. She is 11 weeks gestation by LMP 07/04/07.She is 11 weeks gestation by LMP 07/04/07.

Earlier during the week she had severe Earlier during the week she had severe abdominal pain. No pain now. abdominal pain. No pain now.

4 Pregnancies, 1 live birth, 0 preterm births, 2 miscarriages, 14 Pregnancies, 1 live birth, 0 preterm births, 2 miscarriages, 1 living child. living child.

Companion Patient #1 continuedCompanion Patient #1 continued

PMH: 2SAB, 1 NSVD 7/01. Negative PMH: 2SAB, 1 NSVD 7/01. Negative STIsSTIs, prior , prior abdominal surgeries, or abnormal pap smears.abdominal surgeries, or abnormal pap smears.

ROS: Complains of increased fatigue over the past week. ROS: Complains of increased fatigue over the past week. Denies passage of tissue per vagina, vaginal trauma, or Denies passage of tissue per vagina, vaginal trauma, or recent intercourse.recent intercourse.

On Physical exam: NoOn Physical exam: No adnexaladnexal tenderness or Cervical tenderness or Cervical Motion Motion TendernssTendernss on bimanual.on bimanual.

BB--HCG: 120 HCG: 120

Companion patient #1:Companion patient #1: Pelvic USPelvic US

ECTOPICPREGNANCY

BIDMC PACS

Solid mass with increased peripheral vascularitythat measures 20 x 19 x 22 mm

Companion Patient 1 continued: Companion Patient 1 continued: ““Ring of Fire”

Blood flow around Ectopic on pelvic US

BIDMC PACS

Companion Patient 1 treatmentCompanion Patient 1 treatment

Patient was given Patient was given MethotrexateMethotrexate 75mg IM 75mg IM and and RhogamRhogam IM. IM.

Companion Patient 2Companion Patient 2

Chief complaint: 40Chief complaint: 40--yo woman, at 5 wks yo woman, at 5 wks gestation by LMP. Presents with Abdominal pain gestation by LMP. Presents with Abdominal pain and spotting. and spotting.

HCG: higherHCG: higher thanthan would be expected of a 5 wk would be expected of a 5 wk pregnancy.pregnancy.

EvaluateEvaluate forfor pregnancypregnancy location and location and ovarianovarian blood flow.blood flow.

Companion Patient #2:Companion Patient #2: Interstitial Ectopic Pregnancy on USInterstitial Ectopic Pregnancy on US

ECTOPICPREGNANCY

UTERUS

Right cornual area has a well-defined gestational sac

BIDMC PACS

Companion Patient #3Companion Patient #3 Interstitial pregnancy on USInterstitial pregnancy on USEmpty uterus

Transvaginal US midsagittal plane

Transvaginal US coronal plane

Ectopic

Right Cornual region

Cases of the Day: Us Case of the Day Ackerman et al. 14 (1): 185. (1994)

Companion Patient #4:Companion Patient #4: 29 wk Abdominal pregnancy on US29 wk Abdominal pregnancy on US

Fetus,Not in uterus

Midline transverse US image

maternal spine and right iliac artery

MR Imaging in High-Risk Obstetric Patients: A Valuable Complement to US, Angtuaco et al, RadioGraphics1992; 12:91-109

Companion Patient #4 Continued:Companion Patient #4 Continued: 29 wk abdominal pregnancy29 wk abdominal pregnancy

Longitudinal US image High transverse US image

Vagina

fetal head in the abdomen

body of the uterus

maternal bowel

fetus

MR Imaging in High-Risk Obstetric Patients: A Valuable Complement to US, Angtuaco et al, RadioGraphics 1992; 12:91-109

SITES OF ECTOPIC PREGNANCYSITES OF ECTOPIC PREGNANCY

1. Amputtary2. Isthmic3. Interstitial4. Abdominal5. Ovarian6. Inter- ligamentary7. Cervical

95% of all ectopic pregnancies are Tubal

http://img.tfd.com/dorland/pregnancy_ectopic.jpg

Ectopic PregnancyEctopic Pregnancy

http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9288.jpg

Ectopic Pregnancy and Ectopic Pregnancy and EpidemiologyEpidemiology

Pregnancy that implants outside of the uterine Pregnancy that implants outside of the uterine cavity. In 95% of cases implantation occurs in cavity. In 95% of cases implantation occurs in the fallopian tubes. In the remaining cases the the fallopian tubes. In the remaining cases the pregnancy is in the cervix, abdominal cavity, or pregnancy is in the cervix, abdominal cavity, or ovary.ovary.

If rupture occurs, it can result in rapid If rupture occurs, it can result in rapid hemorrhage, leading to shock, and eventually hemorrhage, leading to shock, and eventually death. death.

Ectopic Pregnancy and Ectopic Pregnancy and Epidemiology continuedEpidemiology continued

BB--HCG (BetaHCG (Beta--human chorionic human chorionic gonadotropingonadotropin) that is low for gestational ) that is low for gestational age. age.

Fails to increase at the expected rate, 2X Fails to increase at the expected rate, 2X every 48hrs.every 48hrs.

Prevalence is 1/100 pregnancies. Prevalence is 1/100 pregnancies.

Risk Factors for Ectopic PregnancyRisk Factors for Ectopic Pregnancy

1.Prior ectopic pregnancy1.Prior ectopic pregnancy2.History of STDs or PID, 2.History of STDs or PID, salpingitissalpingitis3.Previous tubal surgery3.Previous tubal surgery4.Prior pelvic or abdominal surgery resulting in adhesions4.Prior pelvic or abdominal surgery resulting in adhesions5.Endometriosis5.Endometriosis6.Current use of exogenous hormones including 6.Current use of exogenous hormones including progesterone or estrogenprogesterone or estrogen7.In vitro fertilization and other assisted reproduction7.In vitro fertilization and other assisted reproduction8.DES8.DES--exposed patients with congenital abnormalitiesexposed patients with congenital abnormalities9.Congenital abnormalities of the fallopian tube9.Congenital abnormalities of the fallopian tube10.Use of an IUD for birth control10.Use of an IUD for birth control

CLASSICAL TRIAD of CLASSICAL TRIAD of ECTOPIC PREGNANCYECTOPIC PREGNANCY

1. AMENORRHEA1. AMENORRHEA

2. VAGINAL SPOTTING2. VAGINAL SPOTTING

3. ABDOMINAL PAIN3. ABDOMINAL PAIN

AcknowledgementsAcknowledgements

Dr. LiebermanDr. LiebermanDr. CatherineDr. Catherine--Kim, aka AC Kim, aka AC Ms. Ms. NycaNyca BowenBowenDr. Dr. AnghelescuAnghelescuDr. GrahamDr. GrahamDr. LourencoDr. LourencoDr. FerrisDr. FerrisDr. BarthDr. Barth

ReferencesReferencesObstetrics and Gynecology, Blueprints, Callahan and Obstetrics and Gynecology, Blueprints, Callahan and CaugheyCaughey. Chapter2, . Chapter2, pg13pg13--20, 2007.20, 2007.Case Files: Obstetrics & Gynecology, case 30, pg 211Case Files: Obstetrics & Gynecology, case 30, pg 211--218, Lange, 2007.218, Lange, 2007.MR Imaging in High-Risk Obstetric Patients: A Valuable Complement to US1Teresita L. Angtuaco, MDDiagnosis and treatment of ectopic pregnancy. CMAJ 2005 Oct Diagnosis and treatment of ectopic pregnancy. CMAJ 2005 Oct 11;173(8):90511;173(8):905--12. Murray H; 12. Murray H; BaakdahBaakdah H; H; BardellBardell T; T; TulandiTulandi T. T. Epidemiology of ectopic pregnancy during a 28 year period and thEpidemiology of ectopic pregnancy during a 28 year period and the role of e role of pelvic inflammatory disease.pelvic inflammatory disease.AUKamwendoAUKamwendo F; F; ForslinForslin L; L; BodinBodin L; L; DanielssonDanielsson D D SOSexSOSex TransmTransm Infect 2000 Infect 2000 Feb;76(1):28Feb;76(1):28--32.32.Cases of the Day. Us Case Cases of the Day. Us Case oftheofthe Day1. Day1. Ackerman et alAckerman et alPelvic Pain: Overlooked and Pelvic Pain: Overlooked and UnderdiagnosedUnderdiagnosed Gynecologic Conditions,Gynecologic Conditions,KuligowskaKuligowska et alet alhttp://www.yoursurgery.com/procedures/hysteroscopy/images/Anterihttp://www.yoursurgery.com/procedures/hysteroscopy/images/AnteriorNororNormalUterus.jpgmalUterus.jpghttp://http://www.obgyn.net/us/gallery/Gyn_Normal_Ovary.jpgwww.obgyn.net/us/gallery/Gyn_Normal_Ovary.jpghttp://http://img.tfd.com/dorland/pregnancy_ectopic.jpgimg.tfd.com/dorland/pregnancy_ectopic.jpghttp://www.advancedfertility.com/pics/singlefollicle12.jpghttp://www.mayoclinic.com/health/ectopichttp://www.mayoclinic.com/health/ectopic--pregnancy/DS00622 pregnancy/DS00622 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/928http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9288.jpg8.jpg