Ectopic Pregnancy - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/genito/may.pdf · 2 Alison May, HMS IV Gillian Lieberman, MD Definition • Greek ektopos: out of

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Alison May, HMS IV

Gillian Lieberman, MD

Ectopic Pregnancy

Alison May, Harvard Medical School IV

Radiology

11.15.04


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Alison May, HMS IV


Definition

• Greek ektopos: out of place, from ex (out) + topos (place)

• Ectopic pregnancy: a developing blastocyst implants at a site other than the endometrium of the uterus

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Alison May, HMS IV


Where Does Implantation Occur?

http://medlib.med.utah.edu/WebPath/

Fallopian tube (97%)

Abdomen: 1/5000

Ovary: 1/7000

Cervix: 1/9000

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Alison May, HMS IV


Important Statistics

• Incidence: .5- 2% of all pregnancies• 100,000 ectopic pregnancies occur each

year in U.S.• #1 cause of pregnancy-related maternal

death in 1st trimester• Accounts for 10% all pregnancy-related

deaths

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Alison May, HMS IV


Risk Factors: think tubes!• Tubal pathology (PID, endometriosis,

congenital anomalies, tumors)• Tubal surgery (PID or prior ectopic)• Previous ectopic pregnancy• Infertility (higher rate of tubal abnormalities)• DES (diethylstilbestrol) exposure (estrogen

drug given 1938-1971 for “healthy pregnancy”)

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Alison May, HMS IV


Lesser Risk Factors

• IVF (mixed data)• Tubal sterilization• IUD (very low rate pregnancy, but of

that, up to 50% ectopic; Overall rate much lower than in 1970’s)

Over 50% women presenting with an ectopic have no risk factors!

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Alison May, HMS IV


Symptoms and Lab Values• “Classic triad”: red flags in first trimester!

– Pelvic pain– Bleeding– Palpable abdominal mass

• Lab values: b-HCG– IUP: doubles every 48 hours– Ectopic: less than doubles every 48 hours

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Alison May, HMS IV


Role of Ultrasound

• Ultrasound is #1 diagnostic test in the first trimester to rule out ectopic pregnancy

• Transvaginal: gold standard– High frequency allows closest view of uterus/adnexa– Avoids bowel gas– Requires empty bladder

• Transabdominal: can be helpful– Low frequency allows futher penetration, broader view– Requires full bladder

• 6-20% false negative rate FOLLOW UP

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Alison May, HMS IV


Transvaginal Ultrasound: Getting Oriented

http://yalenewhavenhealth.org/library/healthguide

This diagram depicts the sagittal view, one of the main views in transvaginal imaging. The way the uterus looks here is similar to how it appears in images. The other popular view is transverse, similar to an axial CT slice. In an transabdominal ultrasound, the bladder will be visualized superiorly.

uterus

bladder

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Alison May, HMS IV


Color and Power Doppler• Pulses of ultrasound

returning echoes have different frequencies

• Color is assigned to each frequency

• Color Doppler: shows flow velocity and direction of red blood cells

• Power Doppler: shows amplitude, or power, of signal

• Useful in ectopic pregnancy to show a “ring of fire” around an adnexal mass (note this image is “power doppler”)

https://www.iame.com/learning/ectopic/ectopic_content.html

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Alison May, HMS IV


The 3 Main Questions Ultrasound Must Answer in a Symptomatic

Patient in 1st Trimester

1. Can we see an intrauterine gestational sac? *2. If so, are the gestational sac contents normal?3. Are the adnexa normal?

* Note: with IVF, seeing an IUP no longer rules out a possible heterotopic pregnancy may be as high as 1%

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Alison May, HMS IV


A Look at Normal Findings: Intrauterine Gestational Sac

• Gestational sac: fluid collection in the uterus that contains embryo or yolk sac (nourishing fluid) OR is surrounded two echogenic rings (“double sac” or “double decidual ring” sign)

• Yolk sac at week 5• Fetal heartbeat at week 6

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Alison May, HMS IV


Gestational Sac Anatomy

www.obgyn.net/us/gallery

http://education.yahoo.com/reference/gray/

Gestational sac

embryo

yolk sac

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Alison May, HMS IV


“Double Ring” Sign: Normal IUP

Seminars in Roentgenology, p. 341, fig 2

outer ring inner

ringuterus

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Alison May, HMS IV


A Look at Normal Findings: Adnexa

• Adnexa: organs next to uterus (ovaries and fallopian tubes)• Ovaries: isoechogenic, well marginated regions located near

the iliac vessels, contain follicles (hypoechoic cysts)• Fallopian tubes generally not visualized

ovary

www.radiologyinfo.org/

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Alison May, HMS IV


Ectopic Pregnancy on Ultrasound

• Complex adnexal mass (95% chance of ectopic)

• “Ring of fire” sign (95% chance)• Pseudogestational sac: fluid in endometrium

that looks like an IUP but it is not! (Absent “double ring” sign)

• Fluid in cul-de-sac• Live embryo in adnexa

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Alison May, HMS IV

Gillian Lieberman, MD Symptomatic Patient in 1st

TrimesterPositive b-HCG and Pain or Bleeding

Transvaginal sonogram

Intrauterine Gestational Sac Identified ?

NOYES

Extraovarian Adnexal Complex or Solid Mass ?Gestational Sac Contents Normal ?

YESYES NONO

Diagnose Normal IUP Suspect Abnormal IUP High Likelihood of Ectopic Pregnancy

Differential Dx:

-Early IUP

-Abnormal IUP

-Ectopic Pregnancy

Serial b-HCG Levels and Sonograms until Diagnosis

is Established

Look for Other Findings (Ring of

Fire, etc)

Check Criteria for Failing Pregnancy (cardiac activity)

Seminars in Roentgenology Oct 1998, p. 341 fig. 2

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Alison May, HMS IV


Patient Presentation: C.M.

• 35 yo woman• h/o 3 spontaneous abortions• Presented 2/24/03 in the ED with vaginal

bleeding• LMP was 1/14/03• b-HCG 472 (nonpregnant <5)• What to do?

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Alison May, HMS IV


C.M. Ultrasound 2/24/03• Recall the 3 questions:

– Intrauterine gestational sac?– If so, are contents normal?– Are adnexa normal? Uterus: normal

endometrium, no IUP

R ovary: normalL ovary: 3 cm hypoechoic cyst with heterogeneous debrispower doppler: minimal color, c/w

hemorrhagic corpus luteum cystPACS

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Alison May, HMS IV


C.M. 2/24/03 Impression:

• No IUP• Left ovarian hemorrhagic cyst• Patient may have early IUP or

miscarriage• Cannot rule out ectopic pregnancy

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Alison May, HMS IV


C.M.: Time Passes…

• Given the questions posed on the ultrasound, her b-HCG levels are followed:2/24: 4722/26: 7782/28: 15203/03: 3147

• Overall trend: not quite doubling every 48 hours, worrisome for ectopic pregnancy

• Needs another ultrasound

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Alison May, HMS IV


C.M. 3/3/03: Ultrasound

bladder

sagittal transverse

Two transabdominal views of uterus: no IUP

PACS

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Alison May, HMS IV



uterus: normal, no IUP

ovary: normal

unidentified mass between ovary and uterus!

PACS

Transvaginal view of right adnexa

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Alison May, HMS IV



“Ring of fire” on Power Dopplercomplex adnexal mass measuring 1.27 x 1.29 cm

uterus

ovary

PACS

Dx: Ectopic pregnancy!

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Alison May, HMS IV


Treatments for Ectopic Pregnancy

• Medical: methotrexate (inhibits dividing cells, used in medical abortion)– Pro: save fallopian tube. Con: 5% failure rate.

• Surgical: laparoscopy, laparotomy– Mass is removed with/out fallopian tube– Surgery necessary in fallopian tube rupture

• Relocation of embryo: scattered cases published but very controversial

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Alison May, HMS IV


Worst Case Scenario of Ectopic Pregnancy

• Management fails, pregnancy continues, fallopian tube ruptures hemorrhage leading to hypovolemic shock death

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Alison May, HMS IV


C.M. What Happened Next?

• Methotrexate injection• However…her b-HCG remained elevated

3/3: 31473/7: 45103/12: 44393/20: 891

• Presented 3/20 with vaginal bleeding, 10/10 pelvic pain and peritoneal signs

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Alison May, HMS IV


C.M. To the Operating Room!

• Diagnosis: ruptured ectopic pregnancy• Findings on laparoscopy:

-R fallopian tube had 3 x 2 cm ectopic mass, confirmed fetal tissue on path-800 cc blood and clot in pelvis-Mass and fallopian tube removed successfully

www.advancedfertility.com/ectopfot.htmGross image of an unruptured tubal

ectopic pregnancy

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Alison May, HMS IV


Summary

• Recognize “classic triad” in first trimester (pelvic pain, bleeding, mass)

• Rule out ectopic pregnancy by using ultrasound, particularly transvaginal

• Use the three questions (IUP present and normal? Adnexa normal?)

• Negative transvaginal ultrasound does NOT rule out ectopic! Follow up with ultrasound and b- HCG

• Return to ED if symptoms persist

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Alison May, HMS IV


References• Carter, Jonathan. An Atlas of Transvaginal Sonography. J.B. Lippincott company, 1994.• Doubilet, Peter M., Benson Carol B. Emergency obstetrical ultrasonography. Seminars in

Roentgenology, Vol XXXIII, no 4 (October), 1998: pp 339-350 • Laing, Faye C., Jeffrey R. Brooke. Ultrasound evaluation of ectopic pregnancy. Radiological

Clinics of North America, vol. 20, vol. 2, June 1982: pp 383-395• Tulandi, Togas. www.uptodate.com• Weissleder R, Wittenberg J, Harisinghani M. Primer of Diagnostic Imaging, 3rd ed. Mosby, Inc.

2003. pp748-9.• education.yahoo.com/reference/gray/• medlib.med.utah.edu/webPath/• yalenewhavenhealth.org/library/healthguide• www.advancedfertility.com/ectopfot.htm• www.cdc.gov/reproductivehealth/• www.emedicine.com• www.desaction.org• www.iame.com/learning/ectopic/ectopic_content.html• www.medforum.nl/gynfo• www.obgyn.net/us/gallery• www.radiologyinfo.org/

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Alison May, HMS IV


Acknowledgments

Thanks to:Dr. Deborah LevineDr. Cristina CavazosDr. Gillian LiebermanMs. Pamela LepkowskiMr. Larry Barbaras

Documents

Ectopic Pregnancy - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/genito/may.pdf · 2 Alison May, HMS IV Gillian Lieberman, MD Definition • Greek ektopos: out of