Learn About Ectopic Pregnancy PowerPoint Presentation

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First Trimester Complications Fetal Biometry Workshop Day 1

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Objectives Review presentation , consequences & sonographic findings of ectopic pregnancy Discuss different types of abortion Define Blighted Ovum Review different types of molar pregnancy Identify coexisting maternal pelvic masses

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Tubal Implantation Abnormal tubes Congenital PID*** Tubal Surgery Normal tubes Transmigration of ovum Embryonic abnormalities Hormonal imbalance Pelvic masses IUD Reduced tubal motility

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Tubal Implantation Hormonal Imbalance Estrogen Progesterone

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Tubal Implantation Mechanical Developmental anomalies Infectious damage Tubal surgery

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Cervical Implantation Below level of internal os Endometrium unsuitable Endometritis IUD Rapid transit

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Interstitial Implantation

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Abdominal Implantation Primary Normal tubes & ovaries Secondary Tubal abortion with extension into peritoneal surface

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Ovarian Implantation Rare <0.52% Gestational sac occupy ovary position Gestational sac connected to uterus by uteroovarian ligament Ovarian tissue in wall of sac Failure of ovum to leave follicle Tubal abortion implants on ovarian surface

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Clinical Presentation Vaginal spotting or bleeding Abdominal pain Amenorrhea Adnexal tenderness Palpable adnexal mass + Pregnancy test hCG Lower levels in ectopic Rapid decrease Hydatidiform mole Nonviable pregnancy Serum amylase Ruptured tubal pregnancy

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Sonographic Protocol Normal uterine pregnancy GS – 4 to 5 weeks after LMP

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Uterine Image with Ectopic Decidual cyst 3 mm cyst (arrow) is identified within the decidua. Cyst is not an intradecidual gestational sac Peripherally located within the decidua Does not abut the endometrial canal

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Coronal View Right Adnexa Fallopian tube filled with fluid [blood] Trophoblastic ring (arrow) Echo-free fluid surrounds the tube Doppler high-velocity low-resistance flow

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Sonographic Protocol Unruptured tubal pregnancy Salpingotomy

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Sonographic Protocol Ruptured tubal pregnancy

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Sonographic Protocol Chronic tubal pregnancy Blood + trophoblastic tissue + disrupted tubal tissue + inflammatory response = pelvic hematocele Indefinite uterus sign – echogenicity similar to uterus Mimics endometriosis and PID

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Treatment Options Surgical intervention Laparoscopy or laparotomy Salpinectomy Hysterectomy D & C Non-Surgical intervention Administer Methotrexate Culdocentesis

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Treatment Options Wait & See Approach Decreasing hCG No evidence of intrauterine pregnancy No fetal heartbeat No sign of bleeding or tubal rupture

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Case Study Sagittal transvaginal uterine scan

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Case Study Transvaginal scan of the right adnexa

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Case Study Sagittal view of the right adnexa

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Case Study Power Doppler Right Adnexa

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Sonographic Differential

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Abortion (AB) Interruption of a pregnancy Causes of AB Induced Spontaneous Fetal malformation Hormone inadequacies Defective implantation Placental maldevelopment or separation Rh incompatibility Systemic infection or toxic agents Maternal trauma Multiple fibroids/submucosal fibroids

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Varieties of AB Spontaneous AB Inevitable AB Incomplete AB Complete AB Missed AB Septic AB

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Spontaneous AB Abortion before 20 weeks gestation Mostly 5th-12th week Vaginal bleeding Possible no knowledge of pregnancy May require D&C Type Threatened AB (clinical diagnosis) Vaginal bleeding in early preg Mild cramping Possible visible fetus Sac in Isthmus of uterus Not dilatation of cervix 50% go on to abort

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US findings of SAB Check sac placement It should be high for normal preg. Check sac appearance Is there a double decidual sign Uterine size Most likely there will be a recheck for any changes

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Sono Findings - Poor Outcome Abnormal Hi/Low hCG Large subchorionic hematoma Heart rate <80 bpm Abnormal sac size/ embryo size Sac size too small or too big compared to embryo Distorted sac shape Low position in endometrial cavity Beware if heart beat seen, then this takes precedence to show live IUP over all the above

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D&C Dilatation and Curettage Scraping of the endometrium Can leave scarring

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Inevitable AB – In Progress

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Incomplete AB Partial evacuation of fetus and placenta Some retained products, Fetus expelled Placenta usually remains Signs & Symptoms Usually pain Bleeding/clotting D & C needed Sonographic findings Still increase in uterine size Thick heterogeneous and echogenic endometrium w/hypervascularity

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Complete AB The entire pregnancy is totally expelled Sonographic findings Increase in uterine size No gestational sac or fetus seen Decidual reaction might still be visible

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Missed AB Sonographic findings Fetus doesn’t occupy whole uterus Fetus may be macerated Shapeless, ill defined echoes Poor imaging No amniotic fluid to delineate structures Fetal demise Fetal skull plates may overlap – “spaulding sign” Uterus small for date (SGA) No fetal heart motion Retention of dead pregnancy for at least 2 months Fetus and placenta retained before 18-20 wks Placenta remains attached Amniotic fluid reabsorbed

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Septic AB Infected dead fetus May show gas formation Gas in uterus from bacteria How does gas show up on US?

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Abortions Threatened AB due to early abruption of placenta, can correct itself spontaneous

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Blighted Ovum Anembryonic pregnancy Sac with no fetal pole Positive beta hCG Different growth rates of GS Small GS and large uterus Increasing GS size and normal uterus

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Blighted Ovum Intrauterine sac with no fetal pole Irregular borders or ill defined Like a spontaneous or incomplete AB Vaginal bleeding Check sac size with LMP

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Hemorrhage Innocent bleed Small period 1 month s/p conception Implantation bleed Abortions Chorioamniotic elevations Extrachorionic bleed Usually not serious concern Subchorionic Blood accumulation between chorion & decidua vera

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Subchorionic hematoma/hemorrhage

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Subchorionic hematoma/hemorrhage

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Pseudogestational Sac Free fluid within the endometrium Can simulate an IUP early on Typically the sac size is irregular and there is not a pronounced double decidual sign +/- slight echogenicity around the pseudo sac No yolk sac and or fetal pole are signs of a pseudo sac

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Other considerations for pelvic mass Persistent corpus luteum PID/TOA Appendiceal abscess Endometrioma Dermoid Hydrosalpinx Hemorrhagic or ruptured ovarian cyst Fluid filled bowel In these cases what is an important ? To ask

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Molar Pregnancy gestational trophoblastic disease Increase in HCG x 10 for current age of pregnancy Remains elevated after 60 days Previous mole Associated with missed AB or blighted ovum Theca lutein cysts Occur w/ 20-50% of molar pregnancy Form in response to increase HCG Usually large and multiloculated Bilateral Resolve after mole removed

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Molar Classification Hydatidiform mole (complete) Partial mole Coexisting fetus and mole Locally invasive mole Metastatic choriocarcinoma

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Hydatidiform Mole

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Hydatidiform Mole

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Partial Mole

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Coexisting fetus and molar preg By def.- dizygotic twin gestation Mole complete or partial Fetus Can become invasive

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Locally Invasive Mole Aka- chorioadenoma destruens Invasive but does not metastasize By def.- chorionic villi penetrate myometrium Can have invasion of bladder wall with hemorrhage of local vessels Extensive proliferation Villi pattern preserved

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Metastatic Mole Choriocarcinoma

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Molar Pregnancy Symptoms Vaginal bleeding may be present with pain Increase hCG LGA- rapid growth Hyperemesis This is the most common of all the symptoms Signs of preeclampsia (HTN, proteinuria, edema) Theca lutein cysts Vessicles passed vaginally (not typical)

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Leiomyomas / fibroids Common pelvic tumor (esp. >35 year old) Fibromuscular, most are benign Etiology Ovarian hormone imbalance Feed on estrogen and get larger Characteristics Variable size Vascular and can degenerate Can have central cystic necrosis Calcify over time Very dense

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Leiomyomas Presentation during pregnancy 1Tri. Can cause SAB 3Tri. Can interfere with delivery or precipitate preterm labor Symptoms Asymptomatic Increase sensation to urinate Pain Profuse/prolonged bleeding Enlarged and irregular uterus Sonographic findings Depends on location, changes and internal characteristics Hypoechoic and heterogeneous Ring of blood flow Attenuate sound Can look like molar pregnancy Leiomyomas / fibroids

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Leiomyomas Leiomyomas / fibroids

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Cystic Hygroma Cystic lymphangioma Anomalous development in communication between venous system and lymphatic Mostly benign Looks similar to meningomyelocele but no bony defect Sonographic findings Multi septated cystic mass Evaluate spine for defect and herniating mass

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Nuchal Translucency 11-13 weeks gestation Don’t get this mixed up with nuchal fold done later in pregnancy Watch out for amnion Should be less than 3mm Bounce

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Fetal Demise

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Review … A patient presents for ultrasound at 7 weeks gestation with bleeding and acute pain. The patient also reveals a history of endometriosis. The sonographer identifies a uterus without evidence of an IUP. This would suggest? Ectopic pregnancy Threatened abortion Missed abortion Incomplete abortion Spontaneous abortion

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Review … What is the most common patient presentation of an ectopic pregnancy? What are the risk factors for an ectopic pregnancy? What are diagnostic criteria [sonographic & lab] for an ectopic pregnancy?