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Objectives. Review presentation , consequences & sonographic findings of ectopic pregnancy. Discuss different types of abortion. Define Blighted Ovum

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Learn About Ectopic Pregnancy

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Learn About Ectopic Pregnancy PowerPoint Presentation

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Description : Objectives. Review presentation , consequences & sonographic findings of ectopic pregnancy. Discuss ... Read More

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Published on : Nov 13, 2014
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Slide 1 - First Trimester Complications Fetal Biometry Workshop Day 1
Slide 2 - 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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Slide 5 - Tubal Implantation Abnormal tubes Congenital PID*** Tubal Surgery Normal tubes Transmigration of ovum Embryonic abnormalities Hormonal imbalance Pelvic masses IUD Reduced tubal motility
Slide 6 - Tubal Implantation Hormonal Imbalance Estrogen Progesterone
Slide 7 - Tubal Implantation Mechanical Developmental anomalies Infectious damage Tubal surgery
Slide 8 - Cervical Implantation Below level of internal os Endometrium unsuitable Endometritis IUD Rapid transit
Slide 9 - Interstitial Implantation
Slide 10 - Abdominal Implantation Primary Normal tubes & ovaries Secondary Tubal abortion with extension into peritoneal surface
Slide 11 - 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
Slide 12 - 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
Slide 13 - Sonographic Protocol Normal uterine pregnancy GS – 4 to 5 weeks after LMP
Slide 14 - 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
Slide 15 - 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
Slide 16 - Sonographic Protocol Unruptured tubal pregnancy Salpingotomy
Slide 17 - Sonographic Protocol Ruptured tubal pregnancy
Slide 18 - 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
Slide 19 - Treatment Options Surgical intervention Laparoscopy or laparotomy Salpinectomy Hysterectomy D & C Non-Surgical intervention Administer Methotrexate Culdocentesis
Slide 20 - Treatment Options Wait & See Approach Decreasing hCG No evidence of intrauterine pregnancy No fetal heartbeat No sign of bleeding or tubal rupture
Slide 21 - Case Study Sagittal transvaginal uterine scan
Slide 22 - Case Study Transvaginal scan of the right adnexa
Slide 23 - Case Study Sagittal view of the right adnexa
Slide 24 - Case Study Power Doppler Right Adnexa
Slide 25 - Sonographic Differential
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Slide 27 - 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
Slide 28 - Varieties of AB Spontaneous AB Inevitable AB Incomplete AB Complete AB Missed AB Septic AB
Slide 29 - 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
Slide 30 - 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
Slide 31 - 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
Slide 32 - D&C Dilatation and Curettage Scraping of the endometrium Can leave scarring
Slide 33 - Inevitable AB – In Progress
Slide 34 - 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
Slide 35 - 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
Slide 36 - 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
Slide 37 - Septic AB Infected dead fetus May show gas formation Gas in uterus from bacteria How does gas show up on US?
Slide 38 - Abortions Threatened AB due to early abruption of placenta, can correct itself spontaneous
Slide 39 - 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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Slide 41 - 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
Slide 42 - 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
Slide 43 - Subchorionic hematoma/hemorrhage
Slide 44 - Subchorionic hematoma/hemorrhage
Slide 45 - 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
Slide 46 - 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
Slide 47 - 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
Slide 48 - Molar Classification Hydatidiform mole (complete) Partial mole Coexisting fetus and mole Locally invasive mole Metastatic choriocarcinoma
Slide 49 - Hydatidiform Mole
Slide 50 - Hydatidiform Mole
Slide 51 - Partial Mole
Slide 52 - Coexisting fetus and molar preg By def.- dizygotic twin gestation Mole complete or partial Fetus Can become invasive
Slide 53 - 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
Slide 54 - Metastatic Mole Choriocarcinoma
Slide 55 - 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)
Slide 56 - 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
Slide 57 - 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
Slide 58 - Leiomyomas Leiomyomas / fibroids
Slide 59 - 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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Slide 61 - 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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Slide 66 - Fetal Demise
Slide 67 - 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
Slide 68 - 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?