Post on 06-Jul-2018
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ECTOPIC PREGNANCY
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Introduction
Ectopic pregnancy accounts for 1.4% of apregnancies and for appro!i"atey 1#% of"aterna deat$s.
An increase in t$e preaence of ris& factors $ased to a parae increase in t$e incidence ofectopic pregnancy.
T$e case'fataity rate( $o)eer( $as decined
fro" *.# in 1+++ in 1,-+ to ess t$an 1 in 1+++(proay ecause of i"proed diagnosticaccuracy in t$e eary stages of ectopicpregnancy and resutant earier interention.
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/actors Associated 0it$ an IncreasedIncidence of Ectopic Pregnancy Past $istoryof
2apingitis or peic in3a""atory disease Tua surgery Ectopic pregnancy Intrauterine contraceptie deice
Adanced "aterna age Infertiity Ouation Induction In itro fertiiation
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2onograp$ic 5iagnosis
Regardess of cinica presentation( t$e pri"ary goaof eary 6rst tri"ester sonograp$ic diagnosis s$oude to identify t$e ocation of t$e gestationa sac.
7ecause of t$e o) incidence of $eterotopic
pregnancy( sonograp$ic de"onstration of anintrauterine pregnancy reduces t$e i&ei$ood ofectopic pregnancy to an a"ost insigni6cant ee.
8eterotopic pregnancy( $o)eer( s$oud esuspected in t$e appropriate cinica setting(
especiay in $ig$'ris& groups. Eauation of t$e adne!a s$oud e routine in a
patients( incuding t$ose )it$ docu"entedintrauterine pregnancies.
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2onograp$ic 5iagnosis
Heterotopic PregnancyHeterotopic Pregnancy
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2onograp$ic 5iagnosis
T$e de"onstration of a ie e"ryo in t$eadne!a is diagnostic of ectopic pregnancy.
In eary intrauterine pregnancy( inco"pete
"iscarriage( or ectopic pregnancy( onecannot a)ays identify t$e gestationa sac. In t$e asence of speci6c sonograp$ic
6ndings( t$e proaiity of ectopic
pregnancy can e predicted yidenti6cation of nonspeci6c sonograp$icfeatures and y correation )it$ t$ediscri"inatory ee of t$e seru" 9'$CG.
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2onograp$ic 5iagnosis
T$e intradecidua sign can e used tode"onstrate t$e presence of an intrauterinepregnancy efore isuaiation of t$e yo& sac ore"ryo.
In patients )it$ ectopic pregnancies( t$e decidua"ay soug$( resuting in a 3uid coection )it$int$e endo"etria cana t$at is referred to as adecidual cast or pseudogestational sac
A pseudogestationa sac is a 3uid coection)it$in t$e endo"etria cana surrounded y asinge decidua ayer( as opposed to a sac )it$int$e decidua autting t$e endo"etria cana;intradecidua sign< or t$e t)o concentric rings oft$e doue'decidua sign
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2onograp$ic 5iagnosis
Decidual cast.Decidual cast. ;A< 2agitta and ;7< corona sonogra"s of t$e uterus. T$e
=pseudogestationa sac= is co"posed of 3uid ;arro)$ead< and deris ;c
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2onograp$ic 5iagnosis
Intradecidual signIntradecidual sign. Endovaginal sonogram in the sagittal plane(A) and coronal. Endovaginal sonogram in the sagittal plane(A) and coronalplane (B) in a patient at 4.5 ee!s menstrual age. "he # mm gestational sac (electronicplane (B) in a patient at 4.5 ee!s menstrual age. "he # mm gestational sac (electroniccalipers) is demonstrated ithin the decidua a$utting and slightly displacing the echogeniccalipers) is demonstrated ithin the decidua a$utting and slightly displacing the echogenicendometrial canal (arros).endometrial canal (arros).
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2onograp$ic 5iagnosis
Co"parison of t$e utrasound features of an intrauterine pregnancy and apseudogestationa sac.
T$e intrauterine pregnancy appears as a sp$erica>oa i"age( in an eccentric position int$e endo"etriu"( )it$ reguar pro6es( anec$oic content( and a doue $yperec$oice!terna ring.
On t$e contrary( t$e pseudosac $as ?agged "argins( in$o"ogeneous content and irreguar"orp$oogy t$at c$anges oer t$e ti"e of t$e e!a" or et)een t)o successie scans.
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5ecidua cyst
5ecidua cyst in a patient )it$ ectopic pregnancy. A * "" cyst;arro)< is identi6ed )it$in t$e decidua. T$is cyst is not anintradecidua gestationa sac in t$at it is perip$eray ocated)it$in t$e decidua and does not aut t$e endo"etria cana.
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@ie E"ryo in t$e Adne!a
T$e sonograp$ic de"onstration of a iee"ryo in t$e adne!a is speci6c for t$ediagnosis of ectopic pregnancy.
A ie e!trauterine fetus $as eendetected )it$ E2 in 1-% to B% ofpatients )it$ ectopic pregnancies
co"pared )it$ appro!i"atey 1+% )it$ TA2.
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@ie E"ryo in t$e Adne!a
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@ie E"ryo in t$e Adne!a
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NON2PECI/IC /IN5ING2
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Adne!a Dass
An adne!a "ass can e found inconditions ot$er t$an ectopic pregnancyand is t$erefore not diagnostic.
T$e presence of an adne!a "ass inpatients )it$ a positie 9'$CG )$o $aeno sonograp$ic eidence of anintrauterine pregnancy( $o)eer( $as apositie predictie aue of -+% to -#%
for ectopic pregnancy
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Adne!a Dass
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Tua Ring
A tua ring is an ec$ogenic adne!a ringseparate fro" t$e oary created y t$etrop$oast of t$e ectopic pregnancy
surrounding t$e gestationa sac. In t$e series of Nyerg and coeagues
t$e positie predictie aue of a tuaring for ectopic pregnancy )as 1++%.
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Tua Ring
Ectopic pregnancy tua ring. An e!trauterine trop$oastic ring ;arro)$eads< is isuaiedad?acent to t$e uterus ;u
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Tua Ring
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/ree /uid
T$e presence of free 3uid is a nonspeci6c6nding t$at suggests t$e presence of anectopic pregnancy in t$e appropriate cinicasetting
T$e a"ount of 3uid and t$e ec$ogenicity oft$e 3uid are i"portant cues in predicting t$epresence of an ectopic pregnancy.
A arge a"ount of 3uid and increasedec$ogenicity of t$e 3uid are ot$ "ore
indicatie of an ectopic pregnancy. T$e presence of a arge a"ount of free 3uid or
of ec$ogenic free 3uid increases t$e positiepredictie aue fro" F*% to F%.
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/ree /uid
Ectopic pregnancy free 3uid. Ec$ogenic 3uid;< ispresent in t$e adne!a ad?acent to an adne!a cyst;c< in apatient )it$ a ruptured ectopic pregnancy.
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/ree /uid
Ectopic pregnancy gray scae. Corono sonogra" t$roug$ t$e rig$t adne!a s$o)s a faopian tue ;tue<
6ed )it$ ec$ogenic 3uid ;ood< and a trop$oastic ring ;arro)< Ec$o'free3uid ;< surrounds t$e tue
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/ree /uid
At$oug$ t$e presence of a arge a"ountof free 3uid suggests tua rupture( free3uid is not a speci6c 6nding ecause t$e
tue "ay e intact in t$e presence of aarge $e"operitoneu".
In patients )it$ suspected ectopicpregnancy( t$e co"ination of an adne!a
"ass and ec$ogenic free 3uid isassociated )it$ a ,-% positie predictieaue for ectopic pregnancy
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/ree /uid Adne!a Dass
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Nor"a 2onogra"
Patients )it$ ectopic pregnancy "ay $ae aco"petey nor"a peic utrasounde!a"ination.
In t$e series of Nyerg and associates( *4% ofpatients )it$ ectopic pregnancy $ad noeidence of eit$er an adne!a "ass or free 3uid
• Pregnancy o% un!non location (&' uideline) *Pregnancy o% un!non location (&' uideline) *
• No signs of eit$er intra' or e!trauterine pregnancy or
retained products of conception in a )o"an )it$ apositie pregnancy test.
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Endoagina Coor /o)5opper EC/5 diagnosis of ectopic pregnancy is
ased on t$e identi6cation of adne!aperitrop$oastic 3o) de6ned as $ig$'
eocity( o)'resistance 3o) separatefro" t$e oary
2tudies de"onstrate t$at EC/5increases t$e diagnostic sensitiity fordiagnosis of ectopic pregnancy
co"pared )it$ E2 aone
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Endoagina Coor /o)5opper
Endoagina coor 3o) 5opper and pused
5opper de"onstrate peritrop$oasic 3o)s$o)ing $ig$ eocity and o) resistance.
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Endoagina Coor /o)5opper
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Endoagina Coor /o)5opper
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Endoagina Coor /o)5opper
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Ectopic Pregnancy: Extrauterine Findings
Positive Negative
Sensitivity Specificity Predictive Predictive
Sonographic Findings (%) (%) Value (%) value (%)
Adnexal mass 2 !" #$ &
Free fluid '" '! '" '!
oderatetolarge 2! !' &' '2
amount of free fluid
*chogenic fluid+ no mass !& & &
Adnexal mass+ no fluid 22 !, # #
Echogenic fluid plusEchogenic fluid plus 4242 9999 9797 6767adnexal massadnexal mass
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Diagnostic "a$le %or Patients +ith ,uspectedEctopic Pregnancy and Positive Pregnancy"est
B-H'B-H'(irst(irst
InternationalInternational
&e%erence&e%erence
,onographic,onographicindingsindings
Preparation)Preparation)
(uterine and adne/a)(uterine and adne/a)(0st I&P)(0st I&P)
(mI12ml)(mI12ml)
DiagnosisDiagnosis
Intrauterine pregnancyIntrauterine pregnancyithith
Intrauterine pregnancyIntrauterine pregnancy
normal adne/anormal adne/a
Intrauterine pregnancyIntrauterine pregnancyithith
Possi$le heteropic pregnancy3Possi$le heteropic pregnancy3
adne/al mass or %reeadne/al mass or %reeuiduid
clinical correlation reuiredclinical correlation reuired
6o intrauterine6o intrauterinepregnancypregnancy
7089970899 Pro$a$le ectopic pregnancy3 possi$lePro$a$le ectopic pregnancy3 possi$le
ith no adne/alith no adne/ala$normalitya$normality
incomplete miscarriage orincomplete miscarriage ora$normala$normal
intrauterine pregnancyintrauterine pregnancy
6o intrauterine6o intrauterinepregnancypregnancy
:0899:0899 ;i!elihood o% ectopic pregnancy;i!elihood o% ectopic pregnancy
ith no adne/alith no adne/ala$normalitya$normality
depending on clinical
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DO@AR PREGNANCY
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Types of Gestationa Trop$oastic Neopasia HGT5 A )ide spectru" of entities c$aracteried y
anor"a proiferation of pregnancy'reatedtrop$oasts )it$ ariae "aignant potentia1. Non'inasie $ydatidifor" "oe Hco"pete
or partia(B. Inasie "oe(*. C$oriocarcino"a(4. Pacenta site trop$oastic tu"or HP22T
and#. Epit$eioid trop$oastic tu"or Ha ne)erentity.
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Etio'pat$ogenesis
Doar gestations are increased in oder and ery youngfe"aes of reproductie age and in t$ose )it$ a $istory ofprior "oar pregnancy.
Adanced paterna age "ay e a ris& factor for a co"pete"oar pregnancy A co"pete "oar pregnancy occurs )$en a sper" fertiies an
e"pty ou"( resuting in t$e deeop"ent of ony pacenta parts.
A co"pete "oe is co"petey paterna in origin( )it$ a &aryotype ofusuay 4F JJ.
A partia "oe resuts )$en t)o sper"s fertiie a singe ou" andresuts in deeop"ent of certain or a feta parts.
A partia "oe predo"inanty $as a tripoid &aryotype of F,JJJ or F,
JJY or F, JYYK $o)eer( a dipoid &aryotype "ay aso e!ist.
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Cinica Presentation
Patients )it$ a co"pete "oar pregnancyusuay present )it$ t$e cassica sy"pto"sof agina eeding( $ypere"esis( passage ofgrape i&e esices per agina and a uterusarger t$an dates Hat$oug$ so"e "aypresent )it$ a s"aer t$an dates uterus.
0it$ a partia "oar pregnancy( patients are
usuay asy"pto"atic or "ay present )it$sy"pto"s of a "issed or inco"pete"iscarriage
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I"aging Co"pete Doe
T$e diagnosis of "oar pregnancy can neary a)ays e "adey utrasound( ecause t$e c$orionic ii of a typica co"pete"oe proiferate )it$ acuoar s)eing and produce ac$aracteristic esicuar sonograp$ic pattern.
L 0$en t$e diagnosis is "ade at a ater stage of gestation( t$e
cassica Msno)stor" pattern of t$e uterus )as descriedK $o)eert$is is not co""ony seen no).
L T$e "a?ority of 6rst tri"ester co"pete "oes de"onstrated atypica sonograp$ic appearance of a co"pe! and ec$ogenicintrauterine "ass containing "any s"a cystic spaces )$ic$correspond to t$e $ydropic ii on gross pat$oogy.
L One "ay see a arge( centra 3uid coection t$at "i"ics anane"ryonic gestation or "iscarriage.
L Occasionay( t$ere is "erey a centra "ass of ariaeec$ogenicity( presu"ay ecause t$e iiare too s"a to e seen)it$ sonograp$y at t$at ti"e.
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I"aging Co"pete Doe
T$e cassica unc$'of'grapes appearance or sno)'stor"appearance in t$e uterine caity is noted. T$is is t$e typicaappearance of a gestationa trop$oastic disease.
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I"aging Co"pete Doe
Transerse sonogra" of t$e uterus de"onstrates t$e$eterogeneous "ass )it$in t$e endo"etria caity. T$eisuaied anterior and posterior "yo"etriu" appear to enor"a and uninoed.
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I"aging Co"pete Doe
Doar pregnancy )it$ arge cystic spaces
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I"aging Co"pete Doe
Doar pregnancy starting e!pusion
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I"aging Co"pete Doe
2tudies $ae s$o)n coor 5opper to e usefu in t$eeauation and foo) up of gestationa trop$oastictu"ors.
Angiogenesis is an integra part of any tu"ordeeop"ent and coor 5opper usuay reeasincreased ascuarity in t$e "oe( foo)ed y adecrease )it$ treat"ent.
;o resistance $lood vessels ith lo pulsatility;o resistance $lood vessels ith lo pulsatilityand resistance indices have $een noted inand resistance indices have $een noted inmalignant and aggressive gestationalmalignant and aggressive gestational
tropho$lastic tumorstropho$lastic tumors.. T$ese "ay aso e usefu in predicting t$e response to
treat"ent in addition to diagnosis.
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I"aging Co"pete Doe
'olor Doppler scan in a patient ith a molar gestation T$e $yperec$oic "ass in t$e uterus de"onstrates areas of increasedascuarity.
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I"aging Co"pete Doe
,pectral ave%orm analysis in a case o% gestational tropho$lasticneoplasm
T$e spectra )aefor" )it$in t$e cystic "ass in t$e uterus reeas a"i!ed arteria and enous )aefor"( )it$ o) resistance arteria 3o).
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I"aging Co"pete Doe
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I"aging Co"pete Doe
Doar pregnancy EC/5 s$o)ing ascuar "yo"etriu")it$ no 3o) in t$e "oar tissue indicating "oardegeneration
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I"aging Co"pete Doe
Oarian enarge"ent )it$ iatera t$ecaQ utein cysts is a co""on association.
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Inasie GT5
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Partia Doe
Partia "oes are often indistinguis$ae fro"co"pete "oes on utrasound.
8o)eer( de"onstration of feta parts faors t$ediagnosis of a partia "oe.
Nau"o( et a descried t$e foo)ing appearancesL Enarged and t$ic&ened pacenta reatie to t$e sieof t$e uterus.L Cystic spaces )it$in t$e pacenta.L An aie or dead( )e for"ed ut gro)t$ retardedfetus.
L An e"pty gestationa sac Hane"ryonic appearanceor a sac t$at contains i'de6ned feta ec$oes.
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Partia Doe
An enlarged uterus ith multiple cystic areas ithin endometrium2placenta is noted. A roundedAn enlarged uterus ith multiple cystic areas ithin endometrium2placenta is noted. A rounded00 mm structure thought to $e the yol! sac is idention the right side?.00 mm structure thought to $e the yol! sac is idention the right side?.
"his is a$normal as the normal yol! sac diameter should $e : @ mm at 09 ee!s o% gestation."his is a$normal as the normal yol! sac diameter should $e : @ mm at 09 ee!s o% gestation.
"his as a non-invasive partial molar pregnancy= ith hydropic changes in an enlarged"his as a non-invasive partial molar pregnancy= ith hydropic changes in an enlargedplacenta.placenta.
Dierential Diagnosis* Hydropic placental degeneration= typically associated ith an a$normalDierential Diagnosis* Hydropic placental degeneration= typically associated ith an a$normalor %ailing
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"HA6 F1"HA6 F1