ECTOPIC PREGNANCY And

ABORTION

DR.SHAMIM RIMAMBBS,DMU,FCGP

M.PHL, THESIS PARTRADIOLOGY & IMAGIMG

ECTOPIC PREGNANCY

Any pregnancy that occurs outside of the uterine cavity

Tubal

Ampulla (55%)

Isthmus (25%)

Fimbria (17%)

Cervical

Ovarian

Abdominal

GENERAL CONSIDERATIONS

Risk factors

- prev. tubal surgery

- prev. ectopic pregnancy

- PID, endometriosis

- prev. c/sec

- assisted reproduction: GIFT, IVF

- failed contraception

SIGN/ SYMPTOM

Most common presentation:

Woman of reproductive age

Abdominal pain

Vaginal bleeding

Approx 7 weeks after amenorrhea

DIAGNOSITC TESTS

Ultrasound (*test of choice)

No intrauterine gestational sac

bHCG

Do not increase appropriately

Urine pregnancy test

Pregnant / not pregnant

Progesterone level (less reliable)

SONOGRAPHY SUSPECT ECTOPIC PREGNANCY

Specific features:

> Live embryo in the adnexa Non-specific features:

> Empty uterus

> Pseudo-gestational sac of ectopic pg

> Adnexal mass

> Ectopic tubal ring Non-supportive features:

> live intra-uterine pregnancy

> Intra-decidual & double decidual sign of

early intra-uterine pg

> Peritropoblastic blood flow

LIVE EMBRYO

TV image: Right adnexal mass / ring gestational sac with yolk sac,

alive embryo at 7.4 weeksTV image: Embryonic cardiac activity

depicted in M-mode.

 

TV image: Embryonic cardiac activity depicted in M-mode

EMPTY UTERUS

Empty Uterus with Ectopic Pregnancy

PSEUDO-GESTATIONAL SAC OF ECTOPIC PG

The endometrial sac does not have a surrounding chorionic ring and free fluid is visible in the posterior cul-de-sac.

ADNEXAL MASS

TA image: uterus containing clot and decidual reaction, sm

all amount of fluid cul-de-sac

TA image: Vague right  adnexal mass

TUBAL PREGNANCY

TUBAL PREGNANCY

OVARIAN PREGNANCY

ABDOMINAL PREGNANCY

Sagittal transvaginal image shows the fetal head (h) in the cul-de-sac, posterior to the uterus (U)

CESAREAN SCAR ECTOPIC PREGNANCY

ECTOPIC TUBAL RING

Gestational sac surrounded by a thick chorionic ring outside and immediately adjacent to the myometrium

INTERSTITIAL PREGNANCY

Gestational sac with a marked eccentric location in the uterus

CORNUAL PREGNANCY

PATHOGENESIS OF ECTOPIC PREGNANCIES

Tubal pregnancy

- ampullary > isthmic > interstitial

- secondary, tubo-ovarian, tubo-abdimin

al,

broad-ligament pregnancies develop

- fertilized ovum burrows through the epi

thelium

(because, tube lacks a submocosal

layer)

zygote comes to lie within the musc

ular wall

rapidly proliferating trophoblast inva

des the

subjacent muscuralis

maternal blood vessels are opened

TUBAL RUPTURE

- the invading, expanding products of conception

may rupture the oviduct at any sites

- occur in the first few weeks in first trimester

(but, interstitial pregnancy usually occur later)

- usually, spontaneously rupture

(sometimes coitus or bimanual examination)

- rarely, undamaged conceptus into the peritoneal

cavity lithopedion

RUPTURE ECTOPIC

Pelvis- free fluid

MORISON'S POUCH - FREE FLUID

Enlarged uterus with grossly thickened endometrium (decidual cast) of almost 15 mm. The uterus shows absence of any gestation sac. No pseudosac is seen

Transvaginal scan of the pelvis shows a large collection of hemorrhagic fluid in the cul de sac 3) A right adnexal mass, presumably in the Right Fallopian tube is also seen. A left ovarian hemorrhagic cyst is also present.

HETEROTOPIC GESTATION

Also called Heterotopic pregnancy or

simultaneous intrauterine and

extrauterine pregnancy or coexistent

intrauterine and extrauterine

pregnancy

CERVICAL ECTOPIC

•Implantation of the fertilized ovum with

subsequent development within the

cervical structure without involvement

of the corpus uteri (below the level of

internal os)

. In a typical case, the endocervix is

invaded by the trophoblast, and the

pregnancy proceeds to develop in the

fibrous cervical wall. The duration of

pregnancy is dependent upon the site

of embryo implantation. The higher it is

implanted in the cervical canal, the

greater is its capacity to grow and

cause haemorrhage .

•Implantation of the fertilized ovum with

subsequent development within the

cervical structure without involvement

of the corpus uteri (below the level of

internal os)

. In a typical case, the endocervix is

invaded by the trophoblast, and the

pregnancy proceeds to develop in the

fibrous cervical wall. The duration of

pregnancy is dependent upon the site

of embryo implantation. The higher it is

implanted in the cervical canal, the

greater is its capacity to grow and

cause haemorrhage .

Gestational sac in cervico- isthmic region

Transvaginal Ultrasound showing 10 week cervical ectopic gestation

ABORTION

ABORTION

Pregnancy loss at less than 20 weeks’ gestation

Spontaneous Abortion

Threatened abortion

A pregnancy complicated by bleeding before 20 weeks’ gestation

Inevitable abortion

The cervix has dilated, but the products of conception have not been expelled

Complete abortion

All products of conception have been passed without need for surgical or medical intervention

ABORTION

Incomplete abortion

Some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes

Missed abortion

A pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception

Septic abortion

A spontaneous abortion that is complicated by intrauterine infection

Recurrent spontaneous abortion

Three (3) or more consecutive pregnancy losses

CAUSES

First Trimester Miscarriages

Chromosomal abnormalities

Second Trimester Miscarriages

Structural Problems Cavity defects:

uterine fibroidsa septumscar tissue possibly a large polyp

Cervical insufficiency (also termed cervical incompetence)

Thrombosis

Infection Genetic or Chromosomal Problems in the Fetus

RISK FACTORS

Increasing maternal age

9% for a 20-24 year-old 15% for a 30-34 year-old

 51% for a 40-44 year-old

Advancing age of th[e father 

Smoking, alcohol, cocaine and heavy coffee consumption Certain drugs, such as those used for chemotherapy

Certain medical conditions are risk factors as well. These include:

Poorly-controlled diabetesUncontrolled thyroid diseaseHigh prolactin (a hormone associated with breastfeeding) levelsThe polycystic ovarian syndrome.Obesity or severely low weight.

COMPLETE MISCARRIAGE

The absence of the gestational sac and the presence of intrauterine debris

INCOMPLETE ABORTION

Empty gestational sac. 

MISSED ABORTION

In a missed abortion, falling levels of HCG or ultrasound imaging confirm that a miscarriage has occurred, but minimal or no bleeding occurs and the uterus has failed to expel the pregnancy. 

-

The gestational sac is irregularly formed, and also the embryo is missing from inside the gestational sac (Blighted Ovum)

MISSED ABORTION

Missed abortion 9Wks GA by 2D ultrasound and by using color flow mapping to detect absence of color signals from fetal heart. The spectral Doppler shows an artifact from maternal arterial “thump”.