Ectopic Pregnancy U/S

8/17/2019 Ectopic Pregnancy U/S

1/56

ECTOPIC PREGNANCY


2/56

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.


3/56

/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


4/56

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.


5/56


Heterotopic PregnancyHeterotopic Pregnancy


6/56


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.


7/56


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


8/56


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


9/56


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).


10/56


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.


11/56

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.


12/56

@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.


13/56


14/56



15/56



16/56

NON2PECI/IC /IN5ING2


17/56

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


18/56

Adne!a Dass


19/56

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++%.


20/56

Tua Ring

Ectopic pregnancy tua ring. An e!trauterine trop$oastic ring ;arro)$eads< is isuaiedad?acent to t$e uterus ;u


21/56

Tua Ring


22/56

/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%.


23/56

/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.


24/56

/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


25/56

/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


26/56

/ree /uid Adne!a Dass


27/56


28/56

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.


29/56

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


30/56

Endoagina Coor /o)5opper

Endoagina coor 3o) 5opper and pused

5opper de"onstrate peritrop$oasic 3o)s$o)ing $ig$ eocity and o) resistance.


31/56



32/56



33/56



34/56

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


35/56

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


36/56

DO@AR PREGNANCY


37/56

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.


38/56

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.


39/56

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


40/56

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.


41/56

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.


42/56

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.


43/56

I"aging Co"pete Doe

Doar pregnancy )it$ arge cystic spaces


44/56

I"aging Co"pete Doe

Doar pregnancy starting e!pusion


45/56

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.


46/56

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.


47/56

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).


48/56

I"aging Co"pete Doe


49/56

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


50/56

I"aging Co"pete Doe

Oarian enarge"ent )it$ iatera t$ecaQ utein cysts is a co""on association.


51/56


52/56

Inasie GT5


53/56

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.


54/56

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


55/56


56/56

"HA6 F1"HA6 F1

Ectopic Pregnancy U/S

Documents

Transcript of Ectopic Pregnancy U/S