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Common & Uncommon Ectopic Pregnancies

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Common & Uncommon Ectopic Pregnancies Common & Uncommon Ectopic Pregnancies Dr. Gayatri Joshi, MD [email protected] @GayatriJoshiMD June 2, 2019 Disclosures No financial or other disclosures related to this exhibit. @GayatriJoshiMD Learning Objecves ü Recall relevant normal gynecologic anatomy and the appearance ofn ormal 1st trimester intrauterine pregnancy (IUP) ü Idenfy risk factors, imaging findings, and complicaons of ectopic pregnancies, including common ectopic implantaon in the fallopian tube, as well as less common ectopic sites such as cornual, ovarian, Cesarean sec2on scar, cervical, abdominal, and heterotopic pregnancies ü Demonstrate techniques for improving diagnosc accuracy during sonographic evaluaon @GayatriJoshiMD Background Ectopic pregnancies (EP) can pose a diagnosc challenge – Devastang consequences when missed or misdiagnosed – Can result in significant morbidity and mortality When diagnosed early and accurately, many complicaons can be avoided with appropriate medical or surgical intervenon. @GayatriJoshiMD Background Physical exam and clinical presentaon: oen nonspecific or ambiguous during pregnancy, especially when ectopic implantaon is suspected Important to be familiar with: – Spectrum of ectopic implantaon sites – Key US features of both common and uncommon ectopic pregnancies – Complicaons @GayatriJoshiMD Anatomy UTERUS ENDOMETRIAL CAVITY OVARY CERVIX VAGINA @GayatriJoshiMD Anatomy • Intersial Segment: Surrounded by uterine myometrium (referred to as the intersal, intrauterine, myometrial, intramural, or cornual poron of the fallopian tube) • Isthmic Segment: Straight poron of tube; thick muscular wall & narrow lumen • Ampullary Segment: Longest poron of tube; thin wall (almost muscle-free) & wide lumen; usually where ferlizaon takes place • Infundibulum: Funnel-like structure marginated with fimbriae • Fimbriae: Fringe-like structure at end of the tube; sweeps released eggs from the ovary into the fallopian tube @GayatriJoshiMD Nomenclature of 1st Trimester Pregnancy Terminology Definion Viable Pregnancy One that may potenally result in a liveborn baby Nonviable pregnancy One that cannot result in a liveborn baby (including ectopic and failed pregnancies) Pregnancy of unknown locaon (PUL) + Pregnancy test with no signs of IUP or extra-uterine gestaon on TVUS IUP of uncertain viability IUP with fetal CRL <7mm with no cardiac acvity or sac MSD <25 mm with out embryo Live IUP IUP with yolk sac, embryo/fetus, and cardiac acvity Probable IUP Intrauterine sac-like structure without yolk sac or embryo Definite ectopic Extrauterine GS with yolk sac, embryo, cardiac acvity Probable ectopic Heterogeneous adnexal mass or extrauterine sac-like structure without visible fetal parts @GayatriJoshiMD Normal 1st Trimester IUP: Brief Discussion • Probable IUP • IUP of uncertain viability • Live IUP @GayatriJoshiMD Decidua basalis Decidua capsularis Decidua parietalis @GayatriJoshiMD @GayatriJoshiMD Ectopic Pregnancy What is it? When implantaon takes place in a site other than the endometrium of the uterine cavity @GayatriJoshiMD Ectopic Pregnancy What are the risk factors? • Previous ectopic pregnancy • Previous fallopian tube surgery • History of PID • History of IUD placement • In utero diethylslbestrol exposure • Congenital uterine anomalies • Inferlity • History of smoking • Endometriosis • Use of assisted reproducve technology (ART) • History of pelvic or abdominal surgery @GayatriJoshiMD Ectopic Gestaonal Sites ABDOMINAL (~1%) FALLOPIAN TUBE (93-97%) UTERUS ENDOMETRIA L CAVITY OVARY OVARIAN (0.5%) SCAR (<1%) CERVIX CERVICAL (<1%) VAGINA @GayatriJoshiMD Ectopic Pregnancy Sites • Fallopian tube: most common (~95%) • 75%–80% Ampullary • 10% Isthmic • 5% Fimbrial • 2%–4% Intersal • Ovarian, cervical, scar, and abdominal pregnancies are rare • Heterotopic (rare; usually intrauterine + tubal) • Increasing occurrence with assisted reproducve techniques (ART) • 1:30,000 pregnancies without ART (spontaneous) @GayatriJoshiMD Ectopic Pregnancy Sites Absence of an intrauterine gestaonal sac should trigger a detailed search for an ectopic pregnancy Up to 35% of ectopic pregnancies may not display any adnexal abnormalies @GayatriJoshiMD Corpus Luteum Cyst vs. Fallopian Tube EP Can appear similar prior to visible yolk sac or fetal parts – Grayscale US à Thick-walled adnexal cysc structure – Color Doppler à Peripheral hyperemia (ring of fire sign) @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP? Paent #1 IUP? Nonspecific fluid? Pseudogestaonal sac? Corpus luteum cyst? EP? Physiologic fluid? Hyperacute blood? @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP? Paent #1 Answer: IUP and right corpus luteum cyst @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP? Paent #2 @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP? Paent #2 Answer: IUP & hemorrhagic le cyst with hemoperitoneum @GayatriJoshiMD Thick-walled cysc adnexal structures Thick-walled cysc structure Anechoic center (no visible YS or fetus) Located in the adnexal region Differenal consideraons: • Fallopian tube EP • Ovarian EP • Corpus luteum cyst @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP or Ovarian EP? Ask yourself: Is it in the ovary or in the fallopian tube? Use dynamic manual exam + real-me grayscale US to decide What exactly do we do and what do we look for? @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP or Ovarian EP? Push on the thick-walled cysc structure (not simply an anatomic scan) Observe its movement with respect to the ipsilateral ovary @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP or Ovarian EP? • If it moves with the ovary, it is within the ovary • Most likely a corpus luteum cyst • Ovarian EP is a far less common enty à OB evaluaon if this sll is suspected clinically • If it moves discordantly with respect to the ovary, it is in not in the ovary • Most likely a fallopian tube EP @GayatriJoshiMD Corpus Luteum Cyst or Tubal EP? Paent #3 @GayatriJoshiMD Answer: Fallopian Tube EP @GayatriJoshiMD Chief Complaint: 25 year-old female Companion Case Paent #4 with pelvic pain and +HCG Hemorrhage can obscure discrete ovary and EP Assessment for concordant/discordant moon can be difficult @GayatriJoshiMD Differenal consideraons based on inial US images alone: • EP + nonspecific fluid or pseudogestaonal sac in endometrial canal (EMC) • Early intrauterine pregnancy (IUP) with a right ovarian hemorrhagic corpus luteum cyst Addional clinical history and labs: • History PID 2 years ago, treated Risk factor • Current β-hCG 3883 • Four days ago β-hCG 1641 Upward trend (doubled in 4 days…) @GayatriJoshiMD Answer: Ovarian EP • Rare • ~0.5% of EPs (up to 3% in the literature) • Strongly associated with IUD use @GayatriJoshiMD Eccentrically Located EP Angular IUP or Intersal EP? Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantaon Sites of Ectopic Pregnancy: Thinking beyond the Complex Adnexal Mass. Radiographics 2015;35(3):946-59. @GayatriJoshiMD Angular IUP or Intersal EP? Paent #1 @GayatriJoshiMD Answer: Right intersal EP • Also commonly known as: – Intersal ectopic – Intramural ectopic – Cornual ectopic @GayatriJoshiMD Diagnosc pearls: • GS eccentrically located far to the right or le on trans imaging • Inadequate surrounding myometrium – Must look in mulple planes (at least trans and long) – Less than 5mm of myometrium surrounding GS in any plane Inadequate myometrium @GayatriJoshiMD Diagnosc pearls: • GS eccentrically located far to the right or le on trans imaging • Inadequate surrounding myometrium – Must look in mulple planes (at least trans and long) – Less than 5mm of myometrium surrounding GS in any plane • 3D reconstrucons can be helpful • Cine clips if unable to go to scan paent yourself • Remember: ipsilateral ovary can be normal! @GayatriJoshiMD Angular IUP or Intersal EP? Paent #2 @GayatriJoshiMD What is wrong with this set of images? No IUP! Must view the whole uterus to determine LOCATION of gestaonal sac @GayatriJoshiMD Answer: Right intersal EP Use cine clips if unable to go to scanner yourself Important to determine both live AND viable pregnancy No IUP! @GayatriJoshiMD Intersal EP Angular IUP Eccentrically located gestaonal sac Eccentrically located gestaonal sac THIN layer of myometrium (<5 mm) Normal surrounding myometrium (>5 mm) @GayatriJoshiMD Intersal pregnancies • Uncommon but not that uncommon (2–4% of all EPs) • Implantaon in intersal segment of fallopian tube • Increased distensibility of this segment à intersal EP can be up to 16-17 weeks gestaon • Rupture à life threatening hemorrhage (nearby uterine artery) • Look for eccentrically located gestaonal sac surrounded by a THIN layer of myometrium (less than 5 mm) @GayatriJoshiMD Next Case @GayatriJoshiMD Paent without prior prenatal care presents in late 2nd trimester. Fetal survey performed. @GayatriJoshiMD Fetal Survey Collage What is wrong with this set of images? Must view the whole uterus to determine LOCATION of gestaonal sac @GayatriJoshiMD 12 weeks later @GayatriJoshiMD Answer: Abdominal ectopic pregnancy @GayatriJoshiMD Abdominal EP • Rare • Implantaon occurs in the intraperitoneal cavity – Can occur anywhere on the peritoneal surface or viscera, with placental aachment to the bowel, liver, spleen, bladder, etc @GayatriJoshiMD Abdominal EP • Significant morbidity and mortality for the mother and fetus • Risk of massive hemorrhage – Incomplete or complete placental separaon – Trophoblast invasion of maternal organs • Color Doppler can help find the gestaonal sac amidst bowel by locang peri-trophoblasc flow around the sac @GayatriJoshiMD Next Case @GayatriJoshiMD @GayatriJoshiMD Answer: Caesarean secon scar ectopic pregnancy
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