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 secon 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

@GayatriJoshiMD Caesarean secon scar EP • Implantaon in the anterior lower uterine segment wall at the site of a C-secon scar

@GayatriJoshiMD Caesarean secon scar EP • Rare. Less than 1% of EPs • Incidence increasing à rise in C-secon delivery rates • Risk of uterine rupture & uncontrollable hemorrhage

@GayatriJoshiMD Intramural EP • Implantaon in the uterine wall, completely surrounded by myometrium, and separate from the endometrial cavity and fallopian tubes • Extremely rare; Less than 1% of EPs • Risk factors: – Adenomyosis – IVF – Defecve trophoblasc acvity – Prior uterine trauma (D&C or myomectomy) @GayatriJoshiMD Next Case

Differenal consideraons: • Aboron in progress • Cervical EP

Close follow-up US: Imaging appearance persists @GayatriJoshiMD Answer: Cervical EP

@GayatriJoshiMD Companion Case

@GayatriJoshiMD Answer: Aboron in Progress

@GayatriJoshiMD Cervical EP Clinical pearls: • Rare; <1% of Eps

• Risk factors: variant anatomy, fibroids, history of endocervical canal instrumentaon, Asherman syndrome, IUD use, IVF

• Management goals: prevent severe hemorrhage, preserve future ferlity in many cases

@GayatriJoshiMD Cervical EP

Imaging pearls: • Main differenal consideraon is aboron in progress • Both aboron can present with vaginal bleeding • Close follow-up US in the seng of aboron should show further caudal progression or passage of GS • Persistence of imaging appearance is suggesve of cervical ectopic, which is rare compared to incidence of aboron in progress

@GayatriJoshiMD Next Case

@GayatriJoshiMD * * * * *

@GayatriJoshiMD Answer: Ruptured right adnexal EP (Heterotopic versus unilateral twin)

@GayatriJoshiMD Heterotopic EP

• Simultaneous EP with either an IUP or an addional EP – Most common type is IUP + adnexal EP • Rare – 1:30,000 when spontaneous – 1-3% of ART cases – 1% of babies born in the US are conceived with ART – Look for enlarged ovaries from ovarian hypersmulaon

@GayatriJoshiMD Unilateral Twin Tubal EP

• Concurrent unilateral ectopic implantaon of two embryos in the fallopian tube • Rare. 0.5% of EPs • Risk factors: – IVF – PID

@GayatriJoshiMD To Re-cap: ABDOMINAL (~1%)

FALLOPIAN TUBE (93-97%) • Ampullary (75%–80%) • Isthmic (10%) • Fimbrial (5%) UTERUS • Intersal (2%–4%) ENDOMETRIAL CAVITY OVARY OVARIAN (1-3%) SCAR (<1%) HETEROTOPIC (rare) • Usually intrauterine + tubal CERVIX CERVICAL (<1%) • Increasing occurrence with assisted reproducve technologies (ART) • 1:30,000 pregnancies without ART VAGINA (spontaneous) Conclusion and Take-Home Points

• Most EPs are tubal • Diagnosc challenge with magnified devastang consequences such as life-threatening hemorrhage when missed or misdiagnosed

• When recognized early and accurately, EPs at common and uncommon implantaon sites can be medically or surgically managed, oen without severe complicaons Conclusion and Take-Home Points

• Familiarity with the spectrum of ectopic implantaon sites and their respecve imaging appearances and complicaons is crical!

• It is important to determine not only a live pregnancy, but a safe pregnancy. Both are required for viability of the fetus and safety of the mother. ü F allopian tube ü Ovarian Learning Objecves ü Cesarean secon scar ü Cornual ü Abdominal ü Cervical ü Heterotopic ü Recall relevant normal gynecologic anatomy and the appearance of normal 1st trimester intrauterine pregnancy (IUP)

ü Idenfy risk factors, imaging findings, and complicaons of ectopic pregnancies, including common and less common ectopic sites

ü Demonstrate techniques for improving diagnosc accuracy during sonographic evaluaon

@GayatriJoshiMD Suggested Reading

1. 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. 2. Doubilet et al. Diagnosc criteria for non viable pregnancy early in the first trimester. N Engl J Med 2013;369:1443-1451. 3. Lin EP, Bha S, Dogra VS. Diagnosc clues to ectopic pregnancy. Radiographics 2008;28(6): 1661-71. 4. Levine D. Ectopic pregnancy. Radiology 245(2):385-397. 5. Lubner M, Menias C, Rucker C, et al. Blood in the belly: CT findings of hemoperitoneum. Radiographics 2007;27:109-125. 6. Woodward PJ, Kennedy A, Sohaey R, et al. Diagnosc Imaging Obstetrics, 3rd ed. Elsevier. 2016.

@GayatriJoshiMD

1.1. Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantaon Sites of Ectopic Pregnancy: Thinking 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. beyond the Complex Adnexal Mass. Radiographics 2015;35(3):946-59. 2.2. Lin EP, Bha S, Dogra VS. Diagnosc clues to ectopic pregnancy. Radiographics 2008;28(6):1661-71. Lin EP, Bha S, Dogra VS. Diagnosc clues to ectopic pregnancy. Radiographics 2008;28(6):1661-71. Thank You!

[email protected] @GayatriJoshiMD

1.1. Chukus A, Tirada N, Restrepo R, Reddy NI. Uncommon Implantaon Sites of Ectopic Pregnancy: Thinking 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. beyond the Complex Adnexal Mass. Radiographics 2015;35(3):946-59. 2.2. Lin EP, Bha S, Dogra VS. Diagnosc clues to ectopic pregnancy. Radiographics 2008;28(6):1661-71. Lin EP, Bha S, Dogra VS. Diagnosc clues to ectopic pregnancy. Radiographics 2008;28(6):1661-71.