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Ectopic Pregnancy

Ectopic Pregnancy

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Published by dr_shamimr
Ultrasound features of ectopic pregnancy
Ultrasound features of ectopic pregnancy

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Published by: dr_shamimr on Nov 22, 2010
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07/10/2013

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ECTOPIC PREGNANCY And ABORTION

DR.SHAMIM RIMA MBBS,DMU,FCGP M.PHL, THESIS PART RADIOLOGY & 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, small 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-abdiminal, broad-ligament pregnancies develop - fertilized ovum burrows through the epithelium (because, tube lacks a submocosal layer) zygote comes to lie within the muscular wall rapidly proliferating

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 .

Gestational sac in cervico- isthmic region

Transvaginal Ultrasound showing 10 week cervical ectopic gestation

ABORTION

ABORTION
Spontaneous Abortion Pregnancy loss at less than 20 weeks¶ gestation 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 fibroids a septum scar 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 diabetes Uncontrolled thyroid disease High prolactin (a hormone associated with breastfeeding) levels The 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.

MISSED ABORTION

-

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

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 ³thump´.

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