common & uncommon ectopic pregnancies

Common&UncommonEctopicPregnancies

Dr.GayatriJoshi,MDgayatri.joshi@emory.edu

June2,2019

@GayatriJoshiMD

DisclosuresNofinancialorotherdisclosuresrelatedtothisexhibit.

@GayatriJoshiMD

LearningObjecJves

ü  Recallrelevantnormalgynecologicanatomyandtheappearanceofnormal1sttrimesterintrauterinepregnancy(IUP)

ü  IdenJfyriskfactors,imagingfindings,andcomplicaJonsofectopicpregnancies,includingcommonectopicimplantaJoninthefallopiantube,aswellaslesscommonectopicsitessuchascornual,ovarian,Cesareansec2onscar,cervical,abdominal,andheterotopicpregnancies

ü  DemonstratetechniquesforimprovingdiagnosJcaccuracyduringsonographicevaluaJon

@GayatriJoshiMD

BackgroundEctopicpregnancies(EP)canposeadiagnosJcchallenge

–  DevastaJngconsequenceswhenmissedormisdiagnosed–  Canresultinsignificantmorbidityandmortality

Whendiagnosedearlyandaccurately,manycomplicaJonscanbeavoidedwithappropriatemedicalorsurgicalintervenJon.

@GayatriJoshiMD

BackgroundPhysicalexamandclinicalpresentaJon:oWennonspecificorambiguousduringpregnancy,especiallywhenectopicimplantaJonissuspected

Importanttobefamiliarwith:–  SpectrumofectopicimplantaJonsites–  KeyUSfeaturesofbothcommonanduncommonectopicpregnancies–  ComplicaJons

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Anatomy

OVARY

CERVIX

UTERUSENDOMETRIAL

CAVITY

VAGINA

@GayatriJoshiMD

Anatomy•  Intersi2alSegment:Surroundedbyuterinemyometrium

(referredtoastheintersJJal,intrauterine,myometrial,intramural,orcornualporJonofthefallopiantube)

•  IsthmicSegment:StraightporJonoftube;thickmuscularwall&narrowlumen

•  AmpullarySegment:LongestporJonoftube;thinwall(almostmuscle-free)&widelumen;usuallywhereferJlizaJontakesplace

•  Infundibulum:Funnel-likestructuremarginatedwithfimbriae

•  Fimbriae:Fringe-likestructureatendofthetube;sweepsreleasedeggsfromtheovaryintothefallopiantube

@GayatriJoshiMD

Nomenclatureof1stTrimesterPregnancyTerminology Defini2on

ViablePregnancy OnethatmaypotenJallyresultinalivebornbaby

Nonviablepregnancy Onethatcannotresultinalivebornbaby(includingectopicandfailedpregnancies)

PregnancyofunknownlocaJon(PUL) +PregnancytestwithnosignsofIUPorextra-uterinegestaJononTVUS

IUPofuncertainviability IUPwithfetalCRL<7mmwithnocardiacacJvityorsacMSD<25mmwithoutembryo

LiveIUP IUPwithyolksac,embryo/fetus,andcardiacacJvity

ProbableIUP Intrauterinesac-likestructurewithoutyolksacorembryo

Definiteectopic ExtrauterineGSwithyolksac,embryo,cardiacacJvity

Probableectopic Heterogeneousadnexalmassorextrauterinesac-likestructurewithoutvisiblefetalparts

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Normal1stTrimesterIUP:BriefDiscussion

•  ProbableIUP•  IUPofuncertainviability•  LiveIUP

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Deciduacapsularis

Deciduaparietalis

Deciduabasalis

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EctopicPregnancyWhatisit?WhenimplantaJontakesplaceinasiteotherthantheendometriumoftheuterinecavity

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EctopicPregnancyWhataretheriskfactors?•  Previousectopicpregnancy•  Previousfallopiantubesurgery•  HistoryofPID•  HistoryofIUDplacement•  InuterodiethylsJlbestrolexposure•  Congenitaluterineanomalies•  InferJlity•  Historyofsmoking•  Endometriosis•  UseofassistedreproducJvetechnology(ART)•  Historyofpelvicorabdominalsurgery

@GayatriJoshiMD

EctopicGestaJonalSites

FALLOPIANTUBE(93-97%)

OVARY

CERVIX

UTERUSENDOMETRIA

LCAVITY

VAGINA

ABDOMINAL(~1%)

OVARIAN(0.5%)

CERVICAL(<1%)

SCAR(<1%)

@GayatriJoshiMD

EctopicPregnancySites•  Fallopiantube:mostcommon(~95%)

•  75%–80%Ampullary•  10%Isthmic•  5%Fimbrial•  2%–4%IntersJJal

•  Ovarian,cervical,scar,andabdominalpregnanciesarerare•  Heterotopic(rare;usuallyintrauterine+tubal)

•  IncreasingoccurrencewithassistedreproducJvetechniques(ART)•  1:30,000pregnancieswithoutART(spontaneous)

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EctopicPregnancySitesAbsenceofanintrauterinegestaJonalsacshouldtriggeradetailedsearchforanectopicpregnancy

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Upto35%ofectopicpregnanciesmaynotdisplayanyadnexalabnormaliJes

CorpusLuteumCystvs.FallopianTubeEP

@GayatriJoshiMD

Canappearsimilarpriortovisibleyolksacorfetalparts–  GrayscaleUSàThick-walledadnexalcysJcstructure–  ColorDoppleràPeripheralhyperemia(ringoffiresign)

CorpusLuteumCystorTubalEP? PaJent#1

IUP?Nonspecificfluid?PseudogestaJonalsac?

Corpusluteumcyst?EP?

Physiologicfluid?Hyperacuteblood?

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CorpusLuteumCystorTubalEP? PaJent#1

Answer:IUPandrightcorpusluteumcyst

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CorpusLuteumCystorTubalEP? PaJent#2

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Answer:IUP&hemorrhagicleWcystwithhemoperitoneum

CorpusLuteumCystorTubalEP? PaJent#2

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Thick-walledcysJcadnexalstructures

@GayatriJoshiMD

Thick-walledcysJcstructureAnechoiccenter(novisibleYSorfetus)Locatedintheadnexalregion

DifferenJalconsideraJons:•  FallopiantubeEP•  OvarianEP•  Corpusluteumcyst

CorpusLuteumCystorTubalEPorOvarianEP?

@GayatriJoshiMD

Askyourself:Isitintheovaryorinthefallopiantube?

Usedynamicmanualexam+real-2megrayscaleUStodecide

Whatexactlydowedoandwhatdowelookfor?

CorpusLuteumCystorTubalEPorOvarianEP?

@GayatriJoshiMD

Pushonthethick-walledcysJcstructure(notsimplyananatomicscan)

Observeitsmovementwithrespecttotheipsilateralovary

CorpusLuteumCystorTubalEPorOvarianEP?

@GayatriJoshiMD

•  Ifitmoveswiththeovary,itiswithintheovary•  Mostlikelyacorpusluteumcyst•  OvarianEPisafarlesscommonenJtyàOBevaluaJonifthissJllissuspectedclinically

•  Ifitmovesdiscordantlywithrespecttotheovary,itisinnotintheovary

•  MostlikelyafallopiantubeEP

CorpusLuteumCystorTubalEP? PaJent#3

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Answer:FallopianTubeEP

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@GayatriJoshiMD

ChiefComplaint:25year-oldfemalewithpelvicpainand+HCG

HemorrhagecanobscurediscreteovaryandEPAssessmentforconcordant/discordantmo2oncanbedifficult

CompanionCase PaJent#4

@GayatriJoshiMD

AddiJonalclinicalhistoryandlabs:• HistoryPID2yearsago,treated• Currentβ-hCG3883• Fourdaysagoβ-hCG1641

DifferenJalconsideraJonsbasedoniniJalUSimagesalone:

• EP+nonspecificfluidorpseudogestaJonalsacinendometrialcanal(EMC)

• Earlyintrauterinepregnancy(IUP)witharightovarianhemorrhagiccorpusluteumcyst

Upwardtrend(doubledin4days…)

Riskfactor

•  Rare•  ~0.5%ofEPs(upto3%intheliterature)•  StronglyassociatedwithIUDuse

@GayatriJoshiMD

Answer:OvarianEP

EccentricallyLocatedEP

ChukusA,TiradaN,RestrepoR,ReddyNI.UncommonImplanta<onSitesofEctopicPregnancy:ThinkingbeyondtheComplexAdnexalMass.Radiographics2015;35(3):946-59.

@GayatriJoshiMD

AngularIUPorIntersJJalEP?

AngularIUPorIntersJJalEP? PaJent#1

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•  Alsocommonlyknownas:–  IntersJJalectopic–  Intramuralectopic–  Cornualectopic

Answer:RightintersJJalEP

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DiagnosJcpearls:•  GSeccentricallylocatedfartotherightorleWontransimaging•  Inadequatesurroundingmyometrium

– MustlookinmulJpleplanes(atleasttransandlong)–  Lessthan5mmofmyometriumsurroundingGSinanyplane

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Inadequatemyometrium

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DiagnosJcpearls:•  GSeccentricallylocatedfartotherightorleWontransimaging•  Inadequatesurroundingmyometrium

– MustlookinmulJpleplanes(atleasttransandlong)–  Lessthan5mmofmyometriumsurroundingGSinanyplane

•  3DreconstrucJonscanbehelpful•  CineclipsifunabletogotoscanpaJentyourself•  Remember:ipsilateralovarycanbenormal!

AngularIUPorIntersJJalEP? PaJent#2

@GayatriJoshiMD

MustviewthewholeuterustodetermineLOCATIONofgestaJonalsac

Whatiswrongwiththissetofimages?NoIUP!

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NoIUP!

Answer:RightintersJJalEP

@GayatriJoshiMD

Usecineclipsifunabletogotoscanneryourself

ImportanttodeterminebothliveANDviable

pregnancy

IntersJJalEPAngularIUPEccentricallylocatedgestaJonalsacTHINlayerofmyometrium(<5mm)

@GayatriJoshiMD

EccentricallylocatedgestaJonalsacNormalsurroundingmyometrium(>5mm)

IntersJJalpregnancies•  Uncommonbutnotthatuncommon(2–4%ofallEPs)•  ImplantaJoninintersJJalsegmentoffallopiantube•  IncreaseddistensibilityofthissegmentàintersJJalEPcanbeup

to16-17weeksgestaJon•  Ruptureàlifethreateninghemorrhage(nearbyuterineartery)•  LookforeccentricallylocatedgestaJonalsacsurroundedbyaTHIN

layerofmyometrium(lessthan5mm)

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NextCase

@GayatriJoshiMD

PaJentwithoutpriorprenatalcarepresentsinlate2ndtrimester.Fetalsurveyperformed.

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FetalSurveyCollage

Whatiswrongwiththissetofimages?Mustviewthewholeuterustodetermine

LOCATIONofgestaJonalsac

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12weekslater

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Answer:Abdominalectopicpregnancy

@GayatriJoshiMD

AbdominalEP•  Rare•  ImplantaJonoccursintheintraperitonealcavity

–  Canoccuranywhereontheperitonealsurfaceorviscera,withplacentalawachmenttothebowel,liver,spleen,bladder,etc

@GayatriJoshiMD

AbdominalEP•  Significantmorbidityandmortalityforthemotherandfetus•  Riskofmassivehemorrhage

–  IncompleteorcompleteplacentalseparaJon–  Trophoblastinvasionofmaternalorgans

•  ColorDopplercanhelpfindthegestaJonalsacamidstbowelbylocaJngperi-trophoblasJcflowaroundthesac

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NextCase

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Answer:CaesareansecJonscarectopicpregnancy

@GayatriJoshiMD

CaesareansecJonscarEP•  ImplantaJonintheanteriorloweruterinesegmentwallatthesiteofaC-secJonscar

@GayatriJoshiMD

CaesareansecJonscarEP•  Rare.Lessthan1%ofEPs•  IncidenceincreasingàriseinC-secJondeliveryrates•  Riskofuterinerupture&uncontrollablehemorrhage

@GayatriJoshiMD

IntramuralEP•  ImplantaJonintheuterinewall,completelysurroundedby

myometrium,andseparatefromtheendometrialcavityandfallopiantubes

•  Extremelyrare;Lessthan1%ofEPs•  Riskfactors:

–  Adenomyosis–  IVF–  DefecJvetrophoblasJcacJvity–  Prioruterinetrauma(D&Cormyomectomy) @GayatriJoshiMD

NextCase

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DifferenJalconsideraJons:• AborJoninprogress• CervicalEP

Closefollow-upUS:Imagingappearancepersists

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Answer:CervicalEP

CompanionCase

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@GayatriJoshiMD

Answer:AborJoninProgress

CervicalEP

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Clinicalpearls:•  Rare;<1%ofEps

•  Riskfactors:variantanatomy,fibroids,historyofendocervicalcanalinstrumentaJon,Ashermansyndrome,IUDuse,IVF

•  Managementgoals:preventseverehemorrhage,preservefutureferJlityinmanycases

CervicalEP

@GayatriJoshiMD

Imagingpearls:•  Maindifferen2alconsidera2onisabor2oninprogress•  BothaborJoncanpresentwithvaginalbleeding•  Closefollow-upUSinthesexngofaborJonshouldshowfurthercaudalprogressionorpassageofGS

•  Persistenceofimagingappearanceissugges2veofcervicalectopic,whichisrarecomparedtoincidenceofabor2oninprogress

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NextCase

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**

**

*

Answer:RupturedrightadnexalEP

(Heterotopicversusunilateraltwin)

@GayatriJoshiMD

HeterotopicEP•  SimultaneousEPwitheitheranIUPoranaddiJonalEP

– MostcommontypeisIUP+adnexalEP•  Rare

–  1:30,000whenspontaneous–  1-3%ofARTcases–  1%ofbabiesbornintheUSareconceivedwithART–  LookforenlargedovariesfromovarianhypersJmulaJon

@GayatriJoshiMD

UnilateralTwinTubalEP•  ConcurrentunilateralectopicimplantaJonoftwoembryosin

thefallopiantube•  Rare.0.5%ofEPs•  Riskfactors:

–  IVF–  PID

@GayatriJoshiMD

ToRe-cap:

OVARY

CERVIX

UTERUSENDOMETRIAL

CAVITY

VAGINA

ABDOMINAL(~1%)

OVARIAN(1-3%)

CERVICAL(<1%)

FALLOPIANTUBE(93-97%)

SCAR(<1%)

•  Ampullary(75%–80%)•  Isthmic(10%)•  Fimbrial(5%)•  IntersJJal(2%–4%)

•  Usuallyintrauterine+tubal•  Increasingoccurrencewithassisted

reproducJvetechnologies(ART)•  1:30,000pregnancieswithoutART

(spontaneous)

HETEROTOPIC(rare)

ConclusionandTake-HomePoints•  MostEPsaretubal•  DiagnosJcchallengewithmagnifieddevastaJng

consequencessuchaslife-threateninghemorrhagewhenmissedormisdiagnosed

•  Whenrecognizedearlyandaccurately,EPsatcommonanduncommonimplantaJonsitescanbemedicallyorsurgicallymanaged,oWenwithoutseverecomplicaJons

ConclusionandTake-HomePoints•  FamiliaritywiththespectrumofectopicimplantaJonsites

andtheirrespecJveimagingappearancesandcomplicaJonsiscriJcal!

•  Itisimportanttodeterminenotonlyalivepregnancy,butasafepregnancy.Botharerequiredforviabilityofthefetusandsafetyofthemother.

LearningObjecJves

ü  Recallrelevantnormalgynecologicanatomyandtheappearanceofnormal1sttrimesterintrauterinepregnancy(IUP)

ü  IdenJfyriskfactors,imagingfindings,andcomplicaJonsofectopicpregnancies,includingcommonandlesscommonectopicsites

ü  DemonstratetechniquesforimprovingdiagnosJcaccuracyduringsonographicevaluaJon

ü  Fallopiantubeü  Ovarianü  CesareansecJonscarü  Cornualü  Abdominalü  Cervicalü  Heterotopic

@GayatriJoshiMD

SuggestedReading1.  ChukusA,TiradaN,RestrepoR,ReddyNI.UncommonimplantaJonsitesofectopic

pregnancy:thinkingbeyondthecomplexadnexalmass.Radiographics2015;35(3):946-59.

2.  Doubiletetal.DiagnosJccriteriafornonviablepregnancyearlyinthefirsttrimester.NEnglJMed2013;369:1443-1451.

3.  LinEP,BhawS,DograVS.DiagnosJccluestoectopicpregnancy.Radiographics2008;28(6):1661-71.

4.  LevineD.Ectopicpregnancy.Radiology245(2):385-397.

5.  LubnerM,MeniasC,RuckerC,etal.Bloodinthebelly:CTfindingsofhemoperitoneum.Radiographics2007;27:109-125.

6.  WoodwardPJ,KennedyA,SohaeyR,etal.DiagnosJcImagingObstetrics,3rded.Elsevier.2016.

1.  ChukusA,TiradaN,RestrepoR,ReddyNI.UncommonImplantaJonSitesofEctopicPregnancy:ThinkingbeyondtheComplexAdnexalMass.Radiographics2015;35(3):946-59.

2.  LinEP,BhawS,DograVS.DiagnosJccluestoectopicpregnancy.Radiographics2008;28(6):1661-71.

1.  ChukusA,TiradaN,RestrepoR,ReddyNI.UncommonImplantaJonSitesofEctopicPregnancy:ThinkingbeyondtheComplexAdnexalMass.Radiographics2015;35(3):946-59.

2.  LinEP,BhawS,DograVS.DiagnosJccluestoectopicpregnancy.Radiographics2008;28(6):1661-71.

@GayatriJoshiMD

ThankYou!

1.  ChukusA,TiradaN,RestrepoR,ReddyNI.UncommonImplantaJonSitesofEctopicPregnancy:ThinkingbeyondtheComplexAdnexalMass.Radiographics2015;35(3):946-59.

2.  LinEP,BhawS,DograVS.DiagnosJccluestoectopicpregnancy.Radiographics2008;28(6):1661-71.

1.  ChukusA,TiradaN,RestrepoR,ReddyNI.UncommonImplantaJonSitesofEctopicPregnancy:ThinkingbeyondtheComplexAdnexalMass.Radiographics2015;35(3):946-59.

2.  LinEP,BhawS,DograVS.DiagnosJccluestoectopicpregnancy.Radiographics2008;28(6):1661-71.

gayatri.joshi@emory.edu@GayatriJoshiMD