common & uncommon ectopic pregnancies
TRANSCRIPT
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
@GayatriJoshiMD
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
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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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@GayatriJoshiMD
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
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Canappearsimilarpriortovisibleyolksacorfetalparts– GrayscaleUSàThick-walledadnexalcysJcstructure– ColorDoppleràPeripheralhyperemia(ringoffiresign)
CorpusLuteumCystorTubalEP? PaJent#1
IUP?Nonspecificfluid?PseudogestaJonalsac?
Corpusluteumcyst?EP?
Physiologicfluid?Hyperacuteblood?
@GayatriJoshiMD
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
@GayatriJoshiMD
DiagnosJcpearls:• GSeccentricallylocatedfartotherightorleWontransimaging• Inadequatesurroundingmyometrium
– MustlookinmulJpleplanes(atleasttransandlong)– Lessthan5mmofmyometriumsurroundingGSinanyplane
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Inadequatemyometrium
@GayatriJoshiMD
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
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PaJentwithoutpriorprenatalcarepresentsinlate2ndtrimester.Fetalsurveyperformed.
@GayatriJoshiMD
FetalSurveyCollage
Whatiswrongwiththissetofimages?Mustviewthewholeuterustodetermine
LOCATIONofgestaJonalsac
@GayatriJoshiMD
12weekslater
@GayatriJoshiMD
Answer:Abdominalectopicpregnancy
@GayatriJoshiMD
AbdominalEP• Rare• ImplantaJonoccursintheintraperitonealcavity
– Canoccuranywhereontheperitonealsurfaceorviscera,withplacentalawachmenttothebowel,liver,spleen,bladder,etc
@GayatriJoshiMD
AbdominalEP• Significantmorbidityandmortalityforthemotherandfetus• Riskofmassivehemorrhage
– IncompleteorcompleteplacentalseparaJon– Trophoblastinvasionofmaternalorgans
• ColorDopplercanhelpfindthegestaJonalsacamidstbowelbylocaJngperi-trophoblasJcflowaroundthesac
@GayatriJoshiMD
NextCase
@GayatriJoshiMD
@GayatriJoshiMD
Answer:CaesareansecJonscarectopicpregnancy
@GayatriJoshiMD
CaesareansecJonscarEP• ImplantaJonintheanteriorloweruterinesegmentwallatthesiteofaC-secJonscar
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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
@GayatriJoshiMD
DifferenJalconsideraJons:• AborJoninprogress• CervicalEP
Closefollow-upUS:Imagingappearancepersists
@GayatriJoshiMD
Answer:CervicalEP
CompanionCase
@GayatriJoshiMD
@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.
[email protected]@GayatriJoshiMD