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Ectopic pregnancy
Carleen Ong Radiographer 2nd Pelvic Ultrasound workshop 06 Dec 2014, Department of Diagnostic and Interventional Imaging
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Objective
• Important information for U/S
• Sonographic techniques
• Various type of ectopic pregnancy (EP)
• Case studies
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Important information for U/s
1.UPT / B-HCG
2.LMP & cycle length
3.Abnormal vaginal bleeding
4.Spontaneous conception / ART
5.Adnexal tenderness
6.H/O Pelvic operation
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β–hCG vs EP
• Normal pregnancy, β–hCG level doubles every
48 hours; EP may show suboptimal rise in β–
hCG
• A gestational sac should be seen on
transvaginal (TV) scan if the serum B-hCG level
is above 1800mIU/mL. (Vicken,2014)
• When intrauterine pregnancy is not identified,
ectopic pregnancy becomes the diagnosis of
exclusion.
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Techniques
• Sonographic evaluation begin with TA.
• To establish the physical relationship of the uterus and the
adnexal structures.
• Assess upper abdomen for free fluid/ large hematoma.
• TA provide a broader view of the pelvis and can help to
detect any possible intra-abdominal location of the EP.
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Techniques
• Transvaginal (TV) scan is necessary.
• Systematic scanning technique:
- Cervix
- LSCS
- Endometrium
- Ovaries
- Adnexal regions to look for mass
- Free fluid
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Techniques
- Demonstrate how is
mass related to
ovary & uterus
- Vascularities of mass
- Measure the whole
mass
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Techniques Optimise techniques:
• Focal zone
• Harmonics/ spatial compounding
• Magnification (especially when looking at small gestational
sac, to look out for yolk sac or embryo)
• Free fluid- overall gain not too low (echoes that represent
blood)
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Techniques
• When no IUGS and adnexal
mass is vaguely seen, obscured by bowel?
- Use bi-manual approach: Apply gentle pressure on the
anterior abdominal wall while the other hand
manipulates the transducer.
- Separate tubal mass/ring from ovary
- Be very careful as no IUGS does not mean abnormal
pregnancy
• Cannot find the ovary / mass?
- Return to TA
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Techniques
• Doppler is useful to identify the trophoblastic circulation,' Ring of fire’
• Be mindful that Corpus Luteum also demonstrate ‘ring of fire’
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Ectopic pregnancy (EP)
• Ultrasound findings of ectopic pregnancy are
based upon 2 important observations:
1. Identification of extrauterine gestational sac with
either yolk sac or embryo
2. Identification of indirect sign such as:
No evidence of intrauterine pregnancy in the
face of a positive pregnancy test with an adnexal
mass.
Impt: adnexal mass is Not highly predicitve.
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Early IUP
• Important to distinguish early intrauterine
pregnancy (IUP) from pseudogestational
sac that associated with EP, when YS and
Fetal pole not seen
• 2 Sonographic signs of normal IUGS:
Double decidual sign (DDS)
Intradecidual sign (IDS)
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Double decidual sign (DDS)
• 2 concentric rings surrounding an anechoic gestational sac.
Decidua
parietalis Decidua
capsularis
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Intradecidual sign (IDS)
•Echogenic area embedded in
the thickened decidua that is
eccentrically located on one
side of the uterine cavity
•A midline endometrial
cavity should be identified.
•Intradecidual sign can be seen
as early as before 5weeks.
(Chiang,2004) (Dr Yeh,1999)
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Pseudogestational sac
Intrauterine fluid collection surrounded by a single decidual layer Typically located centrally Usually oval, irregular Sometime, contain blood debris that can mimic YS/embryo
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Location of ectopic pregnancy
http://resources.ama.uk.com/glowm_www/graphics/figures/v1/0690/002f.gif
C section scar
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Tubal ectopic Pregnancy
Sonographic features:
• Empty uterus
• Thick echogenic wall surrounding a central
hypoechoic structure located between ovary and
uterus
• Separated from the ovary
• Some might be surrounded by hematoma
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Tubal ectopic
YS
Left ovary
Uterus
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When tubal ring mass is located closely
to ovary
• Is it inside ovary or outside ovary?
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Is it inside ovary or outside ovary?
• Look for normal ovarian tissue (ovarian claw
sign)
• Less than 1% of EP are intra-ovarian
–Therefore, most of the complex cysts in the ovary are
likely to be Corpus Luteum
•Always identify a normal Corpus luteum first
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If you still can’t decide
• Sliding sign: -assess whether the mass slide away from ovary or
move together inseparable with ovary.
• Compare the echogenicity of ectopic pregnancy
mass with corpus luteum: – Ectopic pregnancy more echogenic than ovarian
parenchyma (Stein,2004) – Corpus luteum usually appear less echogenic then
endometrium (Stein , 2004)
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Corpus
luteum
Ectopic P.
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Interstitial Ectopic pregnancy
• Interstitial pregnancy: Implantation of the
blastocyst within the uterine part of the fallopian
tube
• Potential of growing larger and present with
clinical symptoms later than other tubal gestation
• Can result in uterine myometrium rupture
• And cause massive hemorrhage due to
proximity of uterine vessels
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Interstitial Ectopic pregnancy
Sonographic appearance:
• Empty uterus
• Gestational sac located eccentrically
• Thin/no myometrial layer surrounding the gestation
sac. (less than 5mm) Doubilet, P. (2011, April 2).
• Presence of the echogenic line (interstitial line is
considered most reliable diagnostic value for
interstitial EP) Doubilet, P. (2011, April 2).
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Thin interstitial line
Fluid, not GS
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Interstitial Ectopic pregnancy
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Is this an Interstitial Ectopic pregnancy?
Angular
pregnancy, is an
normal
intrauterine
pregnancy that
is located
eccentrically
within the
uterine cavity.
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How to differentiate Interstitial Ectopic
pregnancy from angular pregnancy?
U/s findings Diagnosis
Little or NO visible
myometrium around
superolateral aspect
Interstitial Ectopic
GS primarily surrounded by
endometrium with adjacent
thicker myometrial layer.
Angular pregnancy
(Arleo and DeFilippis, 2014)
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Interstitial Ectopic VS Angular pregnancy
Thickness:
9mm
Clinical management is very different.
Angular pregnancy: may develop normally later:
Interstitial Ectopic Pregnancy: rupture later
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Cervical ectopic
• Account for 0.1% of all EP
• Implantation of the fertilised ovum take place
within cervix.
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Cervical Ectopic pregnancy
Typical sonographic appearance:
•Empty uterus
•Barrel shaped cervix (hour-glass shaped uterus)
•Gestational sac present below the level of the internal
cervical os
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Cervical EP vs Low lying GS
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Caesarean Section scar EP
• Implantation of the fertilised ovum within C-
section scar
• Rare
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Caesarean Section scar EP
• Sonographic features:
Empty uterus
Empty cervical canal
Development of the GS in the anterior part of the
lower uterine segment
Local thinning of myometrium or absence of
myometrium between the bladder wall and
gestational sac.
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How to differentiate Cervical/C-section
scar EP from miscarriage?
Visibility of trophoblastic circulation on Doppler examination
Spontaneous abortion: Absent of cardiac activity
EP: Live cardiac activity is usually seen
• In spontaneous abortion, sac and location should change at serial imaging.
• Closed internal os in cervical implantation
• Dilated internal os in spontaneous abortion
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Abdominal EP
• Rare
• Features:
– Empty uterus
– GS seen surrounded by bowel loops and separated
from uterus
– Free mobility of gestational sac
• TA would be superior as compared to TV scan
in abdominal EP.
• Important tip: do not assume any GS seen is
definitely in UT, always show GS in uterus by
showing myometrium surrounding it.
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Heterotopic Pregnancy
• Presence of an IUP makes the likelihood of
ectopic to be extremely unlikely.
• Risk 1:30,000 in natural conception
• However, increased with assisted reproductive
techniques(ART) . 1:100
• Interview patient:
-natural conception or ART
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IUGS inside uterine cavity
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Mass at LT AD, Yolk Sac
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Ruptured EP
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Why are some ectopic pregnancies not
seen in TV scan?
• Too small or too early in the disease progress.
• Earliest visualization of IUGS in TV is 4.5wk
• 5wks is more practical
• With yolk sac is 5.5wk
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Why are some ectopic pregnancies not
seen in TV scan?
• Presence of fibroid, ovarian pathology making
visualisation of adnexa difficult in TV.
• Especially adnexal mass that located out of
pelvis
• Non visualisation of ovaries should prompt the
need to reassess using TA scan.
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Why are some ectopic pregnancies not
seen in TV scan?
Lt Ov
Lt Ov
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Why are some ectopic pregnancies not
seen in TV scan?
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Why are some ectopic pregnancies not
seen in TV scan?
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Why are some ectopic pregnancies not
seen in TV scan?
• Complex appearance of the ectopic (can
mimic bowels )make it difficult to visualise
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Why are some ectopic pregnancies not
seen in TV scan?
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Interesting cases
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20-year-old patient
C/o sudden onset of lower abdominal pain
Lt adnexal tenderness
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Empty uterus
Fluid with echoes seen surrounding RO
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Patient is UPT negative!
Diagnosis: Ruptured left
hemorrhagic cyst
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30-year-old
11wk GA
presented with abdominal and shoulder tip pain, guarding pain
To r/o hemoperitoneum
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Result
• Patient underwent operation and removed
ruptured right rudimentary horn of uterus
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Conclusion
• Sonography plays a significant role in the
diagnosis and management of ectopic
pregnancy.
• With good techniques, ectopic pregnancy can be
diagnosed much earlier before its too late.
• Pay extra attention to the adnexal region to look
out for any mass.
• Correlate with b-HCG, LMP and follow up scan
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Acknowledgment
• Adj A/Prof Ong Chiou Li
• Yang Yin
• Chan Pei Pei Carman
• And all the sonographers
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Reference • Rumack, C., Wilson, S. and Charboneau, J. (2005). Diagnostic ultrasound. St. Louis: Elsevier
Mosby. • Ajronline.org, (2014). The Intradecidual Sign: Is It Reliable for Diagnosis of Early Intrauterine
Pregnancy? : American Journal of Roentgenology: Vol. 183, No. 3 (AJR). [online] Available at: http://www.ajronline.org/doi/full/10.2214/ajr.183.3.1830725 [Accessed 10sept. 2014].
• Arleo, E. and DeFilippis, E. (2014). Cornual, interstitial, and angular pregnancies: clarifying the terms and a review of the literature. Clinical Imaging, 38(6), pp.763-770.
• Atri, M. (2003, June 5). Ectopic pregnancy versus corpus luteum cyst revisited. Retrieved 150ct, 2014, from http://www.jultrasoundmed.org/content/22/11/1181.full
• Doubilet, P. (2011, April 2). Ectopic Pregnancy. Retrieved November 30, 2014, from http://sonoworld.com/LectureDetails/LectureDetails.aspx?Id=692&Sequence=4
• Jurkovic, D. and Mavrelos, D. (2007). Catch me if you scan: ultrasound diagnosis of ectopic pregnancy. Ultrasound in Obstetrics and Gynecology, 30(1), pp.1-7.
• M. Doubilet, P. (2012, October 11). Journal of Ultrasound in Medicine. Retrieved 28August, 2014, from http://www.jultrasoundmed.org/content/32/7/1207.long
• Sciencedirect.com, (2014). Challenges in the diagnosis and management of interstitial and cornual ectopic pregnancies. [online] Available at: http://www.sciencedirect.com/science/article/pii/S1110569013000071 [Accessed 9 Nov. 2014].
• Stein, M., Ricci, Z., Novak, L., Roberts, J. and Koenigsberg, M. (2004). Sonographic Comparison of the Tubal Ring of Ectopic Pregnancy With the Corpus Luteum. Journal of Ultrasound in Medicine, [online] 23(1), pp.57-62. Available at: http://www.jultrasoundmed.org/content/23/1/57.long [Accessed 16october. 2014].
• R Rastogi, V. (2008). Interstitial ectopic pregnancy: A rare and difficult clinicosonographic diagnosis. Journal of Human Reproductive Sciences, [online] 1(2), p.81. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700669/ [Accessed 9 Nov. 2014].
• P Sepilian, V. (2014, September 2). Ectopic Pregnancy . Retrieved November 26, 2014, from http://emedicine.medscape.com/article/2041923-overview
• Yeh, H. (1999, February 1). Efficacy of the Intradecidual Sign and Fallacy of the Double Decidual Sac Sign in the Diagnosis of Early Intrauterine Pregnancy. Retrieved November 01, 2014, from http://pubs.rsna.org/doi/full/10.1148/radiology.210.2.r99fe23le3