1rst Trimester Dx Ectopic pregnancy Beryl Benacerraf M.D. Harvard Medical School 1 Ectopic Pregnancy Incidence 1.5-2% of all pregnancies Location Isthmus / ampulla of tube 95% Interstitial part of tube 2-5% Ovary <1% 2 • The rate of ectopic pregnancy is ~ 1- 2% that of live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology. • The risk of death among those in the developed world is 0.1 - 0.3%while in the developing world it is 1-3%. 3 Ectopic pregnancy and Pregnancy of Unknown location • What is best estimate for gest. age? • What is the b-HCG and is there a prior one? • Is there pain? • Is there bleeding? Spotting or more? 4 Ectopic pregancy Pregnancy of Unknown location • Is there is a gestational sac? • Is the endometrium plush or thin? • Locate the corpus luteum • Is there an adnexal mass, cyst, ring etc.. • Is there free fluid (echogenic) 5 4.5 weeks sac 6
11
Embed
GoHo - Ectopic pregnancy vegas wide...Ectopic pregnancy Beryl Benacerraf M.D. Harvard Medical School 1 Ectopic Pregnancy Incidence 1.5-2% of all pregnancies Location Isthmus / ampulla
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
1rst Trimester DxEctopic pregnancy
Beryl Benacerraf M.D.Harvard Medical School
1
Ectopic Pregnancy
Incidence1.5-2% of all pregnancies
LocationIsthmus / ampulla of tube 95%Interstitial part of tube 2-5%Ovary <1%
2
• The rate of ectopic pregnancy is ~ 1-2% that of live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology.
• The risk of death among those in the developed world is 0.1 - 0.3%while in the developing world it is 1-3%.
3
Ectopic pregnancy andPregnancy of Unknown location
• What is best estimate for gest. age?
• What is the b-HCG and is there a prior one?
• Is there pain?
• Is there bleeding? Spotting or more?
4
Ectopic pregancyPregnancy of Unknown location
• Is there is a gestational sac?• Is the endometrium plush or thin?
• Locate the corpus luteum• Is there an adnexal mass, cyst, ring etc..• Is there free fluid (echogenic)
5
4.5 weeks sac
6
Fluid collection versus GS
7
Ectopic PregnancyUltrasound Findings
• No intrauterine gestation• Adnexal mass separate from ovary
ü Tubal ringü Adnexal massü Internal yolk sacü Embryo with heartbeat
• Free fluid
8
+ HCG – where is it?
9 10
Ultrasound findings seen in 94.8%among 231 patients with ectopics
Adnexal mass 94.4%Nonspecific mass 54.1%Tubal ring 24.7%Yolk sac only 8.3%Live embryo 7.4%
Free fluid with no mass 0.4%
Frates et al. J Ultrasound Med 2014
11
Mass separate from ovary and with echogenic free fluid
12
Free fluid –helpful to outline tubal mass
13 14
Hemato-salpinx
Echogenic free fluid (+clot)
15
Hemato-salpinx
16
Mass with echogenic rim separate from ovary
17 18
Doppler for Ectopic Pregnancy
• Ring of fire, identical to the corpus luteum
• Must be sure to distinguish from CL• May help to identify the ectopic
within a mass such as a hematosalpinx
19 20
• Ectopic ring brighter than CL
• Same Doppler pattern as CL
21
Doppler signal actually helpful to find actual ectopic location
22
23
Does hCG level help?
• Ectopics have variable and often
low hCG levels (unhelpful)
• hCG level does not predict the
likelihood of rupture.
24
Diagnosing an ectopic pregnancywhen there is no IUP or only fluid in uterus:
Methotrexate handed out too easily
• Often hCG is not helpful because the levels remain low, and non doubling is suggestive but not diagnostic enough.
• Discriminatory threshold is controversial. Used to be 1000-2000 IU/L.
• Probably no single number - but to be conservative, use 3000IU/L as guide.
25
If the hCG is above 2000mIU/mm?
• An embryo with FH have been reported after initial ultrasonography showed no sac with an hCG level above 2000 mIU/mm.
• A patient with an hCG above 2000 mIU/mm who is bleeding may have recently miscarried or carrying a non viable tiny pregnancy.
• F/U scan and hCG in a few days is key and repeat scan if any doubt.
26
Pregnancy of unknown location
• + hCG• No IUP on ultrasound
• No adnexal mass or free fluid
27
Why PUL does not necessary mean ectopic pregnancy• Fibroids, obesity
• Uterine orientation
• Nonvisualization of GS may be due to technical limitations not absence of a pregnancy
• Complete SAB or very early IUP
28
hCG Theshold versus Discriminatory Level
• Threshold is level at which GS is occ. seen (not always). 500-800mIU/ml
• Discriminatory is level at which the pregnancy is not in the uterus. 3000mIU/ml
• Even 3000mIU is not a guarantee!• D&C or MTX, should be avoided
in suspected but unproven ectopics
29
Safe Rule
• Regarless of hCG, D&C or MTX should be delayed in suspected but unproven ectopic.
• Unless patient is unstable, f/u ultrasound and/or hCG before intervention (even just 2-3 days)
Doubilet, Benson et al. N Engl J Med 2013; 369:1443.
30
Interstitial Ectopic Pregnancy
• Embedded in interstitial part of tube• Sac in upper outer edge of uterus• Sac outside uterine cavity• Thin or no myometrium around
outer sac
• 3D imaging essential
31 32
33 34
Is this pregnancy intrauterine?
35 36
Is this pregnancy intrauterine?
37 38
Angular Pregnancy
• Sac in upper outer edge of uterus
• Very difficult to tell if interstitial or intrauterine – need followup scans
• 3D imaging essential
• 40% of angular pregnancies fail likely due to reduced blood flow