Ultrasound Findings of Ectopic Pregnancy - Lieberman's eRadiology

Ultrasound Findings of Ultrasound Findings of Ectopic PregnancyEctopic Pregnancy

Claudia Diaz, HMS IIIClaudia Diaz, HMS IIIRadiology Radiology -- BIDMCBIDMC

May 2008May 2008

ObjectivesObjectives

Index caseIndex caseDDX of abdominal painDDX of abdominal painClinical presentationClinical presentation

Diagnostic TestsDiagnostic TestsTransvaginal Transvaginal UltrasonographyUltrasonographyFemale Reproductive AnatomyFemale Reproductive AnatomyImaging of index case Imaging of index case Transvaginal Transvaginal sonographicsonographic findingsfindingsAdditional patient casesAdditional patient casesEctopic pregnancy locationsEctopic pregnancy locationsEctopic pregnancy facts & managementEctopic pregnancy facts & managementTakeTake--home pointshome points

Image: http://www.aafp.org/afp/20051101/1707.pdfImage: http://www.aafp.org/afp/20051101/1707.pdf

Patient Index CasePatient Index Case

HPI: HPI: 3232--yearyear--old G1P1 with LMP 8 wks ago, presenting with old G1P1 with LMP 8 wks ago, presenting with 3 weeks of ongoing LLQ pain. Reports mild vaginal bleeding for t3 weeks of ongoing LLQ pain. Reports mild vaginal bleeding for the he last 10 days. Negative pregnancy test and normal ultrasound last 10 days. Negative pregnancy test and normal ultrasound 3 weeks ago. 3 weeks ago.

EXAM: EXAM: VITALSVITALS: : T 98.4 HR 100 RR 20 BP 123/67T 98.4 HR 100 RR 20 BP 123/67ABDOMEN: ABDOMEN: Tender to palpation in LLQ with radiation to RLQ.Tender to palpation in LLQ with radiation to RLQ.PELVIC: PELVIC: No active bleeding. Mild cervical motion tenderness, left No active bleeding. Mild cervical motion tenderness, left adnexal tenderness. adnexal tenderness.

LABS: LABS: HCG: HCG: 36103610

Differential diagnosis Differential diagnosis

DDX for abdominal pain in women of reproductive age includes:

Pregnancy-related: Ectopic pregnancy, spontaneous abortion.

Gynecologic: Endometritis, pelvic inflammatory disease, tubo-ovarian abscess, endometriosis, ovarian neoplasm, ovarian torsion/rupture/hemorrhage, uterine fibroids.

Non-gynecologic: Appendicitis, bowel obstruction, diverticulitis, IBD, UTI, pyelonephritis, nephrolithiasis.

Clinical Correlates Clinical Correlates

These clinical findings are nonThese clinical findings are non--specific and also occur in specific and also occur in patients who spontaneously abort. patients who spontaneously abort.

Clinical Triad

Abdominal Pain

Vaginal Bleeding Amenorrhea

Physical exam findingsPhysical exam findings

Enlarged uterus.Enlarged uterus.Vaginal bleeding.Vaginal bleeding.Pelvic pain with manipulation of cervix. Pelvic pain with manipulation of cervix. Palpable adnexal mass. Palpable adnexal mass.

Red flags Red flags for ruptured ectopic pregnancy: for ruptured ectopic pregnancy: Significant abdominal tenderness, hypotension, Significant abdominal tenderness, hypotension, guarding and rebound tenderness.guarding and rebound tenderness.

Urine pregnancy test.Urine pregnancy test.BB--hCG measurement.hCG measurement.Less commonly used: diagnostic curettage Less commonly used: diagnostic curettage & serum progesterone levels. & serum progesterone levels.

Radiologic test of choice: Radiologic test of choice: Transvaginal ultrasound.Transvaginal ultrasound.

Diagnostic TestsDiagnostic Tests

Human Chorionic Gonadotropin Human Chorionic Gonadotropin (B(B--hCG) LevelshCG) Levels

Normal intrauterine pregnancy: BNormal intrauterine pregnancy: B--hCG levels hCG levels should rise by at least 66% over 48hrs.should rise by at least 66% over 48hrs.

Levels of hCG that plateau in first 8wks of Levels of hCG that plateau in first 8wks of pregnancy indicate abnormal pregnancy (SAB or pregnancy indicate abnormal pregnancy (SAB or ectopic).ectopic).

Transvaginal ultrasonography should detect an Transvaginal ultrasonography should detect an intrauterine pregnancy when Bintrauterine pregnancy when B--hCG level is hCG level is >>1500mIU/mL (~15001500mIU/mL (~1500--2000mIU/mL). 2000mIU/mL).

Risk of ectopic pregnancy high if hCG above Risk of ectopic pregnancy high if hCG above discriminatory factor without an intrauterine discriminatory factor without an intrauterine gestational sac. gestational sac.

Transvaginal ultrasonography: Transvaginal ultrasonography: the modality of choicethe modality of choice

How does it work? How does it work? High-frequency sound waves directed into the

body and manner in which sound is reflected back to transducer is recorded.

Advantages: no ionizing radiation, inexpensive, minimal invasive.Disadvantages: operator dependent, moderateresolution.

Transabdominal US is no longer considered to be Transabdominal US is no longer considered to be sufficient for proper diagnosis.sufficient for proper diagnosis.Transvaginal US is the imaging of choice for evaluation Transvaginal US is the imaging of choice for evaluation of ectopic pregnancy:of ectopic pregnancy:

Intrauterine pregnancies are reliably diagnosed earlier. Sensitivity: 67 to 100.Specificity: 100 (virtual certainty).

Image: http://www.stjohnsmercy.org/ healthinfo/test/gyn/TP124.asImage: http://www.stjohnsmercy.org/ healthinfo/test/gyn/TP124.asp#p#

Diagnosing suspected ectopic Diagnosing suspected ectopic following TVSfollowing TVS

Image: http://www.aafp.org/afp/20051101/1707.htmlImage: http://www.aafp.org/afp/20051101/1707.html

Female Reproductive AnatomyFemale Reproductive Anatomy

http://infertility.health-info.org/reproductive-anatomy-physiology/reproductive-anatomy-physiology-home.html

Index CaseIndex Case

UU -- Uterus measuring approximately Uterus measuring approximately 7.2 x 4.8 x 4.9 cm. 7.2 x 4.8 x 4.9 cm.

RORO -- Right ovary.Right ovary.

UU

PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.

RORO

RIGHT ADNEXA: 1.4-cm ring-shaped structure containing a yolk sac and living embryo.



Embryonic crownEmbryonic crown--rump length rump length (CRL) consistent with a 6w3d (CRL) consistent with a 6w3d pregnancy. Embryonic cardiac pregnancy. Embryonic cardiac activity measuring 120 beats activity measuring 120 beats per minute is documented.per minute is documented.


CRLCRL


Patient underwent operative laparoscopy with right salpingectomy.

““Double Sac” SignDouble Sac” SignEarliest Earliest sonographicsonographic sign of IUP is “double sign of IUP is “double sac” sign:sac” sign:True gestational sac True gestational sac –– double double echogenicechogenic rings rings surrounding surrounding hypoechoichypoechoic fluid (sac).fluid (sac).-- inner ring: inner ring: deciduadecidua capsulariscapsularis..-- outer ring: outer ring: deciduadecidua parietalisparietalis. . Visible at 4Visible at 4--5wks of gestation. 5wks of gestation.

Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography. Seminars in Roentgenelogy, Vol XXXIII, No 4(Oct), 1998: pp 339-343.

Likelihood of Ectopic pregnancy based Likelihood of Ectopic pregnancy based on transvaginal sonographic findingson transvaginal sonographic findings

Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical UltrDoubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography. Seminars in Roentgenelogy, asonography. Seminars in Roentgenelogy, Vol XXXIII, No 4(Oct), 1998: pp 339Vol XXXIII, No 4(Oct), 1998: pp 339--343343. .

Ultrasound FindingUltrasound Finding Likelihood of ectopic pregnancy (+BLikelihood of ectopic pregnancy (+B--hCG, hCG, vaginal pain or bleeding, no IUP)vaginal pain or bleeding, no IUP)

Extrauterine embryo with cardiac activityExtrauterine embryo with cardiac activity 100%100%

Adnexal fluid w/ yolk sac or apparent embryo w/out Adnexal fluid w/ yolk sac or apparent embryo w/out heartbeatheartbeat

100%100%

Tubal ringTubal ring 95%95%

Complex or solid adnexal mass w/out tubal ring, Complex or solid adnexal mass w/out tubal ring, yolk sac, or embryo (excluding masses w/in ovary)yolk sac, or embryo (excluding masses w/in ovary)

92%92%

No significant adnexal abnormalityNo significant adnexal abnormality 5%5%

OTHER COMMON RADIOLOGIC FINDINGS:OTHER COMMON RADIOLOGIC FINDINGS:Free fluid in pelvis and/or abdomen.Free fluid in pelvis and/or abdomen.““Ring of fireRing of fire”” –– mass in adnexa surrounded by hypervascular flow mass in adnexa surrounded by hypervascular flow on doppler.on doppler.Pseudogestational sac in uterus. Pseudogestational sac in uterus.

Patient Case #2Patient Case #2HPI: HPI: 3131--yearyear--old G1P0 at 7 weeks GA by LMP with ultrasound old G1P0 at 7 weeks GA by LMP with ultrasound findings suspicious for ectopic pregnancy. Treated with findings suspicious for ectopic pregnancy. Treated with methotrexate, admitted for severe RLQ pain, and subsequent methotrexate, admitted for severe RLQ pain, and subsequent ruptured ectopic pregnancy. Patient underwent operative ruptured ectopic pregnancy. Patient underwent operative laparoscopy and right salpingectomy. laparoscopy and right salpingectomy. LABS:LABS:

HCG: HCG: 3523 (day 1) 3523 (day 1) 1964 (day 3) 1964 (day 3) 1400 (day 4)1400 (day 4)

Patient Case #2Patient Case #2

Transvaginal Ultrasound I: day 1Transvaginal Ultrasound I: day 1No evidence of intrauterine No evidence of intrauterine gestational sac.gestational sac.Adjacent to right ovary, complex Adjacent to right ovary, complex echogenic area thought to be empty echogenic area thought to be empty sac sac (E).(E).

EE


Transvaginal Ultrasound II: day 3Transvaginal Ultrasound II: day 3Slight interval increase in size of right Slight interval increase in size of right ectopic pregnancy ectopic pregnancy (E). (E).

EE

Patient Case #2Patient Case #2Transvaginal Ultrasound III: day 4 Transvaginal Ultrasound III: day 4 ----> RUPTURED ECTOPIC> RUPTURED ECTOPIC

Adjacent to right ovary, heterogeneously echoic structure (ectopAdjacent to right ovary, heterogeneously echoic structure (ectopic pregnancy ic pregnancy -- RERE) increased in size. ) increased in size. Large amount of new free fluid. Large amount of new free fluid.

RERE


FF FF –– free fluid in pelvis.free fluid in pelvis.


FFFF


Patient Case #3Patient Case #3HPI: HPI: 3232--yearyear--old G8P2 at unknown GA with lower abdominal pain old G8P2 at unknown GA with lower abdominal pain and vaginal bleeding, and amenorrhea x1 year. Positive pregnancyand vaginal bleeding, and amenorrhea x1 year. Positive pregnancytest previously but no IUP on recent ultrasound. test previously but no IUP on recent ultrasound. EXAM: EXAM:

VITALSVITALS: : T 97.6 HR 76 RR 18 BP 104/68T 97.6 HR 76 RR 18 BP 104/68ABDOMEN: ABDOMEN: Diffusely tender to palpation suprapubically, no R/G.Diffusely tender to palpation suprapubically, no R/G.PELVIC: PELVIC: Blood at cervical os. Mild cervical motion tenderness, left Blood at cervical os. Mild cervical motion tenderness, left adnexal tenderness. adnexal tenderness.

LABS: LABS: HCG: HCG: 2413 2413 1794 (drop in last 3 days).1794 (drop in last 3 days).

Patient Case #3Patient Case #3Transabdominal & Transvaginal Ultrasound:Transabdominal & Transvaginal Ultrasound:

Large adnexal mass and moderate amount of complex free fluid witLarge adnexal mass and moderate amount of complex free fluid within the pelvis.hin the pelvis.No evidence of IUP, possible pseudosac. No evidence of IUP, possible pseudosac.

BB

FFFF

B – bladderU - uterusCF – cul-de-sac free fluid

UU UU



A:A: Complex, heterogeneous left adnexal mass with internal echoes oComplex, heterogeneous left adnexal mass with internal echoes on left adnexa. n left adnexa.

B:B: Small oval structure with anechoic center within the uterine fuSmall oval structure with anechoic center within the uterine fundus without characteristic intrauterine ndus without characteristic intrauterine gestational sac (no true dedidual reaction) gestational sac (no true dedidual reaction) Pseudosac. Pseudosac.

AABB


Patient underwent left salpingectomy via laparotomy.

Patient Case #4Patient Case #4HPI: HPI: 2222--yearyear--old G1P0 at 8w1d by LMP presenting with 4old G1P0 at 8w1d by LMP presenting with 4--weeks of ongoing weeks of ongoing light vaginal bleeding and severe lower abdominal pain. light vaginal bleeding and severe lower abdominal pain.

EXAM: EXAM: VITALSVITALS: : T 98.4 HR 101 RR 18 BP 142/79T 98.4 HR 101 RR 18 BP 142/79ABDOMEN: ABDOMEN: Rigid, tender to palpation in lower quadrants b/l, +involuntary Rigid, tender to palpation in lower quadrants b/l, +involuntary guarding, + rebound.guarding, + rebound.PELVIC: PELVIC: Deferred. Deferred.

LABS:LABS:HCG: HCG: 488488

Transabdominal Ultrasound:Transabdominal Ultrasound:No IUP visible.No IUP visible.Large heterogeneous mass without definite color flow posterior tLarge heterogeneous mass without definite color flow posterior to uterus o uterus (11.6 x 7.4 x 11 cm).(11.6 x 7.4 x 11 cm).Moderate free fluid in abdomen/pelvis, extending into Morrison’sModerate free fluid in abdomen/pelvis, extending into Morrison’s pouch and pouch and spleen, low level echoes concerning for blood. spleen, low level echoes concerning for blood.

Patient Case #4Patient Case #4U: uterus.U: uterus.M: heterogenous mass.M: heterogenous mass.RK: Kidney.RK: Kidney.L: Liver.L: Liver.Arrow: Morrison’s pouch, hepatoArrow: Morrison’s pouch, hepato--renal space.renal space.

Patient underwent Patient underwent laparotomylaparotomy and right and right salpingectomy. salpingectomy.

RKRK

LL

MM

UU


Ectopic pregnancy locationsEctopic pregnancy locations

Ectopic pregnancy results if the blastocyst implants anywhere outside of the uterine cavity. The vast majority of ectopic pregnancies occur in:

- Ampulla Ectopic Pregnancy --- 75% - 90%- Isthmic Ectopic Pregnancy --- 5% - 15%

Heterotopic pregnancy (one embryo in the uterus and one ectopic embryo): 1/7000 (incidence in heterotopic pregnancies has increased due to assisted reproductive technologies – 1%).

http://www.ectopicpregnancyfoundation.org/ectopicpregnancyplacementdiagram.htm

Predisposing factorsPredisposing factors**Any factor that interferes with the normal fallopian tube func**Any factor that interferes with the normal fallopian tube function**tion**

Previous tubal surgery.Previous tubal surgery.Previous ectopic pregnancy. Previous ectopic pregnancy. InIn--utero diethylstilbestrol exposure.utero diethylstilbestrol exposure.Previous gynecologic infections (PID). Previous gynecologic infections (PID). Treatment of infertility.Treatment of infertility.Current cigarette smoking. Current cigarette smoking. Previous intrauterine device use. Previous intrauterine device use.

Ectopic pregnancy factsEctopic pregnancy facts

Ectopic pregnancies make up 1.9% of all Ectopic pregnancies make up 1.9% of all reported pregnancies (0.5% of all pregnancies in reported pregnancies (0.5% of all pregnancies in 1970 to 2% in 1992).1970 to 2% in 1992).Incidence increasing due to increase in pelvic Incidence increasing due to increase in pelvic inflammatory disease and ART. inflammatory disease and ART. 1010--15% of all maternal deaths are due to 15% of all maternal deaths are due to ectopic pregnancies. ectopic pregnancies. Infertility occurs in 10Infertility occurs in 10--15% of women who have 15% of women who have had an ectopic pregnancy. had an ectopic pregnancy.

Management Management of Ectopicof EctopicPregnancyPregnancy

EXPECTANT EXPECTANT MANAGEMENTMANAGEMENT

1. Low & declining hCG levels.

MEDICAL (MTX)MEDICAL (MTX)1. Small tubal

diameter (<3.5cm).

2. No fetal cardiac activity.

3. hCG concentration <5000mIU/mL.

Serial hCG measurements!

SURGICALSURGICAL1. Ruptured ectopic/

hemodynamically unstable.

2. Contraindicationsto medical therapy.

3. Lack of timely access to medical institution.

4. Failed medical therapy.

TakeTake--home pointshome pointsEctopic pregnancy should always be considered in women of Ectopic pregnancy should always be considered in women of reproductive age presenting with abdominal pain.reproductive age presenting with abdominal pain.

The classic triad of ectopic pregnancy includes abdominal pain, The classic triad of ectopic pregnancy includes abdominal pain, vaginal bleeding, and amenorrhea. vaginal bleeding, and amenorrhea.

Transvaginal ultrasound is the modality of choice when diagnosinTransvaginal ultrasound is the modality of choice when diagnosing g an ectopic pregnancy. an ectopic pregnancy.

With hCG level>1500mIU/mL and no IUP identified on transvaginal With hCG level>1500mIU/mL and no IUP identified on transvaginal ultrasound, this is highultrasound, this is high--risk for ectopic pregnancy. risk for ectopic pregnancy.

Transvaginal ultrasound is diagnostic if a true gestational sac,Transvaginal ultrasound is diagnostic if a true gestational sac, yolk yolk sac, embryo, or cardiac activity is found inside or outside of tsac, embryo, or cardiac activity is found inside or outside of the he uterus. uterus.

Ectopic pregnancy is the leading cause of pregnancy related deatEctopic pregnancy is the leading cause of pregnancy related death h in 1in 1stst trimester of pregnancy. trimester of pregnancy.

ReferencesReferencesBhatt, Shweta; Hamad Ghazale, Vikram S. Dogra. Sonographic evaluation of ectopic pregnancy.

Radiologic clinics of North America. 45 (2007) 549-560.

Derchi, Lorenzo E. et al. Ultrasound in gynecology. Eur Radiol. (2001) 11:2137-2155.

Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography. Seminars in Roentgenelogy, Vol XXXIII, No 4(Oct), 1998: pp 339-343.

Lozeau, M.D., M.S., Anne-Marie & Beth Potter, M.D. Diagnosis and Management of Ectopic pregnancy. American Family Physician. Volume 72, No 9; Nov. 2005.

Nelson AL, DeUgarte CM, Gambone JC. Ectopic pregnancy. In: Hacker NF, Moore JG, Gambone JC. Essentials of obstetrics and gynecology, 4th ed. Philadelphia: Saunders, 2004: 325-333.

Novelline, Robert A. Ultrasound imaging & Ectopic pregnancy. Squire’s Fundamentals of Radiology. Sixth edition. Pgs. 34-35 & 430-431.

Toy, MD, Eugene C., Benton Baker, MD, MSC, Patti Jayne Ross, MD, Larry C. Gilstrap, MD. Case Files: Obstetrics & Gynecology. Pgs. 63-69, 211-218, 329-333.

Yudin, MD, Mark H. MSc, FRCSC, & Harold C. Wiesenfeld, MDCM. Current Diagnosis & Treatment of Sexually Transmitted Diseases. Chapter 5: Lower Abdominal Pain in Women.

Images ReferencesImages References

1. http://www.aafp.org/afp/20051101/1707.pdf

2. http://www.stjohnsmercy.org/ healthinfo/test/gyn/TP124.asp#

3. http://www.aafp.org/afp/20051101/1707.html

4. http://infertility.health-info.org/reproductive-anatomy-physiology/reproductive-anatomy-physiology-home.html

5. http://radiology.rsnajnls.org/cgi/content/full/210/2/579/F2

6. http://www.ectopicpregnancyfoundation.org/ectopicpregnancyplacementdiagram.htm

7. Cases: PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.

AcknowledgementsAcknowledgements

Dr. James KangDr. James KangDr. Jay Dr. Jay PahadePahadeDr. Dr. RolaRola ShaheenShaheen

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Ultrasound Findings of Ectopic Pregnancy - Lieberman's eRadiology