Ch. 19- Ectopic Pregnancy

Gestation located within the intraperitoneal cavity, apart from tubal, ovarian, or intralegamentous sites

abdominal pregnancy

A number of techniques used to aid fertilization; including IVF, intracytoplasmic sperm insertion (ICSI), follicle aspiration, sperm injection, assisted follicular rupture (FASIAR)

assisted reproductive techniques (ARTs)

Glycoprotein hormone produced in pregnancy that is made by the developing embryo soon after conception and later by the placenta

beta-hCG

Gestation located within the endocervical canal

cervical pregnancy

Gestation located within a rudimentary uterine horn or one horn of a bicornuate or separated uterus or a gestation located within a rudimentary horn of a uterus with a Mullerian anomaly

cornual pregnancy

Two concentric hyperechoic rings (representing the echogenic base of the endometrium and the decidua capsular/ chorion laeve) surrounding the anechoic gestational sac in a normal intrauterine pregnancy

double decidual sac sign

Implantation of a fertilized ovum in any area outside of the endometrial cavity

ectopic pregnancy

Concomitant intrauterine pregnancy and ectopic pregnancy

heterotopic pregnancy

• 1:30,000 natural pregnancies

Life-threatening condition owing to a decrease in blood volume

hypovolemic shock

Gestation located in the intramyometrial segment of the fallopian tube

interstitial pregnancy (2-4%)

Gestation located within the myometrium of the uterus

intramural pregnancy

Form of birth control; small, plastic or copper, usually T-shaped device with a string attached to the end that is inserted into the uterus

IUD

Laboratory procedure in which sperm are placed with an unfertilized egg in a Petri dish to achieve fertilization; the embryo is the transferred into the uterus to begin a pregnancy or cryopreserved for future use

IVF

Name for level of beta-hCG at which a normal intrauterine pregnancy can be seen with sonography

discriminatory cutoff

Gestation located within the superior-lateral aspect of the endometrial cavity

eccentric pregnancy

• normally implants midline

Infection of the female reproductive tract that results from microorganisms transmitted especially during sexual intercourse or by other means such as during surgery, abortion, or parturition

PID

Pregnancy in which no signs of an intrauterine pregnancy or ectopic pregnancy are seen by sonography

pregnancy of unknown location (PUL)

When gentle pressure from the transducer moves the gestational sac

sliding sac sign

Hyperechoic ring of trophoblastic tissue that surrounds an extrauterine gestational sac

tubal ring sign

Hepatorenal recess; deep recess of the peritoneal cavity on the right side extending upward between the liver and the kidney; gravity-dependent portion of the peritoneal cavity when in the supine position

Morison’s pouch

Gesation located within the ovary

ovarian pregnancy

Ectopic pregnancy can be caused by:

• elevated beta-hCG

• hypovolemic shock

• oviduct surgical history

• irregular sperm motility

oviduct surgical history

Signs of tubal rupture may include all but:

• hypotension

• rebound tenderness

• tachycardia

• UTI

UTI

When are ectopic pregnancies usually diagnosed?

• 2-4 weeks

• 4-8 weeks

• 6-10 weeks

• 8-12 weeks

6-10 weeks

Beta-hCG levels should approximately double every ______ hours.

• 48

• 36

• 24

• 12

48

At what level of beta-hCG concentration should a normal intrauterine pregnancy be seen?

• 3,000-10,000 U/mL

• 1,500-2,500 mlU/mL

• 500-1,000 mlU/L

• 2,000-3,000 mlU/mL

1,500-2,500 mlU/mL

Interstitial pregnancy occurs in the:

• rudimentary uterine horn

• cervical interstitial

• cornua

• intramyometrial segment of the fallopian tube

intramyometrial segment of the fallopian tube

Ectopic pregnancy most often implant in the:

• fallopian tube

• ovary

• cornua

• cervix

fallopian tube

Even though it is implanted within the uterine cavity, a cornual pregnancy is classified as an ectopic pregnancy because of its propensity to rupture in the:

• early first trimester; weeks 4-9

• late first trimester; weeks 9-13

• second trimester

• third trimester

second trimester

Cervical pregnancy is rare and linked to all of the following except:

• previous curettage

• ovulation induction techniques

• endometriosis

• IUD use

ovulation induction techniques

Procedures that cause an injury to the myometrium, including curettage, hysteroscopy, myomectomy, metroplasty, and C-section can be the cause for ______________ pregnancy.

• infundibular

• interstitial

• heterotopic

• intramural

intramural

Heterotopic pregnancy means pregnancy:

• outside the uterus

• eccentric in the uterus

• simultaneously positioned intrauterine and extrauterine

• with bleeding

simultaneously positioned intrauterine and extrauterine

What beta-hCG levels are necessary to visualize an IUP using transabdominal approach?

• 2,500 mU/L

• 4,000 IU/m

• 6,500 mlU/mL

• 8,500 mlU/mL

6,500 mlU/mL

Which ectopic pregnancy location can support a pregnancy the longest before detection?

• abdominal

• ovarian

• cervical

• intramural

abdominal

A pseudosac:

• is a true gestational sac positioned low in the uterine cavity

• is a fluid collection caused by bleeding from the decidualized endometrium

• abuts the endometrial canal

• has a double decidual sac sign

is a fluid collection caused by bleeding from the decidualized endometrium

Cervical pregnancy frequently presents on US as a(n) __________ shaped uterus.

• oval

• cylindrical

• “T”

• hourglass

hourglass

A sonographic technique that can assist in determining if a gestation is an abortion in progress versus a cervical pregnancy or cesarean scar pregnancy is:

• graded compression

• the abdominal approach

• color Doppler

• low resistive index

color Doppler

• cervical pregnancy will show color Doppler around the gestational sac

A ruptured tubal pregnancy presents as a:

• complex mass-like area representing hemorrhage and free fluid

• circumscribed mass

• solid heterogeneous mass with irregular borders

• hypoechoic cyst with nodular internal foci

complex mass-like area representing hemorrhage and free fluid

An aborting gestational sac will appear ___________ with color Doppler.

• poorly perfused

• avascular

• well perfused

• as a pseudosac

avascular

If US is equivocal in the diagnosis of ectopic pregnancy, ______________ may be used for diagnosis.

• laparoscopy

• laparotomy

• culdocentesis

• curettage

laparoscopy

What imaging method is considered the “gold standard” for diagnosing and locating an abdominal ectopic pregnancy?

• TV US

• TA US

• CT

• MRI

MRI

About ____% of all pregnancies in the U.S. are ectopic.

2%

The pathway from the uterine cavity to the peritoneal cavity is through the ___________ ______.

fallopian tube

Beta-hCG levels increase and then plateau at approximately _______ weeks.

9-11

Repeated or ________ beta-hCG levels are necessary to detect an increase, decrease, or leveling of the hormone.

serial

When the beta-hCG level is below the discriminatory cutoff and an IUP is not visualized, this could indicate an early _________ IUP, a spontaneous abortion, or an ________ pregnancy.

normal; ectopic

Ectopic pregnancy symptoms usually present as vaginal ____________, pelvic _______, and palpable ____________ mass.

bleeding; pain; adnexal

______________ pain is the most frequent symptom seen with heterotopic pregnancy.

Abdominal

Ovarian _________ surrounds an ovarian pregnancy.

cortex

Symptoms of general malaise, nausea, vomiting, vaginal bleeding, and painful fetal movements are associated with _____________ ectopic pregnancy.

abdominal

Transvaginal sonography should demonstrate a fetal pole with cardiac motion at __________ weeks gestation.

5.5-6

Sonographic evaluation of ectopic pregnancy should include the ______________ recess and paracolic ___________ to evaluate for the extent of free fluid.

hepatorenal; gutters

An endometrial stripe thickness less than ___ mm suggests an abnormal or ectopic pregnancy.

8

Three criteria for interstitial pregnancy are ________ uterine cavity, gestational sac greater than ___ cm from the most lateral point of the endometrial cavity, and gestational sac surrounded by a thin _____________ layer.

empty; 1; myometrial

The sliding sac sign suggests an ___________ in progress.

abortion

The yolk sac should be visualized by ___ weeks gestation.

5

The area most likely to collect fluid in the right abdomen between the liver and kidney is called __________ _______.

Morison pouch

Color Doppler presents as a “______ ___ ______” around a viable ectopic pregnancy.

ring of fire

In the setting of an ectopic pregnancy, the uterus may appear _________.

normal

MTX, known as ______________, interferes with cell ___________ and is used to manage ectopic pregnancy in a _______________ manner.

methotrexate; division; conservative

Findings on physical examination of a pregnant female vary with the hemodynamic condition of the patient; hypotension, tachycardia, shoulder pain from diaphragmatic irritation, significant abdominal pain, rebound tenderness and guarding, hypovolemic shock, or even diminished pain may all be signs of _______ __________ and/or ___________________.

tubal rupture; hemoperitoneum

What is the leading cause of maternal death in the first trimester of pregnancy?

• oligohydramnios

• subchorionic hemorrhage

• ectopic pregnancy

• sepsis

ectopic pregnancy

Women with an ectopic pregnancy are ___ times more likely to have had one in the past.

3

Women with ectopic pregnancies will have _________ than normal beta-hCG rate levels that rise at a __________ rate.

lower; slower

Because of the proximity of the uterine arteries, ___________ ectopic pregnancies are 2.5-5 times more likely to rupture than other types of ectopic pregnancies.

interstitial

Which type of ectopic pregnancy is associated with high morbidity and adverse consequences for future fertility?

• interstitial

• ovarian

• cornual

• cervical

cervical

What is the rarest of all ectopic pregnancies?

• abdominal

• heterotopic

• cesarean scar

• eccentric

cesarean scar

TA sonography demonstrates an IUP when beta-hCG levels are above _______ mIU/mL.

4,000

What descriptive factor differentiates a corpus luteum cyst from an ovarian ectopic pregnancy?

an ectopic is more echogenic, whereas a corpus luteum is completely anechoic