Ectopic Pregnancy

Ectopic Pregnancy (EP)

AKA EUP (extrauterine pregnancy)

Pregnancy located anywhere other than the endometrial or uterine cavity

True / False:

Ectopic pregnancies are only possible w/pts experiencing amenorrhea and pain

FALSE

Ectopic pregnancies are possible regardless if a pt has amenorrhea and pain or not. Pts w/menstrual cycles experience them, too.

What’s the most common cause of pelvic pain w/a positive pregnancy test?

Ectopic pregnancy

IUDs & Ectopic Pregnancies

• IUDs prevent pregnancies in endo (fertilization + implantation)

• Altered endo lining makes it difficult for the embryo to implant in uterus

• 50 - 60% IUD pregnancies are ectopic

What’s the most common location of an EUP (extrauterine pregnancy)?

Within fallopian tube » More specifically, ampullary portion

Can severe cervical pain be a possible sign of an ectopic/cervical pregnancy?

YES

PUL means …?

… Pregnancy of Unknown Location

**Small proportion of women w/PUL have an underlying EP

One of the most common diagnostic pitfalls in a suspected ectopic pregnancy is ….

… Mistaking corpus luteal cysts for EPs

**Corpus luteal cysts are / have:

• Within or attached to ovary

• Moves w/ovary

• Normal hCG rise

• Absent GS and FHR

• Peripheral blood flow (“ring of fire”)

What’s the classic clinical triad of an EUP?

• Pain

• Vaginal bleeding

• Palpable abd / pelvic mass

How can the hCG tell if the pt has a normal IUP or an EUP?

• IUP = hCG doubles every 48hrs

• EUP = hCG slowly rises

What are the common sonographical findings of an EUP?

• Extrauterine GS w/fetus and YS

• Pseudo-gestational sac

• Adnexal ring sign w/ “ring of fire”

• Complex adnexal mass between ovary and UT

• Large amount of FF within pelvis and Morrison Pouch (complex = hemoperitoneum)

• Poorly decidualized endo (endo lining hasn’t adequately transformed like a normal IUP which is essential for embryo implantation and placental development)

What sign has a very high likelihood of representing a tubal EP?

(w/Positive Predictive Value > 95%)

“Bagel” Sign

**Other than adnexal ring sign AKA “ring of fire”

Interstitial Pregnancy

An EUP that implants within the PROX intramural portion of the fallopian tube

**This portion’s highly vascular and prone to excessive hemorrhage

**May progress normally until spontaneous rupture » Severe hemorrhage (life-threatening)

**GS in SUPLAT portion of UT

Interstitial Line Sign

ALWAYS LOOK for this to identify an Interstitial Pregnancy!!

• Thin, echogenic line extending from central uterine cavity echo to the periphery of the interstitial sac

Cornual Pregnancy

Rare form of EP where implantation occurs in the cavity of a rudimentary horn of the UT, which may or may not be communicating w/uterine cavity ; Implants within LAT UT (bicornuate or septate)

**All interstitial pregnancies are sometimes called cornual, BUT not all cornual pregnancies are truly interstitial

Rudimentary Uterus / Horn

An underdeveloped or absent uterus caused by an incomplete fusion of 2 Mullerian ducts which can lead to INFERTILITY

Cesarean Scar Pregnancy

Pregnancy in prior cesarean scar region

**Can possibly be cervical pregnancy or inevitable miscarriage

Heterotopic Pregnancy

Simultaneous intrauterine and extrauterine pregnancies (extremely uncommon) even in pts undergoing an infertility treatments

**Ovulation induction and in-vitro fertilization w/embryo transfer lead not only to a higher risk of heterotopic pregnancy, but also EPs (B/L EPs)

Gestational Trophoblastic Disease

AKA Molar Pregnancy and Hydatidiform (HONEYCOMB) Mole

Results from an abnormal combo of male + female gametes

**Excessive growth of trophoblastic cells and amounts of hCG in maternal circulation » Possible HTN and cancer

Trophoblastic Cells

Cells that surround the developing GS and are responsible for implantation and nutrient exchange ; Produce hCG during early pregnancy and help maintain the corpus luteum

What are the common forms of GTD?

• Complete molar pregnancy » MOST COMMON!!

Which molar pregnancy has a higher malignant potential?

COMPLETE MOLAR PREGNANCY

What are the most common forms of malignant GTD?

Invasive Mole and Choriocarcinoma

What are the most common sites of mets involvement?

Lungs, Liver, Vagina

Methotrexate

Suppresses ovarian function and reduces egg quality ; Stops trophoblastic growth

Clomiphene Citrate

(Brand Name: Syphine)

Drug that induces ovulation

Hyperemesis Gravidarum

Excessive vomiting

**Associated w/molar pregnancy

What are the clinical findings of molar pregnancy?

• Hyperemesis Gravidarum

• Elevated hCG >100,000 mIU/mL (complete molar)

• Heavy vaginal bleeding (w/possible passage of grape-like molar clusters)

• Enlarged uterus, HTN, and Hyperthyroidism

• Preeclampsia (proteinuria and headache), Eclampsia » HTN w/seizures

What sonographic findings / hallmark appearance is common in a complete molar pregnancy?

Hydropic Chorionic Villi and “Vesicular Snowstorm appearance”

**Secondary to placental enlargement

Theca lutein cells produce …

… Estrogen

What ovarian mass is associated w/molar pregnancy and elevated hCG?

Theca lutein cysts

What type of fetus is found in a partial molar pregnancy?

Triploid fetus

Partial molar pregnancy has dispermic fertilization meaning …

2 sperm 1 ovum = Dispermic

GTD:

Complete Hydatidiform Molar Pregnancy

• Most common form of GTD

• Characterized by hydropic chorionic villi

• Absent fetus and amnion

• Benign, potentially malignant

• Elevated hCG

GTD:

Partial / Incomplete Hydatidiform Molar Pregnancy

• Coexisting triploid fetus, parts of fetus, or amnion

• Minimal malignancy

• Normal or minimally elevated hCG

GTD:

Invasive Molar Pregnancy

(Chorioadenoma Destruens)

• This pregnancy invades myometrium and possibly through uterine wall and into peritoneum

• Result of » Malignant progression of hydatidiform moles

GTD:

Choriocarcinoma

• Most malignant form of trophoblastic ds w/possible mets

• Result of » Malignant progression of a hydatidiform molar pregnancy

• Most common mets sites » Liver, Lungs, Vagina

Viable

Can potentially result in a liveborn baby

Nonviable

Cannot possibly result in a liveborn baby

Intrauterine Pregnancy of Uncertain Viability

TVS shows an intrauterine GS w/no embryonic heartbeat (no findings of definite pregnancy failure)

Pregnancy of Unknown Location

(PUL)

A positive urine or serum pregnancy test and no intrauterine or extrauterine pregnancy by TVS

Which gestation is diagnosed when there’s no evidence of a fetal pole or YS within the GS at appropriate time of development?

Blighted Ovum or Anembryonic Gestation

Embryonic Demise

(AKA Fetal Demise)

Death of the embryo or fetus

**W/TV, cardiac activity should be detected in the pole that measures 4-5mm

Clinical Findings of Embryonic or Fetal Demise

• Vaginal bleeding

• Small for dates

• Closed cx

• Low hCG (based on LMP)

Intrauterine Hematomas are usually …

… Crescent-shaped and hypoechoic

An early bleed of a subchorionic hematoma is slightly …

… ECHOGENIC

**Red blood cells actively fill area of hemorrhage

Normal FHR at 6w

100 - 110BPM

Normal FHR by 7w

At least 120BPM

Normal FHR between 8 - 9w

Increase slightly and plateau at 150BPM

Absent cardiac activity when CRL is below 7mm is suspicious for …

… Pregnancy failure

An impending embryonic demise is associated with …

… Embryonic Bradycardia

Chromosome abnormalities, like triploidy, have been associated with …

… Embryonic growth restriction (IUGR) and oligohydramnios

Threatened Abortion

Vaginal bleeding before 20w ; Closed cervical os and LOW FHR

Complete (Spontaneous) Abortion

All products of conception are expelled from the UT

**No IU products of conception identified

**Prominent endo » May contain hemorrhage

Incomplete Abortion

Part of the products of conception expelled

**Thickened and irregular endo

**Enlarged UT

Missed Abortion

Fetal demise w/retained fetus

**No detectable FH motion detected

**Abnormal fetal shape

Inevitable Abortion

Vaginal bleeding w/dilated cx

**Low-lying GS

**Open internal os of cx