ECTOPIC PREGNANCY: Here, There and Everywhere

Transcription

1 ECTOPIC PREGNANCY: Here, There and Everywhere Leslie M. Scoutt, M.D. Professor of Diagnostic Radiology & Surgery Chief, Ultrasound Service Yale University School of Medicine OBJECTIVES Discuss the epidemiology of ectopic pregnancy Describe the technique for US examination Discuss the US findings of EP Describe the US appearance of EP in unusual locations ECTOPIC PREGNANCY Increasing incidence stabilized since 1992 accounts for ~1.5-2% of all pregnancies in size of pt population w/ risk factors Earlier dx w/ EVUS likely diagnoses EPs that would have resolved spontaneously w/o coming to medical attention ECTOPIC PREGNANCY: Risk Factors Prior EP 10% risk of recurrence after 1 st > 25% risk after 2 EPs PID Hx and/or Rx for infertility (esp IVF) Tubal surgery IUD Endometriosis Maternal age ( >35 yrs) Prior C-Sxn Smoking ECTOPIC PREGNANCY: Risk Factors 50% of patients w/ EP have NO risk factors ECTOPIC PREGNANCY Earlier dx w/ EVUS decreasing mortality and morbidity 0.5 deaths per 1000 pregnancies remains leading cause of 1 st trimester pregnancy related death ~ 6% of maternal deaths 80% of EPs stable at time of diagnosis 1

2 TECHNIQUE EVUS: best spatial resolution for evaluating the adnexa Optimize technique highest frequency transducer possible optimize focal zone harmonics spatial compounding magnify images: endometrial stripe/adnexa TECHNIQUE: EVUS Bimanual approach - palpate anterior abdominal wall moves gas out of way pushes area of interest towards the transducer identifies area of pt s pain may separate tubal mass/ring from ovary Examine cul-de-sac carefully Doppler interrogation adnexa, +/- endometrial stripe TECHNIQUE Transabdominal scanning is a required part of protocol assess upper abdomen for free fluid helps quantitate hemoperitoneum look for any adnexal mass that might have been missed on EVUS esp higher out of pelvis non-visualization of ovaries area of pt s pain TECHNIQUE Correlate w/ LMP, ß-HCG, Sx Follow up examination may be required ECTOPIC PREGNANCY: Clinical Dx Classical triad pain, vaginal bleeding, adnexal mass present in < 20-40% Clinical accuracy < 50% 70-90% of women clinically suspected of harboring an EP turn out to have an IUP ECTOPIC PREGNANCY: US Evaluation The primary role of EVUS in evaluating a woman with a suspected EP is to document the presence of a normal IUP Presence of an IUP makes an EP extremely unlikely risk of heterotopic pregnancies is 1:7000 except for pts undergoing ART incidence ~ 1:100 2

3 INTRAUTERINE GESTATIONAL SAC: US Diagnosis Intradecidual sign: eccentric cystic structure w/ echogenic rim adjacent to central linear echogenic complex INTRAUTERINE GESTATIONAL SAC: US Diagnosis Double decidual sac sign chorion (decidua capsularis) decidua vera IUP: US Diagnosis Should see IUP on EVUS if: ß-HCG is > miu/ml (IRP) > 5-6 wks GA QUANTITATIVE ß-HCG LEVEL Wide range with EP tends to be lower for a given gestational age increases more slowly than normal IUP tends to fall less quickly than miscarriage Serial levels may be helpful POSITIVE ß-HCG / EMPTY UTERUS IUP < 5 weeks gestational age Miscarriage Ectopic pregnancy IMPORTANCE OF CLINICAL CORRELATION Empty uterus + ß-HCG > 2000 miu/ml (IRP) normal IUP < 5 wks GA unlikely unless multiple gestations, technically limited examination correlate w/ dates No history of vaginal bleeding miscarriage unlikely Ectopic pregnancy 3

4 ECTOPIC PREGNANCY: US Findings IMPORTANCE OF CLINICAL CORRELATION Empty uterus + ß-HCG < 2000 miu/ml (IRP) early IUP < 5 wks GA check dates miscarriage look for history of vaginal bleeding ectopic pregnancy PSEUDOGESTATIONAL SAC Central fluid collection No double decidual sac sign PSEUDOGESTATIONAL SAC No evidence of trophoblastic flow No IUP pseudo sac Extrauterine GS Tubal ring Adnexal mass Free fluid PSEUDOGESTATIONAL SAC Oval, irregular, empty decidua may fragment into endometrial canal and mimic YS or embryo EXTRAUTERINE GESTATIONAL SAC Most specific finding embryo, cardiac activity, yolk sac 4

5 EXTRAUTERINE GESTATIONAL SAC Most specific finding embryo, cardiac activity, yolk sac TUBAL RING Slightly less specific finding than extrauterine GS Echogenic More specific if clearly separate from ovary TUBAL RING Echogenic +/- vascular rim Usually located between ovary and uterus contralateral to CL in 1/3 of cases Check cul-de-sac EXTRAUTERINE GESTATIONAL SAC Most specific finding embryo, cardiac activity, yolk sac TUBAL RING Echogenic +/- vascular rim TUBAL RING May be surrounded by hematoma Optimize technique color and power Doppler may conspicuity O 5

6 TUBAL RING Optimize technique to identify YS check focal zone tx frequency harmonics spatial compounding magnify image ADNEXAL MASS Hematoma complex, amorphous, variable echogenicity ADNEXAL MASS Hematoma complex, amorphous, variable echogenicity and vascularity FREE FLUID It s important may be the ONLY US finding in 15% of EPs helps assess pt stability not necessarily indicative of tubal rupture ADNEXAL MASS Hematoma tubular in configuration FREE FLUID: Pitfalls It s free if lift buttocks, will move cephalad ALWAYS scan cul-de-sac AND upper abdomen 6

7 FREE FLUID: Pitfalls It s echogenic gain settings must be correct moving tx will cause true particles to swirl FREE FLUID: Pitfalls It s echogenic clot can look a lot like bowel FREE FLUID: Pitfalls It s non-specific other causes of hemoperitoneum FREE FLUID: Pitfalls It s non-specific infection or debris may have similar appearance Ruptured Corpus Luteum TUBAL RUPTURE Main cause of maternal death Contraindication to medical / expectant management Less common with small, ampullary EP Not correlated with ß-HCG levels TUBAL RUPTURE: Are US Findings Predictive? Intact echogenic tubal ring Large hemoperitoneum NO! 7

8 ECTOPIC PREGNANCY: US Findings Meta-analysis of 10 studies Any non cystic, extraovarian adnexal mass Sensitivity 84.4% Specificity 98.9% PPV 96.3% NPV 94.8% Brown, JUM: 1994 ECTOPIC PREGNANCY: US Findings PPV Extraut. gest sac w/yolk sac/embryo 100% Mass and large amount of free fluid100% Adnexal mass 69% Pelvic fluid 75% Fluid & mass 78% Russell, JUM: 1993 ECTOPIC PREGNANCY: Role of Doppler US CFI of adnexa conspicuity of tubal ring may demonstrate a focal area of vascularity w/o obvious mass on grey scale imaging not all EP are vascular Pulse Doppler evaluation of the endometrium may help differentiate IUP from pseudo sac be cautious w/ use of Doppler in early pregnancy ECTOPIC PREGNANCY: US Diagnosis As many as 8-25% have a normal initial EVUS esp early Follow-up imaging, serial ß-HCG levels may be required PREGNANCY OF UNKNOWN LOCATION + ß-HCG No IUP or EP on EVUS No evidence of retained products of conception Hemodynamically stable No sign of hemoperitoneum on US PREGNANCY OF UNKNOWN LOCATION Common ~ 8-31% Depends on: how early one is asked to image how well one images Most are failing IUPs or EPs BUT, 1/3 = early normal IUPs Correlate with serial ß-HCG levels 8

9 TREATMENT OF PUL If stable WATCH repeat ß-HCG in 48 hours may need to follow again If ß-HCG doubles probable IUP If ß-HCG significantly drops failed IUP > EP If ß-HCG plateaus or has minimal or usu EP Rx with MTX? if need to do laparoscopy +/- D & C first due to possibility of a ß-HCG secreting germ cell tumor PITFALLS IN US DIAGNOSIS OF ECTOPIC PREGNANCY PITFALLS IN US DIAGNOSIS OF ECTOPIC PREGNANCY Early gestational age Poor visualization obesity, fibroids, retroverted uterus, myometrial contractions, bowel gas, inexperience Coexistent adnexal pathology Differentiating a corpus luteum from an EP PITFALLS IN US DIAGNOSIS OF ECTOPIC PREGNANCY Coexistent adnexal pathology Bilateral Dermoids ECTOPIC PREGNANCY: Bilateral Dermoids PITFALLS IN US DIAGNOSIS OF ECTOPIC PREGNANCY Differentiation of a corpus luteum from an EP CL is intraovarian claw sign vs acute angle wall of CL thicker, more hypoechoic ring of EP more echogenic ~ endometrium dynamic scanning 9

10 CORPUS LUTEUM Thick, vascular wall May contain hemorrhage/debris Crenulated inner margin CORPUS LUTEUM CORPUS LUTEUM Thick, vascular wall May contain hemorrhage May appear solid CORPUS LUTEUM VS ECTOPIC Arises from the ovary intraovarian exophytic claw sign Corpus Luteum Ectopic Pregnancy CORPUS LUTEUM VS ECTOPIC CORPUS LUTEUM VS ECTOPIC Dynamic scanning CFI or pulse Doppler waveform palpation/pressure on anterior abdominal wall Leslie3.avi Leslie3.avi characteristics NOT helpful in differentiating the exophytic corpus luteum from an EP both have PSV and EDV, trophoblastic flow both may demonstrate Ring of Fire 10

11 UNUSUAL LOCATIONS INTERSTITIAL PREGNANCY 2-4% of all EP Higher morbidity/mortality sac is partially surrounded by myometrium grows larger before rupturing end result = massive hemorrhage Pts present late 1st, early 2nd trimester Medical Rx less successful than in other EP locations INTERSTITIAL PREGNANCY: US Findings INTERSTITIAL PREGNANCY Eccentric location of sac surrounding myometrium absent or thinned INTERSTITIAL PREGNANCY: US Findings Myometrium between sac and endometrium INTERSTITIAL PREGNANCY: DDX Cornual pregnancy - septate, bicornuate uterus Fibroid Myometrial contraction 11

12 INTERSTITIAL PREGNANCY: DDX CERVICAL PREGNANCY 0.15% of all EP Risk factors: IVF D & C C/Sxn IUD Asherman s syndrome Fibroids Idiopathic Ectopic pregnancy adherent to uterine surface CERVICAL PREGNANCY: RX D & C may lead to life threatening hemorrhage hysterectomy systemic MTX local injxn MTX or KCl D & C with careful control of local bleeding, UAE, tamponade with balloon CERVICAL PREGNANCY CERVICAL PREGNANCY: US Findings Intracervical location of sac empty fundus closed OS trophoblastic flow CERVICAL PREGNANCY: DDX Impending, incomplete AB will change on follow-up examination less likely to demonstrate trophoblastic flow or cardiac activity 12

13 PREGNANCY IN C/SXN SCAR PREGNANCY IN C/SXN SCAR Rate increasing as rate of C/Sxn increases Risk of uterine rupture and severe hemorrhage D & C contraindicated Rx = local injection of KCl or MTX, systemic MTX or surgery ABDOMINAL ECTOPIC PREGNANCY HETEROTOPIC PREGNANCY Incidence in general population: 1/7,000 to 1/30,000 pregnancies Increased incidence in women s/p ART (esp IVF), PID, tubal surgery risk factors additive 1 /100 pregnancies Lt Kidney Risz, Am J Ob Gyn: 1991 Goldman, Ob Gyn Sur: 1992 Always examine the area of the patient s pain! HETEROTOPIC PREGNANCY HETEROTOPIC PREGNANCY 13

14 CONCLUSIONS Use both EV and TA imaging highest frequency transducer optimize focal zone harmonics spatial compounding magnified images both hands! Selective use of Doppler Look in adnexa, cul-de-sac, and area of CONCLUSIONS Be suspicious of any extra-ovarian mass in pts with clinical concern for EP especially if no IUP and ß-HCG > 2000 miu/ml Be suspicious of heterotopic EPs in pts s/p ART incidence may be as high as 1:100 patient s pain CONCLUSIONS Evaluate free fluid carefully you may be the first to realize that the pt is hemodynamically unstable CONCLUSIONS Correlate US findings w/ ß-HCG, date of LMP, history of vaginal bleeding F/U examination may be required Know your limitations! not all EVUS examinations are created equal 14