ectopic pregnancy

Vaginal
ultrasonography image of a blob sign of ectopic pregnancy. Case description The otherwise healthy 31 year old woman had begun to feel symptoms of pregnancy, including breast tenderness. A urine pregnancy was positive. However, three months prior she had a Mirena intrauterine device inserted, which thus made the probability of an intrauterine pregnancy very unlikely. The vaginal ultrasonography showed the image as displayed, including a spherical mass (or "blob") close to the right ovary. The intrauterine device was in optimal location within the uterine cavity. There was no trace of a gestational sac within the uterus. Serum hCG was 1254 IU/L, at which level any intrauterine pregnancy is usually seen with the ultrasonography device. A cross-section of the Mirena is shown within the uterine cavity, leaving an ultrasound shadow distally to it. Macroscopic histopathology the fallopian tube and ectopic pregnancy, with no distinguishable fetal parts. A diagnosis of ectopic pregnancy was made. Laparoscopy was performed, and showed a fallopian tube that was swollen and bluish as by circulatory obstruction. There was 40-50 milliliters of fluid within the rectouterine pouch and around the uterus. The affected tube was removed by salpingectomy. The postoperative phase was uncomplicated.
Wikipedia • CC0
Primary
abdominal ectopic pregnancy: a case report. T2W SPAIR sagittal MRI of lower abdomen demonstrating the placental invasion. Placenta (a), invasion area (b), sigmoid colon (c), uterine cavity (d).
casesjournal.biomedcentral.com • CC-by-2.0
Imaging for
acute pelvic pain in pregnancy. A 27-year-old woman presenting at the emergency department with acute pelvic pain. Abdominal US (a) shows a rounded lesion adjacent to the uterus, clearly separate from the left ovary. Axial CT scan shows a voluminous mass in the pelvic cavity (b); for the characterisation an MRI was required. Axial (c) and coronal (d) T2-weighted and T1-weighted images (e) of the pelvis show a right heterogeneous adnexal mass (arrow) with fallopian tube haematoma. Note the normal ovary (short arrow) in (c). Pre-contrast T1-weighted fat-saturated image (f) shows bloody ascites (short arrows). These findings are due to ectopic pregnancy with tubal rupture and haemoperitoneum
insightsimaging.springeropen.com • Open Access
Imaging for
acute pelvic pain in pregnancy. A 35-year-old woman presented with amenorrhea for 7 weeks, abdominal pain and vaginal bleeding; the B-HCG level was elevated. Transvaginal 3D sonogram in sagittal scan shows the interstitial portion of the tube (arrow) located between the gestational sac (GS) and endometrium (e). CT of the pelvis (b) shows a small lesion on the left side of the uterus. Axial (c) and coronal (d) T2-weighted images and axial contrast T1-weighted image (e) of the pelvis show a left gestational-like structure measuring 10 mm in diameter, surrounded by a thick wall according to interstitial pregnancy
insightsimaging.springeropen.com • Open Access
Ultrasound
evaluation of ectopic pregnancy. A well-defined complex adnexal mass seen on the left side adjacent to the uterus on the outside, with thick hyperechoic wall and internal cystic component with fetal pole inside (arrow).
www.eurorad.org • CC by-nc-sa-4.0
Cesarean scar
ectopic pregnancy • Cesarean scar twin ectopic pregnancy - Ganzer Fall bei Radiopaedia
Biswas D, Cesarean scar twin ectopic pregnancy. Case study, Radiopaedia.org (Accessed on 04 May 2024) https://doi.org/10.53347/rID-180512 • CC by-nc-sa 3.0 (modified)
Radiopaedia • CC-by-nc-sa 3.0 • de

Ectopic pregnancy refers to the implantation of a fertilised ovum outside of the uterine cavity.

Epidemiology

The overall incidence has increased over the last few decades and is currently thought to affect 1-2% of pregnancies. The risk is as high as 18% for first trimester pregnancies with bleeding . There is an increased incidence associated with in-vitro fertilisation pregnancies.

Clinical presentation

The classic presentation is with abdominal pain and bleeding. In practice, the symptoms are not necessarily severe - often there may be only mild pelvic pain and spotting in early pregnancy (5-9 weeks of amenorrhea ). Nonetheless, monitoring of hemodynamic status is crucial, as hemorrhage can be life-threatening.

Pathology

Locations

In the vast majority of cases, the ectopic implantation site is within a Fallopian tube.

Risk factors
Markers

Serum beta HCG levels tend to increase at a slower rate. Whereas a normal doubling rate in early pregnancy is approximately 48 hours, an increase of 50% or less in 48 hours is strongly suggestive of a non-viable (either intra- or extrauterine) pregnancy . Rarely the urinary and/or serum b-HCG will be negative despite an ectopic pregnancy .

Serum progesterone levels are generally lower in a non-viable (including ectopic) pregnancy ; progesterone of 5 ng/ml or less is strongly associated with pregnancy failure, whereas in a viable pregnancy, progesterone is usually 20 ng/ml or more . Clearly, there is a significant grey zone. Furthermore, serum progesterone levels may take days to process. Progesterone is therefore not included in standard protocols for managing the suspected ectopic pregnancy.

Radiographic features

It is useful to know a quantitative beta HCG prior to scanning as this will guide what you expect to see. At levels <2000 IU, a normal early pregnancy may not be visible.

The most reliable sign of ectopic pregnancy is the visualization of an extra-uterine gestation, but this is not seen in 15-35% of ectopic pregnancies .

Ultrasound

The ultrasound exam should be performed both transabdominal and transvaginally. The transabdominal component provides a wider overview of the abdomen, whereas a transvaginal scan is important for diagnostic sensitivity.

Positive sonographic findings include:

  • uterus
    • an empty uterine cavity or no evidence of an intrauterine pregnancy
    • pseudogestational sac or decidual cyst: may be seen in 10-20% of ectopic pregnancies
      • current evidence suggests that one should not initiate treatment for ectopic pregnancy in a haemodynamically stable woman on the basis of a single hCG value
    • decidual cast
    • thick echogenic endometrium
  • tube and ovary
    • simple adnexal cyst: 10% chance of an ectopic
    • complex extra-adnexal cyst/mass: 95% chance of a tubal ectopic (if no IUP)
    • solid hyperechoic mass is possible but non-specific
    • tubal ring sign
      • 95% chance of a tubal ectopic if seen
      • described in 49% of ectopics and in 68% of unruptured ectopics
    • ring of fire sign: can be seen on color Doppler in a tubal ectopic, but can also be seen in a corpus luteum
    • an absence of color Doppler flow does not exclude an ectopic
    • live extrauterine pregnancy (i.e. extra-uterine fetal cardiac activity): 100% specific, but only seen in a minority of cases
  • peritoneal cavity
    • free pelvic fluid or hemoperitoneum in the pouch of Douglas
      • the presence of free intraperitoneal fluid in the context of a positive beta HCG and the empty uterus is
        • ~70% specific for an ectopic pregnancy
        • ~63% sensitive for ectopic pregnancy
        • not specific for ruptured ectopic (seen in 37% of intact tubal ectopics)
    • free fluid in the hepatorenal recess
      • interrogation of the right upper quadrant for free fluid reduces time to diagnosis
      • free fluid in Morison's pouch in the context of an ectopic pregnancy is highly suggestive that operative management will be necessary
    • live pregnancy: 100% specific, but only seen in a minority of cases

In patients receiving in vitro fertilisation (IVF), it is important not to be completely reassured by the presence of a live intrauterine pregnancy , as there is a possibility of a coexisting ectopic pregnancy in ~1-3:100 (i.e. heterotopic pregnancy). In patients not receiving IVF, the risk of heterotopic pregnancy is minuscule (1:30,000).

Complications

Complications somewhat depend on the type of ectopic. General complications for a typical (tubal) ectopic pregnancy include:

Treatment and prognosis

Management depends on the location of the ectopic pregnancy and the patient's hemodynamic status. In general, the options are:

  • surgical: (in the case of tubal ectopics with open or laparoscopic salpingectomy or salpingotomy)
  • medical
    • methotrexate (a folate antagonist) either administered systemically or by direct ultrasound-guided injection
    • relative contraindications to methotrexate include :
      • rupture
      • mass >3.5 cm
      • fetal cardiac activity
      • bHCG >6000-15,000 mIU/mL
    • the gestational mass can paradoxically increase in size following methotrexate on subsequent scanning and does not necessarily imply failure of methotrexate therapy
    • potassium chloride (via ultrasound-guided direct injection only)
  • conservative or expectant management is being recognized as an option for those ectopics where rupture has not occurred (i.e. no hemoperitoneum) and fetal demise has already taken place

Differential diagnosis

The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded by ultrasound. Other common diagnoses in this setting include:

The scenario of clinically suspected ectopic pregnancy that is not confirmed on ultrasound, is referred to as a pregnancy of unknown location, with the alternative possibilities being of very early pregnancy or a completed miscarriage.

Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu Extrauteringravidität:
tubal ectopic
pregnancy
www.eurorad.org • CC by-nc-sa-4.0
akuter
Beckenschmerz in der Schwangerschaft
insightsimaging.springeropen.com • Open Access
blob sign of
ectopic pregnancy
Wikipedia • CC0
gleichzeitige
intrauterine und ektope Schwangerschaft
ejrnm.springeropen.com • CC-by-4.0
Extrauteringravidität
in der Leber
ejrnm.springeropen.com • CC-by-4.0