Alison May, HMS IV
Gillian Lieberman, MD
Ectopic Pregnancy
Alison May, Harvard Medical School IV
Radiology
11.15.04
Gillian Lieberman, MD
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Alison May, HMS IV
Gillian Lieberman, MD
Definition
• Greek ektopos: out of place, from ex (out) +
topos (place)
• Ectopic pregnancy: a developing blastocyst
implants at a site other than the
endometrium of the uterus
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Alison May, HMS IV
Gillian Lieberman, MD
Where Does Implantation Occur?
Abdomen: 1/5000
Fallopian tube
(97%)
Ovary: 1/7000
http://medlib.med.utah.edu/WebPath/
Cervix: 1/9000
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Alison May, HMS IV
Gillian Lieberman, MD
Important Statistics
• Incidence: .5- 2% of all pregnancies
• 100,000 ectopic pregnancies occur each
year in U.S.
• #1 cause of pregnancy-related maternal
death in 1st trimester
• Accounts for 10% all pregnancy-related
deaths
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Alison May, HMS IV
Gillian Lieberman, MD
Risk Factors: think tubes!
• Tubal pathology (PID, endometriosis,
congenital anomalies, tumors)
• Tubal surgery (PID or prior ectopic)
• Previous ectopic pregnancy
• Infertility (higher rate of tubal abnormalities)
• DES (diethylstilbestrol) exposure (estrogen
drug given 1938-1971 for “healthy pregnancy”)
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Alison May, HMS IV
Gillian Lieberman, MD
Lesser Risk Factors
• IVF (mixed data)
• Tubal sterilization
• IUD (very low rate pregnancy, but of
that, up to 50% ectopic; Overall rate
much lower than in 1970’s)
Over 50% women presenting with an
ectopic have no risk factors!
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Alison May, HMS IV
Gillian Lieberman, MD
Symptoms and Lab Values
• “Classic triad”: red flags in first trimester!
– Pelvic pain
– Bleeding
– Palpable abdominal mass
• Lab values: b-HCG
– IUP: doubles every 48 hours
– Ectopic: less than doubles every 48 hours
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Alison May, HMS IV
Gillian Lieberman, MD
Role of Ultrasound
• Ultrasound is #1 diagnostic test in the first
trimester to rule out ectopic pregnancy
• Transvaginal: gold standard
– High frequency allows closest view of uterus/adnexa
– Avoids bowel gas
– Requires empty bladder
• Transabdominal: can be helpful
– Low frequency allows futher penetration, broader view
– Requires full bladder
• 6-20% false negative rateÆFOLLOW UP
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Alison May, HMS IV
Gillian Lieberman, MD
Transvaginal Ultrasound:
Getting Oriented
This diagram depicts the sagittal view, one of the main views in
transvaginal imaging. The way the uterus looks here is similar to how it
appears in images. The other popular view is transverse, similar to an axial
CT slice. In an transabdominal ultrasound, the bladder will be visualized
superiorly.
bladder
uterus
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http://yalenewhavenhealth.org/library/healthguide
Alison May, HMS IV
Gillian Lieberman, MD
Color and Power Doppler
•
•
•
•
•
Pulses of ultrasoundÆ
returning echoes have different
frequencies
Color is assigned to each
frequency
Color Doppler: shows flow
velocity and direction of red
blood cells
Power Doppler: shows
amplitude, or power, of signal
Useful in ectopic pregnancy to
show a “ring of fire” around an
adnexal mass (note this image
is “power doppler”)
https://www.iame.com/learning/ectopic/ectopic_content.html
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Alison May, HMS IV
Gillian Lieberman, MD
The 3 Main Questions Ultrasound
Must Answer in a Symptomatic
st
Patient in 1 Trimester
1. Can we see an intrauterine gestational sac? *
2. If so, are the gestational sac contents normal?
3. Are the adnexa normal?
* Note: with IVF, seeing an IUP no longer rules out a possible heterotopic
pregnancyÆmay be as high as 1%
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Alison May, HMS IV
Gillian Lieberman, MD
A Look at Normal Findings:
Intrauterine Gestational Sac
• Gestational sac: fluid collection in the uterus
that contains embryo or yolk sac (nourishing
fluid) OR is surrounded two echogenic rings
(“double sac” or “double decidual ring” sign)
• Yolk sac at week 5
• Fetal heartbeat at week 6
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Alison May, HMS IV
Gillian Lieberman, MD
Gestational Sac Anatomy
embryo
yolk sac
www.obgyn.net/us/gallery
http://education.yahoo.com/reference/gray/
Gestational sac
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Alison May, HMS IV
Gillian Lieberman, MD
“Double Ring” Sign: Normal IUP
outer
ring
uterus
Seminars in Roentgenology, p. 341, fig 2
inner
ring
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Alison May, HMS IV
Gillian Lieberman, MD
A Look at Normal Findings:
Adnexa
• Adnexa: organs next to uterus (ovaries and fallopian tubes)
• Ovaries: isoechogenic, well marginated regions located near
the iliac vessels, contain follicles (hypoechoic cysts)
• Fallopian tubes generally not visualized
ovary
www.radiologyinfo.org/
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Alison May, HMS IV
Gillian Lieberman, MD
Ectopic Pregnancy on Ultrasound
• Complex adnexal mass (95% chance of
ectopic)
• “Ring of fire” sign (95% chance)
• Pseudogestational sac: fluid in endometrium
that looks like an IUP but it is not! (Absent
“double ring” sign)
• Fluid in cul-de-sac
• Live embryo in adnexa
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Alison May, HMS IV
Gillian Lieberman, MD
Symptomatic Patient in 1st
Trimester
Positive b-HCG and Pain or Bleeding
Transvaginal sonogram
Intrauterine Gestational Sac Identified ?
YES
Gestational Sac Contents Normal ?
YES
Diagnose Normal IUP
NO
Suspect Abnormal IUP
Check Criteria for
Failing Pregnancy
(cardiac activity)
Seminars in Roentgenology Oct 1998, p. 341 fig. 2
NO
Extraovarian Adnexal Complex or Solid Mass ?
YES
High Likelihood of
Ectopic Pregnancy
Look for Other
Findings (Ring of
Fire, etc)
NO
Differential Dx:
-Early IUP
-Abnormal IUP
-Ectopic Pregnancy
Serial b-HCG Levels and
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Sonograms until Diagnosis
is Established
Alison May, HMS IV
Gillian Lieberman, MD
Patient Presentation: C.M.
• 35 yo woman
• h/o 3 spontaneous abortions
• Presented 2/24/03 in the ED with vaginal
bleeding
• LMP was 1/14/03
• b-HCG 472 (nonpregnant <5)
• What to do?
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Alison May, HMS IV
Gillian Lieberman, MD
C.M. Ultrasound 2/24/03
• Recall the 3 questions:
– Intrauterine gestational sac?
– If so, are contents normal?
– Are adnexa normal?
L ovary: 3 cm hypoechoic cyst with
power doppler: minimal color, c/w
heterogeneous debris
hemorrhagic corpus luteum cyst
Uterus: normal
endometrium, no IUP
R ovary: normal
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PACS
Alison May, HMS IV
Gillian Lieberman, MD
C.M. 2/24/03 Impression:
• No IUP
• Left ovarian hemorrhagic cyst
• Patient may have early IUP or
miscarriage
• Cannot rule out ectopic pregnancy
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Alison May, HMS IV
Gillian Lieberman, MD
C.M.: Time Passes…
• Given the questions posed on the ultrasound, her
b-HCG levels are followed:
2/24: 472
2/26: 778
2/28: 1520
3/03: 3147
• Overall trend: not quite doubling every 48 hours,
worrisome for ectopic pregnancy
• Needs another ultrasound
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Alison May, HMS IV
Gillian Lieberman, MD
C.M. 3/3/03: Ultrasound
bladder
sagittal
PACS
transverse
Two transabdominal views
of uterus: no IUP
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Alison May, HMS IV
Gillian Lieberman, MD
C.M. 3/3/03: Ultrasound
ovary: normal
unidentified mass between ovary and uterus!
uterus:
normal, no
IUP
PACS
Transvaginal view of right adnexa
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Alison May, HMS IV
Gillian Lieberman, MD
C.M. 3/3/03: Ultrasound
ovary
uterus
PACS
complex adnexal mass measuring
1.27 x 1.29 cm
“Ring of fire” on Power Doppler
Dx: Ectopic pregnancy!
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Alison May, HMS IV
Gillian Lieberman, MD
Treatments for Ectopic
Pregnancy
• Medical: methotrexate (inhibits dividing
cells, used in medical abortion)
– Pro: save fallopian tube. Con: 5% failure rate.
• Surgical: laparoscopy, laparotomy
– Mass is removed with/out fallopian tube
– Surgery necessary in fallopian tube rupture
• Relocation of embryo: scattered cases
published but very controversial
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Alison May, HMS IV
Gillian Lieberman, MD
Worst Case Scenario of Ectopic
Pregnancy
• Management fails, pregnancy continues,
fallopian tube rupturesÆ hemorrhage
leading to hypovolemic shockÆ death
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Alison May, HMS IV
Gillian Lieberman, MD
C.M. What Happened Next?
• Methotrexate injection
• However…her b-HCG remained elevated
3/3: 3147
3/7: 4510
3/12: 4439
3/20: 891
• Presented 3/20 with vaginal bleeding, 10/10 pelvic
pain and peritoneal signs
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Alison May, HMS IV
Gillian Lieberman, MD
C.M. To the Operating Room!
• Diagnosis: ruptured ectopic pregnancy
• Findings on laparoscopy:
-R fallopian tube had 3 x 2 cm ectopic mass,
confirmed fetal tissue on path
-800 cc blood and clot in pelvis
-Mass and fallopian tube
removed successfully
Gross image of an unruptured tubal
ectopic pregnancy
www.advancedfertility.com/ectopfot.htm
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Alison May, HMS IV
Gillian Lieberman, MD
Summary
• Recognize “classic triad” in first trimester (pelvic
pain, bleeding, mass)
• Rule out ectopic pregnancy by using ultrasound,
particularly transvaginal
• Use the three questions (IUP present and normal?
Adnexa normal?)
• Negative transvaginal ultrasound does NOT rule
out ectopic! Follow up with ultrasound and bHCG
• Return to ED if symptoms persist
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Alison May, HMS IV
Gillian Lieberman, MD
References
•
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•
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Carter, Jonathan. An Atlas of Transvaginal Sonography. J.B. Lippincott company, 1994.
Doubilet, Peter M., Benson Carol B. Emergency obstetrical ultrasonography. Seminars in
Roentgenology, Vol XXXIII, no 4 (October), 1998: pp 339-350
Laing, Faye C., Jeffrey R. Brooke. Ultrasound evaluation of ectopic pregnancy. Radiological
Clinics of North America, vol. 20, vol. 2, June 1982: pp 383-395
Tulandi, Togas. www.uptodate.com
Weissleder R, Wittenberg J, Harisinghani M. Primer of Diagnostic Imaging, 3rd ed. Mosby, Inc.
2003. pp748-9.
education.yahoo.com/reference/gray/
medlib.med.utah.edu/webPath/
yalenewhavenhealth.org/library/healthguide
www.advancedfertility.com/ectopfot.htm
www.cdc.gov/reproductivehealth/
www.emedicine.com
www.desaction.org
www.iame.com/learning/ectopic/ectopic_content.html
www.medforum.nl/gynfo
www.obgyn.net/us/gallery
www.radiologyinfo.org/
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Alison May, HMS IV
Gillian Lieberman, MD
Acknowledgments
Thanks to:
Dr. Deborah Levine
Dr. Cristina Cavazos
Dr. Gillian Lieberman
Ms. Pamela Lepkowski
Mr. Larry Barbaras
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