Ectopic Pregnancy
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Transcript of Ectopic Pregnancy
ECTOPIC PREGNANCY And
ABORTION
DR.SHAMIM RIMAMBBS,DMU,FCGP
M.PHL, THESIS PARTRADIOLOGY & IMAGIMG
ECTOPIC PREGNANCY
Any pregnancy that occurs outside of the uterine cavity
Tubal
Ampulla (55%)
Isthmus (25%)
Fimbria (17%)
Cervical
Ovarian
Abdominal
GENERAL CONSIDERATIONS
Risk factors
- prev. tubal surgery
- prev. ectopic pregnancy
- PID, endometriosis
- prev. c/sec
- assisted reproduction: GIFT, IVF
- failed contraception
SIGN/ SYMPTOM
Most common presentation:
Woman of reproductive age
Abdominal pain
Vaginal bleeding
Approx 7 weeks after amenorrhea
DIAGNOSITC TESTS
Ultrasound (*test of choice)
No intrauterine gestational sac
bHCG
Do not increase appropriately
Urine pregnancy test
Pregnant / not pregnant
Progesterone level (less reliable)
SONOGRAPHY SUSPECT ECTOPIC PREGNANCY
Specific features:
> Live embryo in the adnexa Non-specific features:
> Empty uterus
> Pseudo-gestational sac of ectopic pg
> Adnexal mass
> Ectopic tubal ring Non-supportive features:
> live intra-uterine pregnancy
> Intra-decidual & double decidual sign of
early intra-uterine pg
> Peritropoblastic blood flow
LIVE EMBRYO
TV image: Right adnexal mass / ring gestational sac with yolk sac,
alive embryo at 7.4 weeksTV image: Embryonic cardiac activity
depicted in M-mode.
TV image: Embryonic cardiac activity depicted in M-mode
EMPTY UTERUS
Empty Uterus with Ectopic Pregnancy
PSEUDO-GESTATIONAL SAC OF ECTOPIC PG
The endometrial sac does not have a surrounding chorionic ring and free fluid is visible in the posterior cul-de-sac.
ADNEXAL MASS
TA image: uterus containing clot and decidual reaction, sm
all amount of fluid cul-de-sac
TA image: Vague right adnexal mass
TUBAL PREGNANCY
TUBAL PREGNANCY
OVARIAN PREGNANCY
ABDOMINAL PREGNANCY
Sagittal transvaginal image shows the fetal head (h) in the cul-de-sac, posterior to the uterus (U)
CESAREAN SCAR ECTOPIC PREGNANCY
ECTOPIC TUBAL RING
Gestational sac surrounded by a thick chorionic ring outside and immediately adjacent to the myometrium
INTERSTITIAL PREGNANCY
Gestational sac with a marked eccentric location in the uterus
CORNUAL PREGNANCY
PATHOGENESIS OF ECTOPIC PREGNANCIES
Tubal pregnancy
- ampullary > isthmic > interstitial
- secondary, tubo-ovarian, tubo-abdimin
al,
broad-ligament pregnancies develop
- fertilized ovum burrows through the epi
thelium
(because, tube lacks a submocosal
layer)
zygote comes to lie within the musc
ular wall
rapidly proliferating trophoblast inva
des the
subjacent muscuralis
maternal blood vessels are opened
TUBAL RUPTURE
- the invading, expanding products of conception
may rupture the oviduct at any sites
- occur in the first few weeks in first trimester
(but, interstitial pregnancy usually occur later)
- usually, spontaneously rupture
(sometimes coitus or bimanual examination)
- rarely, undamaged conceptus into the peritoneal
cavity lithopedion
RUPTURE ECTOPIC
Pelvis- free fluid
MORISON'S POUCH - FREE FLUID
Enlarged uterus with grossly thickened endometrium (decidual cast) of almost 15 mm. The uterus shows absence of any gestation sac. No pseudosac is seen
Transvaginal scan of the pelvis shows a large collection of hemorrhagic fluid in the cul de sac 3) A right adnexal mass, presumably in the Right Fallopian tube is also seen. A left ovarian hemorrhagic cyst is also present.
HETEROTOPIC GESTATION
Also called Heterotopic pregnancy or
simultaneous intrauterine and
extrauterine pregnancy or coexistent
intrauterine and extrauterine
pregnancy
CERVICAL ECTOPIC
•Implantation of the fertilized ovum with
subsequent development within the
cervical structure without involvement
of the corpus uteri (below the level of
internal os)
. In a typical case, the endocervix is
invaded by the trophoblast, and the
pregnancy proceeds to develop in the
fibrous cervical wall. The duration of
pregnancy is dependent upon the site
of embryo implantation. The higher it is
implanted in the cervical canal, the
greater is its capacity to grow and
cause haemorrhage .
•Implantation of the fertilized ovum with
subsequent development within the
cervical structure without involvement
of the corpus uteri (below the level of
internal os)
. In a typical case, the endocervix is
invaded by the trophoblast, and the
pregnancy proceeds to develop in the
fibrous cervical wall. The duration of
pregnancy is dependent upon the site
of embryo implantation. The higher it is
implanted in the cervical canal, the
greater is its capacity to grow and
cause haemorrhage .
Gestational sac in cervico- isthmic region
Transvaginal Ultrasound showing 10 week cervical ectopic gestation
ABORTION
ABORTION
Pregnancy loss at less than 20 weeks’ gestation
Spontaneous Abortion
Threatened abortion
A pregnancy complicated by bleeding before 20 weeks’ gestation
Inevitable abortion
The cervix has dilated, but the products of conception have not been expelled
Complete abortion
All products of conception have been passed without need for surgical or medical intervention
ABORTION
Incomplete abortion
Some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta, or membranes
Missed abortion
A pregnancy in which there is a fetal demise (usually for a number of weeks) but no uterine activity to expel the products of conception
Septic abortion
A spontaneous abortion that is complicated by intrauterine infection
Recurrent spontaneous abortion
Three (3) or more consecutive pregnancy losses
CAUSES
First Trimester Miscarriages
Chromosomal abnormalities
Second Trimester Miscarriages
Structural Problems Cavity defects:
uterine fibroidsa septumscar tissue possibly a large polyp
Cervical insufficiency (also termed cervical incompetence)
Thrombosis
Infection Genetic or Chromosomal Problems in the Fetus
RISK FACTORS
Increasing maternal age
9% for a 20-24 year-old 15% for a 30-34 year-old
51% for a 40-44 year-old
Advancing age of th[e father
Smoking, alcohol, cocaine and heavy coffee consumption Certain drugs, such as those used for chemotherapy
Certain medical conditions are risk factors as well. These include:
Poorly-controlled diabetesUncontrolled thyroid diseaseHigh prolactin (a hormone associated with breastfeeding) levelsThe polycystic ovarian syndrome.Obesity or severely low weight.
COMPLETE MISCARRIAGE
The absence of the gestational sac and the presence of intrauterine debris
INCOMPLETE ABORTION
Empty gestational sac.
MISSED ABORTION
In a missed abortion, falling levels of HCG or ultrasound imaging confirm that a miscarriage has occurred, but minimal or no bleeding occurs and the uterus has failed to expel the pregnancy.
-
The gestational sac is irregularly formed, and also the embryo is missing from inside the gestational sac (Blighted Ovum)
MISSED ABORTION
Missed abortion 9Wks GA by 2D ultrasound and by using color flow mapping to detect absence of color signals from fetal heart. The spectral Doppler shows an artifact from maternal arterial “thump”.