1rst Trimester DxEctopic pregnancy

Beryl Benacerraf M.D.Harvard Medical School

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Ectopic Pregnancy

Incidence1.5-2% of all pregnancies

LocationIsthmus / ampulla of tube 95%Interstitial part of tube 2-5%Ovary <1%

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• The rate of ectopic pregnancy is ~ 1-2% that of live births in developed countries, though it may be as high as 4% among those using assisted reproductive technology.

• The risk of death among those in the developed world is 0.1 - 0.3%while in the developing world it is 1-3%.

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Ectopic pregnancy andPregnancy of Unknown location

• What is best estimate for gest. age?

• What is the b-HCG and is there a prior one?

• Is there pain?

• Is there bleeding? Spotting or more?

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Ectopic pregancyPregnancy of Unknown location

• Is there is a gestational sac?• Is the endometrium plush or thin?

• Locate the corpus luteum• Is there an adnexal mass, cyst, ring etc..• Is there free fluid (echogenic)

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4.5 weeks sac

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Fluid collection versus GS

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Ectopic PregnancyUltrasound Findings

• No intrauterine gestation• Adnexal mass separate from ovary

ü Tubal ringü Adnexal massü Internal yolk sacü Embryo with heartbeat

• Free fluid

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+ HCG – where is it?

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Ultrasound findings seen in 94.8%among 231 patients with ectopics

Adnexal mass 94.4%Nonspecific mass 54.1%Tubal ring 24.7%Yolk sac only 8.3%Live embryo 7.4%

Free fluid with no mass 0.4%

Frates et al. J Ultrasound Med 2014

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Mass separate from ovary and with echogenic free fluid

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Free fluid –helpful to outline tubal mass

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Hemato-salpinx

Echogenic free fluid (+clot)

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Hemato-salpinx

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Mass with echogenic rim separate from ovary

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Doppler for Ectopic Pregnancy

• Ring of fire, identical to the corpus luteum

• Must be sure to distinguish from CL• May help to identify the ectopic

within a mass such as a hematosalpinx

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• Ectopic ring brighter than CL

• Same Doppler pattern as CL

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Doppler signal actually helpful to find actual ectopic location

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Does hCG level help?

• Ectopics have variable and often

low hCG levels (unhelpful)

• hCG level does not predict the

likelihood of rupture.

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Diagnosing an ectopic pregnancywhen there is no IUP or only fluid in uterus:

Methotrexate handed out too easily

• Often hCG is not helpful because the levels remain low, and non doubling is suggestive but not diagnostic enough.

• Discriminatory threshold is controversial. Used to be 1000-2000 IU/L.

• Probably no single number - but to be conservative, use 3000IU/L as guide.

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If the hCG is above 2000mIU/mm?

• An embryo with FH have been reported after initial ultrasonography showed no sac with an hCG level above 2000 mIU/mm.

• A patient with an hCG above 2000 mIU/mm who is bleeding may have recently miscarried or carrying a non viable tiny pregnancy.

• F/U scan and hCG in a few days is key and repeat scan if any doubt.

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Pregnancy of unknown location

• + hCG• No IUP on ultrasound

• No adnexal mass or free fluid

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Why PUL does not necessary mean ectopic pregnancy• Fibroids, obesity

• Uterine orientation

• Nonvisualization of GS may be due to technical limitations not absence of a pregnancy

• Complete SAB or very early IUP

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hCG Theshold versus Discriminatory Level

• Threshold is level at which GS is occ. seen (not always). 500-800mIU/ml

• Discriminatory is level at which the pregnancy is not in the uterus. 3000mIU/ml

• Even 3000mIU is not a guarantee!• D&C or MTX, should be avoided

in suspected but unproven ectopics

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Safe Rule

• Regarless of hCG, D&C or MTX should be delayed in suspected but unproven ectopic.

• Unless patient is unstable, f/u ultrasound and/or hCG before intervention (even just 2-3 days)

Doubilet, Benson et al. N Engl J Med 2013; 369:1443.

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Interstitial Ectopic Pregnancy

• Embedded in interstitial part of tube• Sac in upper outer edge of uterus• Sac outside uterine cavity• Thin or no myometrium around

outer sac

• 3D imaging essential

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Is this pregnancy intrauterine?

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Is this pregnancy intrauterine?

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Angular Pregnancy

• Sac in upper outer edge of uterus

• Very difficult to tell if interstitial or intrauterine – need followup scans

• 3D imaging essential

• 40% of angular pregnancies fail likely due to reduced blood flow

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7 wks

10 wks 12 wks

Angular pregnancy

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Heterotopic Pregnancy

Incidence~ 1 / 4,000 - 8,000 (natural)10x – 20x higher (Rx infertility)

Ultrasound findingsIntrauterine gestationAdnexal mass, ring, sac or echogenic free fluid in an ART patient(more likely).

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Is this pregnancy intrauterine?

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Pt came in for NT scan

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Pregnancy in a uterus withduplication anomaly may mimic

abnormal location.

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Septate Uteri: Reproductive Outcome

• Highest Risk of Adverse Reproductive Outcome

• Vascularity to septum abnormal

Homer et al. Fertil Steril 2000

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Meta-Analysis - 9 studies, 3805 ptsConcep

-tion1rst tri

SAB2nd tri SAB

Malpres.

Arcuate 1.03 1.35 2.39* 2.53*Septate 0.86 2.89* 2.22* 6.24*Bicorn. 0.86 3.40* 2.32* 5.38*Didelphys 0.90 1.10 1.39 3.70*Unicorn. 0.74 2.15* 2.22 2.74*

Chan et al. UOG 2011;38:371* signif.

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Twins in anom. uteri

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3D

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Non-communicating horn

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Twins in 2 different horns

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Conclusion• Establishing the location of an

early pregnancy requires combination of ultrasound findings, hCG levels, follow-up scans and levels and patient symptoms (pain, bleeding, stability).

• Give the fetus the benefit of the doubt. Wait if not sure.

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