Ectopic Pregnancy Flashcards
“Out of place”
a fertilized egg has implanted in an area OUTSIDE the endometrial cavity OR possibly both within AND outside of endometrial cavity
Ectopic
95% of the time…. the egg settles in the ______ tubes… aka TUBAL PREGNANCY (ectopic pregnancy)
A “classic” ectopic pregnancy will NEVER develop into a live birth BUT some ectopic pregnancies will continues as a LIVE ectopic pregnancy and most likely will ______ at some point because of pregnancy/fetal growth and then becomes FATAL to the patient because rupture = rupturing surrounding maternal vessels = bleeding which can end in death if the patient isn’t taken to the OR to remove the pregnancy and stop the bleeding
The egg can also implant:
on or around the _______ (adnexa pregnancy)
within the uterine _____ (cornual pregnancy- very dangerous because it is a highly vascular area)
within the _______ (abdominal pregnancy)
within the _______(cervical pregnancy)
**These areas DO NOT have much space nor nurturing tissue as the uterus for a pregnancy to develop. As the fetus grows, it will eventually burst the organ that contains it. This can cause severe bleeding because of major vessels in the area and endanger the mother’s life
fallopian rupture ovary cornu abdomen cervix
Sonographic findings of Ectopic Pregnancy (EUP)
Most important finding —– NO ______
Complex _____ mass with FP and _____ activity, diagnostic of an ectopic pregnancy
Identification of an extrauterine sac with DDSS BUT within the _______ is the most frequent finding of an ectopic pregnancy
EUP (GS) more often demonstrates a thickened echogenic ring (DDSS), separate from the ____ or within the ovary which represents _______ tissue or chronic villi; a ____ sac and/or embryo may be present
A ____ sac (decidual reaction that may occur within the endometrial cavity in a patient with an ectopic pregnancy) will be seen in 20% of patients with an ectopic pregnancy; a pseudogestational sac will have the following characteristics;
-DOES NOT contain an ____ or ____ sac and will be centrically located in the endometrial cavity, unlike the NL GS which is eccentrically located in the endometrial cavity
____ mass in the presence of free pelvic fluid is the best sonographic correlation in diagnosis of ectopic pregnancy, especially with no ____ and knowledge of a positive pregnancy test
Always Doppler the IUP/EUP with ____ flow… in presence of ectopic, there will be a vascular ring around the GS = “____ of ____” which is highly indicative of ectopic.
80% of patients with an ectopic pregnancy will have at least ____ ml of blood (free fluid) within the pelvic cavity
A ____ pregnancy is a simultaneous IUP and EUP ; uncommon, except with in vitro fertilization and transfer; ovulation induction
in vitro fertilization with embryo transfer ____ the risk of heterotopic pregnancies
IUP adnexal cardiac adnexa ovary trophoblastic yolk pseudogestational embryo yolk adnexal IUP color Ring of Fire 25 heterotopic increases
Sonographic Characteristics of Intrauterine Pregnancy (IUP)
Most Important finding: IUP approx. ____-____ weeks LMP with cardiac motion
Suggestive signs of IUP = ____ (Double decidual sac sign, a.k.a. choriodecidual reaction), ____ sac, and a ____ = Normal pregnancy
ABNORMAL = “____ sac” - irregular sac-like structure identified in the endometrial canal which has been created by the decidual reaction and bleeding which creates an anechoic fluid center; no ____ nor ____ will be identified
DDSS = ____ concentric rings = decidua vera and decidua capsularis; pseudogestational sac = ____ ring— no DDSS and found within the endometrial cavity
DDSS demonstrates positive ____ findings; pseudogestational sac demonstrates no significant Doppler findings
Enlarged empty ____ with possible thickened ____ = “too early”
5 6 DDSS yolk GS pseudogestational FP YS 2 1 doppler uterus endometrium
What are the 5 types of Ectopic Pregnancy?
Interstitial or cornu Fallopian Tube Ovarian Abdominal Cervical
Possible Sites of Ectopic Pregnancies:
#1 MOST OFTEN -97% = F: \_\_\_\_ (93%) \_\_\_\_ (4%)
2nd most often
-2.5% ____/____ area; 2nd leading cause of maternal death due to forced expulsion, rupture and hemorrhage
3rd most often - ____ (0.5%)
Other areas = ____ and ____
ampulla isthmus interstitial cornual ovarian abdomen cervix
Fallopian tube Ectopic
93% - ampulla, 4% isthmus = (97%)
Villous ____ invades endosalpinx
w/ imaging… can separate from ____
Sono:
US finding of a large complex mass involving or containing the ____; tube may/may not be seen
EUP between ____ and ____
Fluid filed ____, ____, and/or ____
“____ of ____” Appearance because of increased Vascular Flow due to pregnancy
trophoblast ovary FT uterus ovary adnexal PCDS FT
CORNUA Pregnancy or INTERSTITIAL Pregnancy
Def and SONO Findings: a ____ seen/misplaced laterally within endometrial cavity approx less than 1cm from where the interstitial portion of the FT enters the uterine ____; GS will have a thin ____ layer BUT less than 5mm myometrium around it; measurement is to be documented
____% of ectopic pregnancies
GS
cornua
myometrial
2.5
High Risk Concerns of Interstitial Pregnancy / Cornu Pregnancy
Considered an ____ pregnancy
Makes up about ____% of the different types of ectopic pregnancies
Adjacent to uterine ____ (area where the FT connects to the uterus), never completely surrounded by ____; this area is highly vascular because of the uterine ____ encompassing the periphery of the uterus
Most life threatening of all ectopic pregnancies because of the ____ vascularity in this area = the arcuate artery around the periphery of the uterus
Sonographically, the ____ is eccentrically within the uterus and has an incomplete ____ mantel surrounding the GS; is best diagnosed in the ____ view of the uterus that will demonstrate the GS off centered within the uterus
ectopic 2 cornu myometrium artery increased GS myometrial transverse
Ovarian Ectopic
____% of ectopic pregnancies
RARE; on any portion of the ____; may be a “LIVE” pregnancy or not (mass)
1 = ____ - ova not expelled; fertilization occurs in Ccyst
2 = early ____ abortion with implantation on the ovary
.5
ovary
interfollicular
tubal
Sonographic Characteristics of Ovarian Pregnancy
US finding of a ____ w/ DDSS, ____, or ____ or FHTs on ovary (LIVE ECTOPIC) OR a large complex mass involving or containing the ____ (NOT LIVE)
Rare type —– less than ____% of all ectopic pregnancies
EUP close to the ovary may be described as being on the ____ because often it is so large or so close that it cannot be differentiated from an EUP at the distal end of the ____ or adjacent to the ____
GS YS FP ovary 3 ovary FT ovary
Cervical Ectopic
Unsuitable ____ for implantation
____ incidence with patient history of: endometriosis, IUCD, previous c-section, and/or fibroids; 50% cervical pregnancies require ____ due to uncontrollable bleeding
SONO Findings:
Below level of ____ os; may be ____ abortion
cannot distinguish this type from a ____ abortion that may be exiting the uterus, therefore may not be referred to as a cervical pregnancy
endometrium hysterectomies internal inevitable spontaneous
Abdominal Ectopic
pregnancy adherent to ____ surface (spleen, liver, lesser sac, diaphragm)
usually occur because of ____ rupture… extension and implantation of pregnancy onto the peritoneal surfaces. Early diagnosis crucial = massive ____
____ maternal risk of dying than a tubal pregnancy
Most fetuses die; remaining may have ____ delay, ____ hypoplasia, pressure deformities of ____ and ____
not as common anymore with more prevalency of ____ imaging during a pregnancy term, especially 1st trimester and more people aware of US and problems with pregnancy
peritoneal tubal hemorrhage increased growth pulmonary limb face US
Risk Factors of Having an Ectopic Pregnancy
History of:
____ or other STD - 30-50% (6-10 times higher than in women with no previous history of PID)
____ is usually caused by invasion of either gonorrhea or chlamydia from vaginal canal, through cervical canal, through endometrial cavity then extending into the tubes. The infection causes an intense inflammatory response; inner lining of the tubes (tubal mucosa) may be permanently scarred. The end of the tube by the ovaries may become partially or completely blocked, and scar tissue often forms on the outside of the tubes and ovaries. All of these factors can impact ovarian or tubal function and the chances for conception in the future. If pelvic inflammatory disease is treated very early and aggressively with IV antibiotics, the tubal damage might be minimized, and fertility maintained.
Previous ____ pregnancy - pt has a 25% chance of reocurrance
HX of ____ surgery
HX of ____ surgery - scar tissue outside the tube - cause constriction on -tube, closing or narrowing
____ ligation
____ or ____ in the tubes
____ being restored through the reversed tubal ligation and/or pregnancies achieved by means of assisted reproductive techniques, such as in vitro fertilization
Uterine ____ - may block the tube’s entrance into the uterus
____ of the FT
HX of induced ____
____ - an IUCD functions to prevent uterus pregnancies, so any fertilization that does not occur may result in an ectopic pregnancy.
PID PID ectopic tubal pelvic tubal tumors cysts fertility fibroids endometriosis abortions IUCD
Etiology
1) ____ Obstruction = tubal developmental, prior or current infectious disease within tube, tubal surgery causing scarring of the tube
2) Transmigration (evidenced by contralateral corpus luteum cyst)
- ____ - Ovum fertilized in one tube, crosses uterus and enters other tube
- ____ - Fertilized in PCDS, then enters FT and implants
3) Abnormal blastocyst
- ____ imbalance - excessive levels of progesterone or estrogen may interfere with the contraction of the FT
-Reduced ____ mobility
mechanical internal external hormonal tubal
Heterotopic Pregnancy
Combined ____- and ____- uterine pregnancy
- IUP + EUP (ectopic pregnancy)
Current rate is about 1/____ pregnancies
Rate is ____ with the use of ovarian stimulation
With IVF, rate is about 1/____-1/____ clinical pregnancies
ALWAYS look in ____, bilateral ovaries even when IUP is documented in case of an heterotopic pregnancy, mass or any other abnormality
intra extra 4000 increased 35 100 adnexa
Clinical Presentation (S and S) ACUTE -VS- CHRONIC
ACUTE:
Classis triad = ____, ____ pain, ____ mass
____ pregnancy test
____
Possible ____ pain from intraperitoneal bleeding with diaphragmatic irritation
CHRONIC:
Recurrent, intermittent, low-grade ____, palpable solid ____ mass, (LDH)
LDH - lactose deoxygenase hormone - ____ because of hemorrhage and shock (pt goes into shock because of so much loss of blood)
Physical Exam:
____
-softens and increasingly dilates
____
-Abd pain, N/V, fetal movements seen and felt within the abd cavity by pt because of fetus increasing in size
bleeding pelvic adnexal positive amenorrhea shoulder fever adnexal increases cervix abdomen
LAB Values
Based on quantitative hCG produced by the syncytiothrophoblast about ____ days post-conception
Normal intrauterine pregnancy hCG ____ every 2-3 days (48-72 hours), peaking at about 10 weeks of pregnancy
Ectopic pregnancies ____ in 2-3 days or 48-72 hours… read below
Normally, hCG levels will ____ every 2-3 days or 48-72 hours, until about 10 weeks at which it plateaus…. Ectopic pregnancy causes the hCG levels to increase but the levels are not doubling, instead the levels will be less than double from the last hCG level.
7
doubles
subdoubles
double
____-____ weeks LMP
Sac size 27-29 mm
CRL 5-8 mm
7,650 - 229,000 mlU/ml
7
8
____ hCG levels may indicate a miscalculated date of conception, an ectopic pregnancy, or a possible miscarriage. However, a perfectly healthy pregnancy may have low hCG levels.
____ hCG levels may indicate a miscalculated date of conception, a molar pregnancy, or a multiple pregnancy
What can interfere with hCG levels?
Some fertility drugs containing hCG affect your hCG levels. Other than that, other medications including ____ and ____ contraceptives will not affect your hCG level.
Low
high
antibiotics
oral
Ruptured / Unruptured
Sono Characteristics
Unruptured Ectopic
- ____ mass - appearance variable
- Definitive if ____ and (+) ____ motion identified
- When villous ____ invades, endosalpinx bleeding may occur; blood may be found in the PCDS and Morrison’s pouch
- ____ ring = trophoblast (in color- “ring of fire”) with sonolucent center
- Corpus ____ cyst in either adnexa
Ruptured Ectopic
- Complex ____ mass changing as progressing to chronic stage
- Variety of ____ appearance
- Free ____ with or without ____ (hemoperitoneum)
- ____= gradual disintegration of tubal wall with repeated episodes of hemorrhage—- complex extrauterine mass
- Corpus ____ cyst in either adnexa
adnexal GS cardiac trophoblast echogenic luteum adnexal sonographic fluid hemorrhage chronic luteum
Color Doppler with Ectopic Pregnancy
True GS has a ____ velocity, ____/low resistance impedence (RI) flow around its periphery; possibly with ectopic
Pseudogestational sac = ____/____ resistance Rl
Significant color flow surrounding periphery of an adnexal mass separate from ovary and corpus luteum = “____ of ____” chracteristic
____ resistance less than 0.4; due to throphoblastic erosion
____ Rl also noted in corpus luteum cyst
high decreased increased high ring of fire low decrease
Sonographic Differential Diagnosis
____
- Corpus Luteal (CL) cyst/adnexal mass
- Adhesed bowel
- Salpingitis
- Acute appendicitis
____
- Tubal ectopic
- Bowel (mass-like)
- Hemorrhagic corpus luteum cyst
____
- severely retroflexed uterus
- Bicornuate uterus
____
- Impending or incomplete abortion
- Degenerating cervical myoma
____ ectopic
- PID
- Degenerating myoma
- Endometriomas
____
- Myoma
- Bicornuate uterus with pregnancy in one horn
Tubal ovarian abdominal cervical chronic interstitial
Treatment and/or Alternate Diagnostic
Methods of EUP
____ =
- Uterine dilation and currettage (D and C)
- recovery of chorionic villi confirms IUP, DOES NOT ruleout EUP - Heterotopic pregnancy = concurrent IUP + EUP
____ =
-diagnostic if hemoperitoneum; only performed i nthe presence of a ruptured tubal pregnancy
____ =
- Has replaced laparatomy
- Laparascopy is performed by inserting a scope into the umbilicus to view inside the abdominopelvic areas
Salpingectomy -vs- salpingostomy
____
NON SURGICAL
____ = Early Tubal before embryonic cardiac activity - Induces tubal abortion and resorption of EUP
Surgical Culdocentesis Laparoscopy hysterectomy methotrexate
