Module 6: 1st Trimester Abnormal; Ectopic Pregnancies Flashcards
When do we use mean sac diameter (MSD)?
When the embryo is not identified
What do you need ensure to use mean sac diameter?
Ensure you can see the double decidual reaction
What is the time frame for use of mean sac diameter?
Used from 4 to 7 or 8 weeks
What is the formula for mean sac diameter?
(length + width + height)/3
What is the use for Mean sac diameter?
Early diagnosis of oligohydramnios or low fluids
When do we expect oligohydramnios?
From weeks 5.5-9 weeks if the MSD mm - CRL mm is <5mm
What measurements can we do in the 1st trimester of sonography? 3
- Mean sac diameter
- Crown rump length
- Nuchal
For a endovaginal scan what is the MSD size where the yolk sac is seen?
8mm MSD
For a endovaginal scan what is the msd size where the embryo is seen?
16mm MSD
For a transabdominal scan what is the MSD size we will see the yolk sac?
MSD 20 mm
For a transabdominal scan what is the MSD size we will see the embryo?
25mm
What timeframe should we use Crown rump length? (Weeks)
Between 6 and 13 weeks
What is the accuracy of Crown rump length?
+/- 3 days
How should we measure for Crown rump length?
Measure from the tip of the head to end of the rump
Should we include the yolk sac for the crown rump length measurement?
no
What position should the fetus/ embryo be in?
Neutral position
What the classical clinical triad?
- Pain
- Bleeding
- Adnexal mass
How many people demonstrate the classical clinical triad?
45%
Others that do not demonstrate the classical clinical triad, demonstrate what other symptoms? 3
- Amenorrhea
- Adexal tenderness
- Cervical tenderness
When do ectopic pregnancies usually present? (Weeks)
5 and 8 weeks
What are some historic risk factors for ectopic pregnancies? 3
- Previous ectopic pregnancies
- Gynecologic surgery
- Pelvic inflammatory disease
What are some risk factors for ectopic that does not have to do with history? 5
- Endometriosis
- IUCD use
- Congenital anomalies
- Assisted reproductive techniques/ infertility
- Increased maternal age
What are some normal sites for ectopic pregnancies? 4
- Fallopian tubes
- Cervix
- Ovary
- Peritoneal cavity
95% of ectopic pregnancies occur where?
Isthmus or ampulla of tube
What is the most common location for ectopic pregnancies?
Ampulla
What is the most dangerous areas to have a ectopic pregnancy?
The cervix and interstitial segment of the fallopian tube areas
Why is the Cervix and interstitial segment of the fallopian tubes bad areas for ectopic pregnancies?
High risk of hemorrhage because they are very vascular areas with little or no thickened endometrium for the embryo to burrow into
What are some sonographic features of ectopic pregnancies? 3
- Adnexal mass
- Free fluid
- Absence of IUP or presents with a pseudo sac
Is it possible to see a viable ectopic pregnancy instead of a adnexal mass?
Yes, Some times we can see a gestational sac with an embryo with a heart beat seen outside of uterus.
This may also indicate that the pregnancy has not yet ruptured
In a ectopic pregnancy what is the common levels for beta hCG levels?
Lower, but still can be in normal range
What is the beta hCG levels trend normally and what is it with ectopic pregnancies?
It should double every 2 days but will not with ectopic pregnancies
What is the DDX for determining a ectopic pregnancy in early gestation?
In pregnancies under 5 weeks beta hCG should increase
What is the DDX for ectopic pregnancy for spontaneous abortion?
beta hCG should decrease
What is the DDX for ectopic pregnancy for P.I.D (pelvic information disease)?
beta hCG should be negative - not pregnant
pelvic inflammatory disease
What is the DDX for ectopic pregnancy for a complex ovarian cyst?
beta hCG negative
What is the DDX for ectopic pregnancy for endometriosis?
beta hCG negative
What does the term “ring of fire” mean?
Common term to describe increased blood flow around ectopic gestation
What is the most common lesion mistaken for a ectopic pregnancy?
Corpus luteal cyst
In practice a hyper vascular ring tends to be seen when/where?
Surrounding a corpus luteum than ectopic
What is a useful tool for determining if a gestation is an intrauterine abortion in progress vs an ectopic?
Doppler
How do we know if a GS is plausible?
Avascular vs ectopic pregnancy is well perfused
Doppler is also helpful for determining what?
Pseudosac vs Viable IUP
What is a sliding sac sign?
When gentle pressure from the transducer can move the gestation sac
When is Sliding sac sign useful?
Useful for assessing a GS within the cervix determining abortion in progress vs. cervical ectopic
If gentle pressure can move the GS, what does this mean?
It is not implanted and is likely an abortion in progress
What is a heterotopic pregnancy?
An intrauterine pregnancy with a twin ectopic pregnancy
When does heterotopic pregnancy occurs?
When two fertilized ova implant
How common is heterotopic pregnancy occurs?
1 in 30,000 incidence in natural pregnancies
When would the incidence of heterotopic pregnancies increase?
Increased due to assisted reproductive technology
Heterotopic pregnancy incidences from Assisted reproductive technology increase by what rate?
1-3% of IVF pregnancies
What does negative ultrasound results mean for ectopic pregnancies?
Does not rule it out, it may just be too small to recognize with sonography
Just because the negative ultrasound results is negative (for ruling out ectopic pregnancies) what must we do? 4
- Follow up!
- EV - if not done already
- Repeat beta hCG in 2-3 days
- Repeat scan as recommended 2-7 days
What is the interstitial line sign?
Hyperechoic line extending from the endometrial canal up to the center of the interstitial sac or hemorrhagic mass
What is the interstitial line sign used for?
To help diagnose interstitial ectopic pregnancies
Gestational sacs must have a minimum of how much myometrium surrounding them?
5mm
Interstitial ectopic pregnancies will be located where?
Very superiorly in the uterine fundus and have <5mm of tissue surrounding the gestational sac
What should we look for in terms of interstitial pregnancies on ultrasound?
Look for a band of myometrium between sac and endometrium
What are treatment (TX) for ectopic pregnancies? 3
- Conservative management
- Medical therapy
- Surgery
What is the conservative management treatment plan for ectopic pregnancies? 3
Some very early ectopic pregnancies can resolve on their own.
1. Failure to progress
2. Serial monitoring of beta hCG - looking for a decrease
3. Follow up with ultrasound
What is the greatest success for conservative management treatment?
If initial beta hCG is low, levels decrease and absent gestational sac
What is the medical therapy for ectopic pregnancies?
Methotrexate
What is methotrexate?
A cell growth inhibitor
What is methotrexate also used for?
Cancer
How is methotrexate administered?
- Administered systemically or injected directly into ectopic site
- Can be given orally as well
- Single or multiple doses
How can we get the greatest success for medical therapy for ectopic pregnancies?
If beta hCG less than 5,000 monitored after treatment, and not fetal cardiac activity
What is the surgical treatment for ectopic pregnancies? 3
- Laparoscopy or laparotomy
- Salpingostomy
- Salpingectomy
What is a salpingostomy?
Incision into the tube to remove ectopic/ restore patency
Preferred for women desiring future fertility
What is a salpingectomy?
- removal of the fallopian tube
- Required tubal rupture, recurrent ectopic in the same tube, damaged tube, or GS >5mm
What does surgery do for a patients risk for a repeat ectopic?
It increases it
What is hypovolemic shock?
Life threatening condition due to decreased blood volume
patient is hemodynamically unstable with internal bleeding
What is a laparoscopy?
Surgical removal with laparoscope
When would a laparotomy be required? 4
If the ectopic is
1. Interstitial
2. Cervical
3. Abdominal
4. If the patient is severely hemodynamically stable - going into shock
