TEST 3 STUDY GUIDE ECTOPIC PREG & MORALS Flashcards
ectopic pregnancy:
- Location of pregnancy outside uterus
- 10% maternal deaths related to ectopic pregnancy
- Effect on future fertility & recurrance
true or false? A woman capable of conceiving is capable of having a pregnancy in a location other than the uterine cavity
true
clinical findings ectopic pregnancy:
- Positive pregnancy test
- Pain 97%
- Shoulder, generalized abd, lower abd, lower quadrant ipsilateral to ectopic, lower quadrant contralateral to ectopic, back, vaginal
- Vaginal bleeding
- Palpable adnexal mass
- Clinical Triad – Pain, Bleeding, Adnexal mass – 45%
- Not specific for ectopic pregnancy – 14% confirmed ectopic
- Ovarian cysts (27%), PID (15%), DUB (4%), Spont Ab (5%)
- Present at 5-6 weeks
ectopic prenancy occurs in fallopian tubes in almost __ of patients
95%
when ectopic pregancy is located in the _____ portion of the ____ ____ near the ___ ___, an increased risk of massive hemorrhage exists, which may lead to hysterectomy or even death.
interstitial
fallopian tube
uterine cornua
true or false?
serum beta hCG levels in an ectopic pregancy do not increase as they do in a normal pregnancy
true
what is the clinical triad found w/ ectopic pregnancy?
Pain, Bleeding, Adnexal mass – 45%
- Not specific for ectopic pregnancy – 14% confirmed ectopic
- Ovarian cysts (27%), PID (15%), DUB (4%), Spont Ab (5
when are clinical findings present for ectopic pregnancy?
5-6 weeks
Pregnancy Testing w/ hCG: what is 2IS
2IS (Second International Reference)
- Introduced in 1960’s
- 800 - 1000 IU/L - normal intrauterine gest sac can be seen
slight risk factors for ectopic pregnancy:
- Previous pelvic/abd surgery (.9-3.8),
- smoker (2.3-2.5),
- Vaginal douching (1.1-3.1),
- early age 1st intercourse <18 yrs (1.6)
Moderate Risk factors for Ectopic Pregnancy:
- Infertility (2.5-21),
- Previous genital infections (2.5-3.7),
- Multiple sexual partners (2.1)
High risk factors for Ectopic Pregnancy:
- Tubal Surgery (21.0),
- Sterilization (9.3,
- Previous ectopic (8.3),
- DES daughter (5.6),
- Use of IUD (4.2-45.0),
Documented tubal disease (3.8-21.0)
Pregnancy Testing with hCG: what is 1st IRP
(First International Reference Preparation)
- Purer standard – main standard used today
- 1000 - 2000 IU/L - normal intrauterine gest sac can be seen
what is the minimum lwvel of hCG in normal pregnancy?
2000 mIU/mL, IRP
- If no gest sac seen ≥ these levels=suspect ectopic
- Differential dx -> possible early IUP, miscarriage, ectopic
- As many as 19% may have IUP on followup
- Guideline only – use clinical indications and f/u if stable
Serial quantitative beta hCG levels
- hCG levels double every 2 days in normal preg
- & 21% of ectopic
- 90% ectopic preg nonviable -> beta hCG levels low
- Falling hCH levels may indicate missed or incomplete abortion
TRUE OR FALSE?
90% ectopic preg nonviable -> beta hCG levels low
true
Falling hCH levels may indicate:
missed or incomplete abortion
common sites of ectopic pregnancy
- Tubal 95-97%
- Ampullary – most common
- Isthmus – second most common
Uncommon Sites of Ectopic Pregnancy
- Interstitial (Cornual) – rare 2-5%
- Ovary – rare 0.5 – 1.0% (text states <3%)
- Fimbria – very rare
- Cervix – very rare 0.1%
- Abdominal – very rare
image: sites of ectopic preg
A
Interstitial (cornual)
B
isthmus
C
abdominal
***D
ampullary
**E
fimbrial
**F
Ovary
**G
cornual (interstitial)
**H
fornix
**I
cervical
**J
body of uterus
**K
abdominal peritoneum
true or false? a increased risk of a complete hysterectomyexists when an ectopic pregnany is located in the uterine cervix.
a combination of ___ ___ and an ___ ___ is the best correlation in dagnosis of an ectopic pregnancy.
free fluid; adnexal mass
echogenic free fluid is related to a __% risk of ectopic pregnancy.
92% (86%-93%)
what are the Sonographic Findings: Ectopic
-
Determine if normal early intrauterine pregnancy
- Intrauterine gestational sac preferably with heart beat
- Extra-ovarian Adnexal mass
-
Fluid in cul-de-sac
- Echogenic fluid (86-93% for ectopic)
- Check kidneys for hemoperitoneum
-
Pseudogestaional sac
- Differentiate betwn normal IUP & pseudo
- 20% ectopic preg demonstrate pseudo gest sac
- Finding of live embryo within adnexa (specific)
- Extrauterine gestational sac or ring in adnexa - 71%
- 26.3% ectopic preg with a normal sonogram
what is a pseudogestational sac?
located in middle of endometrium, does not have a yolk sac, has internal echoes, and a high resistive spectral waveform
EARLY IUP: shape, location, margins, decidual reaction, sac
round
eccentric location in endometrium
well defined margins
well defined decidual reaction
possible double decidual sac sign
Pseudosac: shape, location, margins, decidual reaction, sac
ovoid shape
cebtral location in endometrium
poorly defined margins
absent decidual reaction
single decidual layer
pseudogestational sac characteristics
- No living embryo
- No yolk sac
- Sac central endometrium
- Low level echos
- Best seen endovaginal
- High resistance pattern
* (low diastolic flow) with low peak velocities
decidual cast - pseudosac
gestational sac
echogenic ring - classic chorionic ring
Double decidual sac sign
–Inner ring – echogenic chorionic vili
–Outer ring- deeper layer of decidua vera (D)
gestational sac
Double decidual sac sign plus yolk sac
Adnexal Masses with Ectopic
Complex adnexal mass
- Extrauterine gest sac
- Hematoma within peritoneal cavity
- Within fallopian tube or broad ligament
- Ovarian Cyst: Corpus luteum cyst
- Differentiate with surrounding ovarian tissue
- Quantitative beta-hCG levels
- 80% with ectopic have @25 ml blood pooling in peritoneum
- 60% Intraperitoneal fluid - moderate to large quantities
- Check abd gutters to eval extent of fluid present
what is the most frequent sonographic finding in an ectopic pregancy?
adnexal mass
Pregnancy Testing w/ hCG: what is 1st IRP
1st IRP (First International Reference Preparation)
- Purer standard – main standard used today
- 1000 - 2000 IU/L - normal intrauterine gest sac can be seen
___ ___ cysts usually regress and are not seen beyond 16 to 18 weeks, but are commonly seen with ectopic pregnancy
corpus luteum
most common mass in 1st trimester
corpus luteum
**ectopic preg
Rt adnexal ectopic pregnancy
Note: echogenic ring between Right ovary and Uterus - Double white arrows
Note: embryo within ring (E)
**extraovarian adnexal ring
- Left tubal ring adjacent to left ovary
- Lt ovarian corpus luteum cyst
- No intrauterine preg seen
- Small amount free fluid adjacent to ovary (f)
adnexal echogenic ring
Rt adnexa mass with echogenic ring consistent with ectopic gestational sac
Ring represents trophobastic Tissue or chorionic villi
**Ectopic Pregnancy
corpus luteum cyst on left ovary
adnexal mass
ectopic pregnancy with blood around it (found during surgery)
ectopic scenario
**definitive ectopic
90% do not show heart beat
true or false? blood + positive hCG results has 86-93% positive perdictive value for ectopic pregnancy
true
assessment of cul-de-sac
- Cul-de-sac should be examined for free fluid
- Characterize as simple or complex
- Complex (echogenic) is suggestive of blood
- Blood + positive hCG results has 86-93% positive predictive value for ectopic pregnancy
- May be only TV sonographic finding
- Check kidneys to evaluate for hemoperitoneum
free fluid in pelvis
intraabdominal blood
types of ectopic pregnancy
heterotopic
interstitial
cervical
ovarian
abdominal
heterotopic pregnancy:
- Increased incidence with ovulation induction
- Increased incidence with IVF & embryo transfer
- Increased risk bilateral ectopic pregnancy
interstitial pregnancy (cornual)
- Most life threatening with parauterine & myometrial vasculature
- life threatening hemorrhage
- 2% occurance in ectopic pregnancies
- Eccentrically placed gest sac with incomplete myometrial mantel surrounding sac.
interstital pregnancy
cervical pregnancy
- Gestational sac within cervix
- May contain spontaneous abortion in progress
- Color doppler: eritrophoblastic flow in cervical preg
- Increased risk of complete hysterectomy
- Uncontrolled bleeding w/ increased vascularity of the cervix
- Risk factors: multiparity, prior abortion or instrumentation of cx or endometrial cavity
cervical ectopic pregnancy
- In past, led to hysterectomy
- Result of life-threatening hemorrhage
- Current treatment conservative
- US guided local potassium chloride injection
- Systemic or local methotrexate
- Preoperative uterine artery embolization before D&C
- TV scan of sagittal uterus showing cervical ectopic pregnancy
- No GS present in endometrial cavity.
- Intact GS containing YS present in cervix
- Magnified view of GS shows embryonic pole with cardiac activity documented with M-mode tracing
ovarian ectopic pregnancy
- Very rare - less than 0.5-1% all ectopic
- Textbook states <3%
- Complex adnexal masses may involve or contain ovary - making it difficult to distinguish from other ovarian process
true or false? if gestational sac is moving it is a spontaneous abortion in progress.
true
color is also an easy way to tell if spontaneous abortion or ectopic
true or false?
the embryo is attracted to c section scars?
true
abdominal pregnancy
- Pregnancy develops outside tubes within peritoneal cavity
-
Sonographic Findings
- Fetus, placenta, amniontic fluid outside the uterus
- Membrane around abdomnal pregnancy very thin - no myometrium
- Pregnancy lies close to abdominal wall
- Abdominal pregnancies often fail before term
-
C-section delivery with placenta left in place
- Methotrexate to help reabsorption
c section scar pregnancy
treatment of ectopic pregnancy
-
Microsurgery through laparoscope to maintain function of unruptured tube
- Linear salpingostomy with milking pregnancy out of distal ampulla
- Possible resection of segment of fallopian tube w/ gestation w/ or w/o reanastomosis
- Linear salpingostomy with milking pregnancy out of distal ampulla
-
Methotrexate injection - antimetabolite chemotherapeutic agent that interferes with DNA synthesis & disrupts cell multiplication.
- Eliminates morbidity from surgery & general anesthesia
- less tubal damage, less cost & need for hospitalization
- Patient must return for follow up
- Lower success rate w/ ectopic with cardiac activity
-
Surgery
- Live ectopic
- Large adnexal mass > 4cm
indications for 1st trimester exam
- confirm IUP vs. EUP
- define cause of bleeding
- pelvic pain
- viability
- # of embryos
- gestational age
- detect anomalies
- r/o hydatidform mole
- adjunct to CVS, amnio, embryo transfer, IUD removal
- 1st trimester exam done only when deemed necessary
gravidity:
of pregnancies including this one
parity:
all pregnancies
fullterm, premature&stillborn, early loss or abortion, living children.
In US P+A= G
1st trimester
till 14 weeks (0-14 weeks)
**2nd trimester
till 27 weeks (14-27 weeks)
**3rd trimester
27 weeks-term
2nd and 3rd trimester indications
- gestational age
- fetal growth
- vag. bleeding
- abd/pelvic pain
- incompetent cervix
- # fetuses
- determine fetal presentation
- size descrepancies to dates
- pelvic mass
- r/o ectopic
- suspect hydatidform mole
- cervical cerclage placement
- fetal viability
- uterine abnormality
- amniotic fluid
- evaluate fetal well being
- placental abruption
- external cephalic version
- premature rupture of membranes
- abnormal chemical markers -lab values
- f/u fetal anomaly
- hx prev congenital anomaly
- eval for late to prenatal care (cant see bones block view
maternal risk factors
- Maternal Age
- Abnormal triple screen biochemistry values
- Maternal disease
- Uterus measures large or small for dates
- Previous child with chromosomal disorder
- Exposure to teratogenic drug or infectious agent
- Maternal environment
- Nutrition
- Genetic
patient history
- LMP - first day of last menstrual period
- EDC determined by earliest ultrasound
- Current medications
- Clinical problems with pregnancy
- Problems with previous pregnancies
- Incompetent cervix, fibroids, fetal anomalies
- C-section delivery, hypertension
safety of ultrasound
- Used in pregnancy since 1950’s - no side effects
- exisiting studies not large enough to document small increases in normally occurring anomalies
- Studies in animals have suggested:
- Growth differences
- Increase in left handedness
- Delayed speech
Obstetrical US factors
- Theoretical effects of US energy on fetus has potential biological effects not yet documented
- Energy produced by US equipment today is higher than that produced by earlier units
- Doppler imaging produces higher energy
- Study of US bioeffects are not definitive- continued research is essential
- Sonographers have responsibility to be knowledgeable about US bioeffects and use the least amount of energy necessary to produce clinical information needed.
biologic effects
- Thermal - a rise in temperature
- Minimize thermal effects
- Don’t stay in one spot for long period of time over bone
- Extend focus of beam deep for adequate image
- Minimize thermal effects
- Cavitation - production and collapse of gas filled bubbles
- Dependent on the presence of gas preexisting within tissue
- Neonatal lung
- Dependent on the presence of gas preexisting within tissue
guidelines for US exam
- Examination protocol
- AIUM guidelines
- Qualification of personnel
- National board certification
- Documentation standards
- Patient name, date, image orientation
- Written report in patient records
- Equipment
- Transducer frequency selection
- ALARA- (as low as reasonably achievable) principle
- Transducer frequency selection
- Safety
- HIPAA, Infection control, Quality control,
- Musculoskeletal injury - ergonomic protection
informed consent is an ____ based right
autonomy
what did thomas percival do?
changed medical ethics
- Redefined patient as anyone needing care.
- Team approach in health care and public health
- Needs of patient came over competition or professional interests
Hippocrates said what and what does it mean?
“First do no harm”
- ethical principle of nonmaleficence
- emphasized tmts based on best benefit to patient
- treat pt like you would your own family
what emphasizes individual rights and autonomy, which has beecome a key element in modern day ethics
Nuremberg Code
-came from experimenting on prisoners
basic principles put into research , professional codes and clinical practice throughout the world
basic principles of ethics
- autonomy
- justice
- beneficence
- nonmaleficence
- integrity
- respect for persons
___ethics serve as a foundation for ___ ethics
philosophic
medical
ethics
- systematic reflection on and analysis of morality
- stuy seeks to articulate clear, constant, coherent, and practical guidelines for conduct and character
nonmaleficence
cause no harm
education, competency, skill, impressions are appropriate
which principle directs the sonographer not to cause harm
nonmaleficence principle
beneficence:
seeks greatest benefit from exam
the goal seeking a greater balance of clinical goods over clinical harms
integrity:
ino difference exists in what a person says and what he or she does
primum non-nocere (first do no harm)
stresses choosing a treatment based on the best benefit to the patient
pain
physiologic phenomenon involving the central nervous system processing tissue damage
morality
reflects duties and values &
matters concerning right and wrog conduct and good and bad character
confidentiality:
of HIPPA
from principle of beneficence
pateint spouse and familes are third parties
no info given w/out pt explicit permission
the job of the healthcare professional to protect and respect a patients privacy
**HIPPA practices conform to what principle of medical ethics?
confidentiality of findings
**continuing ed is an ex. of what principle of ethics?
non-maleficience
true or false? SDMS has adopted a code of ethics for medical sonographers?
true
what type of issue is family tradition?
moral issue
providing a detailed explanantion of the exam is an ex. of what principle of ethics?
autonomy
integrity
adhering to moral and ethical principles
reading current medical literatures, and being aware of new developments is an ex. of what principle of ethics?
nonmaleficience
the principle of ______requires sonographers to preform only medically indicated examinations and to perfor all examinations in keeping with ALARA to get desired results
nonmaleficience
veracity:
truthfulness
justice:
fair ditribution of benefits and burdens
sonographers must thrive to treat all pateints equally
____ encourages sonographer to go beyond the minimum standard protocol and to seek additional images and info if achievable and in the best interest of the patient
beneficence
principle of ____ obligates the sonographer to seek the greates benefit for the pt
beneficience
autonomy:
key ethical principle is the right to self-determination, patient right to refuse, right to information (1st trimester scan for abortion)
self governing or self directing freedom to choose and have their decision respected
an obligation to the fetal patient going to term to protect and promote both fetal interests and those of the child it will become as understood from a rigorous clinical perspective ai what principle of medical ethics?
beneficence
which ethics principle requires sonographers to perform all examinations with ALARA
nonmaleficence
true or false? info receivewd from a sonogram enhances a woman’s choice or autonomy, and failure to provide these choicesw to some women and not others is an example of injustice.
true
truthfullness w/ respect to abilites and limits is an example of ____
veracity
