Ultrasonography in an Acutely Symptomatic First Trimester Pregnancy

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PATIENT JC. HPI: 34 year old woman who is 4 weeks ... pregnancy with placental abruption and subchorionic ... Cardiac activity is visible at 6 weeks ( seen in a.
Dayle Whiteman, HMS III Gillian Lieberman, MD

January 2004

Ultrasonography in an Acutely Symptomatic First Trimester Pregnancy Dayle Whiteman, Harvard Medical School Year III Gillian Lieberman, MD

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Dayle Whiteman, HMS III Gillian Lieberman, MD

CLINICAL PRESENTATION OF PATIENT JC HPI: 34 year old woman who is 4 weeks and 2 days pregnant (by date of LMP) CC: Presents with pelvic pain PMH: H/o ovarian cyst. Previous difficult pregnancy with placental abruption and subchorionic hematoma. Important lab values: B-HCG of 1457 mIU/mL 2

Dayle Whiteman, HMS III Gillian Lieberman, MD

Differential Dx of Presentation Ectopic pregnancy Ovarian torsion Ruptured corpus luteum cyst or ovarian follicle Pelvic Inflammatory Disease Spontaneous abortion Appendicitis Salpingitis 3

Dayle Whiteman, HMS III Gillian Lieberman, MD

Assessment of Symptomatic first trimester pregnancy Woman with Positive B-HCG and pain or bleeding Transvaginal Sonogram Intrauterine Gestational Sac Identified? Yes Gestational Sac Normal? Yes Nml IUP

No

No Extraovarian Adnexal Complex or Mass Yes

Suspect Abnml IUP Suspect ectopic preg

No Differential diagnosis: -Early IUP -Abnml IUP -Ectopic Pregnancy 4

Dayle Whiteman, HMS III Gillian Lieberman, MD

Why Transvaginal US? •Provides detailed evaluation of the endometrial cavity and ovaries. •Uses a high frequency transducer, allowing for improved near field resolution. www.2womenshealth.co.uk

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Advantages of Transabdominal US Provides a full view of the uterus and adnexa (eg when fibroids limit scan of the pelvis) Better than TV if mass is high in the pelvis Can use lower frequency More highly penetrating transducer Greater latitude in placement of transducer www.diabetes.com.au/graphics/ultrasound.jpg

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Normal Sonographic Findings in First Trimester Gestational sac identifiable at 5 weeks of menstrual age (seen when B-HCG >1000 mIU/mL-1st and 3rd International Ref Prep) Yolk sac is seen within the gestational sac at 5.5 weeks (visible when sac diameter > 8 mm) Embryo seen when mean sac diameter > 16 mm Cardiac activity is visible at 6 weeks (seen in a living embryo whose CRL is > 5 mm)_ Normal heart rate is > 100 bpm before 6.3 weeks and > 120 bpm at 6.3 to 7 weeks

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Comparison Patient 2: Double sac sign of early pregnancy Bladder

Intrauterine fluid collection

Inner ring Outer ring BIDMC (appprox 7 weeks)

A gestational sac should be diagnosed only if it is surrounded by two echogenic rings or….. 8

Dayle Whiteman, HMS III Gillian Lieberman, MD

Comparison Patient 2: Gestational sac of a normal early pregnancy

Yolk sac

BIDMC (approx 7 weeks)

if a fluid collection in the uterus contains a yolk sac or… 9

Dayle Whiteman, HMS III Gillian Lieberman, MD

Comparison Patient 2: Normal Intrauterine Pregnancy Developing brain

Gestational sac

BIDMC (approx 7 weeks)

if a fluid collection in the uterus contains an embryo 10

Dayle Whiteman, HMS III Gillian Lieberman, MD

Initial Transabdominal US of Our Patient JC: Uterus Bladder

Uterus

Endometrial canal

BIDMC (4 weeks and 2 days by LMP)

The uterus is empty, but given the early point of pregnancy, this does not exclude an intrauterine gestation 11

Dayle Whiteman, HMS III Gillian Lieberman, MD

Initial Transvaginal US of JC: Ovary

BIDMC (4 weeks and 2 days by LMP)

Normal L ovary 12

Dayle Whiteman, HMS III Gillian Lieberman, MD

Initial Transvaginal US of JC: Abdomen Free fluid

Bowel loops BIDMC (4 weeks and 2 days by LMP)

Free fluid with low level echoes

assume blood 13

Dayle Whiteman, HMS III Gillian Lieberman, MD

Assessment of Our Patient JC after the US Woman with Positive B-HCG and pain or bleeding Transvaginal Sonogram Intrauterine Gestational Sac Identified? Yes Gestational Sac Normal? Yes Nml IUP

No

No Extraovarian Adnexal Complex or Mass Yes

Suspect Abnml IUP Suspect ectopic preg

No Differential diagnosis: -Early IUP -Abnml IUP -Ectopic Pregnancy 14

Dayle Whiteman, HMS III Gillian Lieberman, MD

Patient JC returns four days later HPI: 34 year old woman now 4 weeks and 6 days pregnant CC: Presents with crampy suprapubic pain Important labs: B-HCG now 2681 mIU/mL

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Dayle Whiteman, HMS III Gillian Lieberman, MD

JC Emergency Repeat Transvaginal US Free fluid Bowel loops

BIDMC (4 weeks and 6 days by LMP)

Normal R ovary surrounded by echogenic free fluid 16

Dayle Whiteman, HMS III Gillian Lieberman, MD

JC Emergency Transvaginal US

BIDMC (4 weeks and 6 days by LMP)

Large ovoid structure in L adnexa with heterogeneous internal echoes 17

Dayle Whiteman, HMS III Gillian Lieberman, MD

JC Emergency Transvaginal US

The mass does not demonstrate internal blood flow

BIDMC

Vessel

Artifact

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Color Doppler and ectopic pregnancy Increases sensitivity of detecting an ectopic pregnancy when used with TV Adnexal mass and peritrophoblastic flow on color Doppler Blood flow in the fallopian tube with the ectopic pregnancy is 20-45% higher than in the opposite tube

www.iame.com/learning/ectopic/ ectopic_content.html

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Sites of Ectopic Pregnancy

A. Ampullary: 80% B. Isthmic: 12% C. Fimbrial: 5%

E. Abdominal: 1.4% F. Ovarian: 0.2% G. Cervical: 0.2%

D. Cornual/Interstitial:

2%

www.emedicine.com Article by Vicken Sepilian, MD 20

Dayle Whiteman, HMS III Gillian Lieberman, MD

Signs and Sx of Ectopic Pregnancy Classical Clinical Triad pain abnormal vaginal bleeding palpable adnexal mass Amenorrhea Adnexal tenderness Cervical “excitation” pain 21

Dayle Whiteman, HMS III Gillian Lieberman, MD

Increased risk of ectopic pregnancy Tubal abnormality that prevents passage of the zygote or results in delayed transit Previous tubal pregnancy Previous history of tubal reconstructive surgery In utero DES exposure In vitro fertilization or ovulation induction Pelvic inflammatory disease Chlamydial salpingitis Intrauterine contraceptive devices Increased age and parity 22

Dayle Whiteman, HMS III Gillian Lieberman, MD

IUP or Ectopic Pregnancy?

Pseudogestational sac

This is a right ectopic pregnancy (arrowheads). There is an intrauterine decidual cast (arrow). Decidual casts are intrauterine fluid collections surrounded by a single decidual layer.

Levi CS, et al Diagnostic Ultrasound 23

Dayle Whiteman, HMS III Gillian Lieberman, MD

Natural history of ectopic pregnancy Tubal rupture Tubal abortion Spontaneous resolution

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Role of US in Treatment of Ectopic Pregnancy MTX is contraindicated if the patient has a complex adnexal mass > 3 cm in diameter or a large amount of free intraperitoneal fluid Monitors response to therapy In cervical ectopic pregnancies, can use a transvaginal transducer with needle guide to inject KCl or MTX 25

Dayle Whiteman, HMS III Gillian Lieberman, MD

Patient JC follow-up Had operative laparoscopy for L ectopic pregnancy in the fallopian tube Treated with partial left salpingectomy

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Dayle Whiteman, HMS III Gillian Lieberman, MD

References Doubilet PM, Benson CB: Emergency Obstetrical Ultrasonography. Seminars in Roentgenology, 1998;33(4):339-350 Levi CS, Lyons EA, Dashefsky SM: The first trimester. In: Rumack, CM et al Diagnostic Ultrasound, St. Louis: Mosby Year Book; 1991:688-722 Reeder MM. Gamuts in Radiology. 3rd ed. New York: Springer-Verlag; 1993: 574-576 www.uptodate.com www.emedicine.com www.iame.com/learning/ectopic/ ectopic_content.html

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Dayle Whiteman, HMS III Gillian Lieberman, MD

Acknowledgments Deborah Levine, MD Michelle Swire, MD David Kelly, MD Lucy Hann, MD Larry Barbaras our Webmaster Pamela Lepkowski Gillian Lieberman, MD Devon McGoldrick

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