goho - ectopic pregnancy vegas wide...ectopic pregnancy beryl benacerraf m.d. harvard medical school...
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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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