Ruptured ectopic, large amount of bloodbetter appreciated transabdominally
If clinically unstable, can terminate examwithout demonstrating ectopic pregnancy
Sagittal Transverse
R Adnexa: Transverse Sagittal
Ruptured Right Ectopic Pregnancy
Color Doppler helps locate EP
-HCG 890
Images of “Mass” in cul-de-sac
At surgery fallopian tube was intact,with EP aborted into cul-de-sac
Acute pain, - HCG 22
Ruptured left ectopic pregnancy
Sent by ER and OB to confirmdemise
Where is uterus?
Ruptured ectopicpregnancy
42 yo with acute pain and hypotension
Acutely bleeding, ruptured EP
Doppler Analysis
Low impedance placental(trophoblastic) flow
–Extrauterine
–Corpus luteal
Bizarre waveforms: very high andvery low resistive indices
Use of color Doppler slightlyincreases ability to detect the EP
Atri. JUM 2003;22:1181
Left-Transverse
Left Sag
Left ectopic pregnancy
Left corpus luteum
Similar low resistance flow in corpusluteum and ectopic pregnancy
7mm “donut” separate
from left ovary
L corpus luteal flow
Flow in “mass” near ovary
7mm left ectopic
Color Doppler aids
visualization
Value of Doppler
Presence of extra-uterine trophoblastic flowhas sensitivity of 48% for EP
Doppler has lower sensitivity and NPV than2D imaging.
May have benefit for directing therapy. Ifvascular, surgery or medical therapyindicated. If avascular with dropping HCGlevels, ectopic tissue is being aborted.
Hypervascular ring of low resistance flow more likelyindicates corpus luteum than ectopic pregnancy
Management of Ectopic Pregnancy
Surgery- usually laparoscopy with eithersalpingotomy or salpingectomy
Spontaneous resolution- more common forstable patients with declining -HCG.Success rates near 70% in select group
Medical - methotrexate
Yao, Fertil Steril 1997;67:421
Methotrexate Therapy
Systemic vs. local
hCG levels at presentation predictoutcomes: 92.5% success if hCG < 4000IU/l
Criteria:
1. Stable patient
2. Growing EP (-hCG)
3. No findings of rupture
4. EP < 3.5 cm
Stovall, Am J Obstet Gyn 1993
Tawfiq, Fertl Steril 2000; 74:877
Gamzu, Fertl Steril 2002; 77:761
Methotrexate vs. Surgery
Saraj, etal Ob Gynec 1998; 92:989
–78% success single dose methotrexate
–92% success laparoscopic surgery
Sowter, etal BJOG 2001; 108:192
–65% success single dose methotrexate
–93% success laparoscopic surgery
Sowter, etal BJOG 2001; 108:204
–Medical treatment associated with reduced directand indirect costs although at hCG levels > 1500IU/l benefits were lost due to need for prolongedfollow-up and surgical intervention
Methotrexate Therapy
Sonography
–Initially may increase in size or vascularity, free fluid.
–May take as long as 5 months for EPresolution
–Rupture may occur, causing pelvic pain and ahemorrhagic mass on sonography.
Atri et al, Radiology 1993
Pregnant patient with right sided pain and prior left
Salpingectomy for ectopic pregnancy
Dx: Right Ectopic
Pregnancy (2/23)
Treatment: Methotrexate
3/2 tubal ring visible 3/16 smaller
6 months later- hysterosalpingogram
Free spill right tube
Increasing size of tubal “mass”with methotrexate therapy
Right ectopic pregnancy treated with methotrexate on6-6-07, returns with pain on 7-3-07
Increased size of ectopic pregnancy, leakingblood, required surgery
No consensus on treatment: Can try medical therapy,but only surgery will allow removal of the pregnancyand repair of the defect
Fylstra, Obstet Gyn Survey 2002;57:537
Pregnant patient with
Bleeding, 4-30
Interpreted asspontaneous abortionin progress
Still bleeding 6-06
Retained products ofconception of scar ectopic
Abortion in progress or ectopic pregnancy?
Patient A
Patient B
Live Cervical Ectopic Pregnancy
Patient B 10 days later
Cervical Ectopic Pregnancy
Occurs in 0.15% of all ectopic pregnancies
If sac is within endocervical canal and embryodemonstrates cardiac activity and/or trophoblasticflow, more likely a cervical ectopic than an abortionin progress
Surgery may lead to significant hemorrhage soconservative treatments include: US guided localinjection methotrexate or KCl or preoperative uterineartery embolization before dilation and evacuation
Levine Radiology 2007;245:385
Right Sag
Right Trv
Right pelvic pain in pregnancy conceived with Clomid