Ectopic Pregnancy Ultrasound Imaging: Practice Essentials, Preparation, Technique

A 29-year-old woman who was gravida 4, para 3, and had a 2-week history of lower abdominal pain and vaginal bleeding with large clots presented to the emergency gynecology assessment service. Five weeks had passed since her last period when she made her presentation. Her urinary beta-hCG test was positive. There were no adnexal masses and an empty uterus, according to an ultrasound scan (USS). She was released after being informed that she had a complete miscarriage. She returned 6 days later with severe lower abdominal pain that was radiating throughout her abdomen from her right iliac fossa. An adnexal mass was discovered by a USS in her right fallopian tube. For a right tubal ectopic pregnancy, she underwent a laparoscopic salpingectomy. The patient was started on antibiotics and recovered successfully.

Shalev and colleagues[7] found that the use of TVS in the diagnosis of an ectopic pregnancy has a sensitivity of 87%, specificity of 94%, and positive predictive value of 92 5%. Another study[9] gave a sensitivity of 93%, specificity of 99%, and positive predictive value of 98%, and when a TVS finding of an adnexal mass was combined with serum beta-hCG, this increased the sensitivity to 97%, with equivalent specificity and positive predictive value

The reported case serves as an illustration of a circumstance in which an ectopic pregnancy was improperly excluded and a complete miscarriage was incorrectly diagnosed. The mistake was that an ectopic pregnancy was incorrectly ruled out because there were no adnexal masses on the TVS and no intrauterine gestational sac.

With thanks to Ms. Alpa Shah, Ms. Rashna Chenoy, Dr. Essam El Mahdi, and Dr. Kalpana Rao.

A retrospective study[11] of ultrasonographic s found that a tubal ring (an adnexal mass with a concentric echogenic rim of tissue [a gestational sac] surrounding a hypoechoic [empty] center) was present in 68% of ectopic pregnancies in which the tube had not ruptured For the diagnosis of an ectopic pregnancy, Brown and Doubilet[10] identified the 4 aforementioned ultrasonographic findings. They came to the conclusion that any noncystic adnexal mass is the best indicator of an ectopic pregnancy. The absence of adnexal findings on TVS does not rule out an ectopic pregnancy, it must be noted, so serial serum beta-hCG levels should be assessed. [1].

The risk of ectopic pregnancy is not increased by intrauterine devices (IUDs) used for contraception, and there is no proof that the IUDs currently on the market can cause pelvic inflammatory disease. The fact that ectopic pregnancy occurs more frequently when an IUD is present than intrauterine pregnancy could be one explanation for the false association between IUDs and ectopic pregnancies. 1,8 Simply put, implantation is more likely to take place in an ectopic location because IUDs are more effective at preventing intrauterine pregnancy than ectopic pregnancy.

The low doses of methotrexate used in patients with ectopic pregnancies typically only cause mild, self-limited reactions, despite the possibility for serious toxic effects. Frequent urination, mild diarrhea, and nausea and vomiting are typical side effects. Consequently, if the diagnosis is certain and the ectopic mass is under 3 5 cm in greatest dimension, methotrexate therapy is an option.

Because it is more sensitive and has a smaller discriminatory zone than abdominal ultrasound, transvaginal ultrasound diagnoses intrauterine pregnancies on average one week earlier than abdominal ultrasound (i) e. , a level of hCG between 1,00022 and 1,500 mIU/mL (1,000 and 1,500 IU/L)) When the hCG level is greater than 1,500 mIU per mL and a transvaginal ultrasound does not reveal an intrauterine gestational sac, an ectopic pregnancy may be suspected.

Criteria for methotrexate therapy are listed in Table 2. 11 In addition to -hCG levels, methotrexate indications include hemodynamic stability, ultrasound confirmation of an ectopic pregnancy, significant risk associated with general anesthesia, patient compliance, absence of methotrexate therapy contraindications, small size of the ectopic mass, and absence of fetal cardiac motion.

With each subsequent occurrence, a prior ectopic pregnancy becomes a more significant risk factor. The recurrence rate after linear salpingostomy for a single prior ectopic pregnancy varies from 15 to 20 percent, depending on the health of the contralateral tube. 1,9 A subsequent intrauterine pregnancy lowers the risk of recurrence, which rises to 32% after two prior ectopic pregnancies. 1,10.

An intrauterine pregnancy (IUP) can be seen using obstetric ultrasonography in the emergency department (ED). There should be transvaginal ultrasonographic evidence of an IUP when the beta-human chorionic gonadotropin (-hCG) level is greater than 1500 mIU/mL. The first visible structure is the gestational sac. Later yolk sac, embryonic, and fetal cardiac activity should manifest at regular intervals and with consistent mean sac diameter sizes.

Emergency medicine practitioners and other acute care practitioners can assess patients’ risk for potential ectopic pregnancy using bedside ultrasound. Early diagnosis can significantly reduce morbidity and mortality. The likelihood that the patient can be treated medically or through tube-conserving surgery increases when the diagnosis is made prior to tubal rupture, which can prevent life-threatening hemorrhage.

When a circular, anechoic structure that resembles a gestational sac is seen in the endometrial cavity, take pictures and measure its length, height, and width to determine its mean sac diameter (MSD). These measurements are obtained from the interior of the sac’s echogenic border.

A pathognomonic sign of an early IUP is the perception of a double decidual ring, which is two echogenic rings surrounding the gestational sac. This is regarded as the earliest reliable indication of an IUP in radiology literature. However, because double decidual signs are not always present, care should be taken when using them to determine whether an IUP is present or not. Simple gestational sac demonstration before this point is an unreliable ultrasonographic finding.

When the MSD is greater than 8 mm, the yolk sac should definitely be present by 5–6 weeks of gestation. When the MSD is greater than 16 mm, the embryo, or fetal pole, should be present. It can be seen on transvaginal ultrasound by 6 weeks’ gestation and on transabdominal ultrasound by 7 weeks’ gestation.

How To: Pathology Ectopic Pregnancy 1st Trimester TV 3D Video

Leave a Comment