Johns Hopkins Radiology Case of the week Cindy Lee October 15, 2010 Case • 34 y/o F • PMHx: Peripartum cardiomyopathy • HPI: diffuse body aches, nausea, abdominal cramping since this morning. Came to ED for lower abdominal cramping. While in ED waiting room, started to have mild vaginal bleeding. • LMP 2 weeks ago. • Labs: mild anemia (Hgb 10), b-hcg 23633. US Follow up • Laparoscopy: Right adnexal ectopic involving the right fallopian tube and right ovary with rupture site 1cm from the cornua. • Friable vascular tissue adherent to the sidewall near the round ligament and the anterior cul de sac. - felt to be c/w placental tissue from rupture of the ectopic. • Postoperative MTX Ectopic Pregnancy • 2% of all pregnancy in US • Incidence increased 6x in past 25 yrs – Better detection – IVF • Sx: abdominal pain (97%), vaginal bleeding (79%). Typically 5-6 wks GA. – Classic triad of pain, abnml vag bleeding, palpable adx mass (45%). • RF: prior EP (13%), IVF (4-5%), IUD, tubal ligation/disease, PID. • Locations: >90% tubal (ampullary 75%), ovary, abd, cervix, c-scar. +B, Pain. IUD Value of F/u US and hCG • In normal IUP, expect to see yolk sac if MSD>13mm, FP if MSD>18mm. • Ex: No clear IUP. hCG 950. Nml adnexae. What then? – When hCG<1000 and no IUP seen, ddx: early IUP, spontaneous abortion or EP. – When hCG rises abnormally (<60% increase in 48hrs and not steadily declining), assumed EP. – f/u hCG and/or US in 2-3 days. GS grow 0.8mm/day. – 5-18% EP detected only at repeat US. • Visualization of IUP lowers risk of EP (heterotopic pregnancy 1:2000-10000), except in IVF (3%) Sonographic diagnosis of EP • Endometrium – – Decidual cyst/Pseudocyst: Eccentric fluid collection without echogenic rim. Not spec or sens.. Pseudosac: Central fluid collection (blood) with one echogenic rim. No round well defined shape like IUP. Intradecidual sign Pseudocysts Pseudosac Sonographic diagnosis of EP • Endometrium – Decidual cyst: Eccentric fluid collection without echogenic rim. – Pseudosac: fluid collection centrally in endometrial cavity. • Adnexa – – – • Live EUP most specific (8-26%). Extraovarian tubal ring (40-68% sens) Most common: Complex adx mass sep from ovary. Pelvic: hemoperitoneum. – – • Echogenic fluid in +B pt, has PPV (86-93%) for EP. Ruptured EP vs hemorrhagic cyst in unstable pt. Doppler: “ring of fire. “ – – Help diff from bowel loops. 70-90% EP occur in same side as corpus luteum. Spotting. MTX. Bleeding, +B, LMP8wks, Sx. B 17K, bleeding. Most common Presentation Sx Bleeding, B1150, YS, Sx Tubal ligation. +B, bleeding, LMP8wks, EU GS Rupture EP Mimics of EP • most common: exophytic or a ruptured hemorrhagic corpus luteum cyst. – – – – – TOA, ovarian torsion Pedunculated fibroids Spontaneous abortion w retrograde flow of blood Tubal cysts Bowel. +hCG, abd pain. Hemorrhagic cyst Management of EP • Expectant management – Minimally symptomatic women w declining or stable hCG levels and small adnexal masses can be safely monitored. – High prob of spontaneous resolution when hCG<1000. • Medical treatment – May be given as 1 IM dose MTX (can be repeated in 7 days) – Effective 80-85% – Criteria: 1. <10,000 hCG. 2. EP <4cm in diameter 3. No heart beat. 4. Pt compliance – Preferred if previous Sx, extensive pelvic adhesions, intolerance of general anesthesia, failure of expectant mgt. – Repeat US indicated only in suspected rupture. – Most pt show increasing hemorrhage near EP, increased mass size. Adx mass visible up to 3 months post MTX. • Surgery – Laparascopy typically; Indications: unstable, poor compliance, criteria not met/failed MTX. Laparotomy indications: tubal rupture, hypotension or anemia. Management of EP • US guided intra-amniotic injection – KCl or MTX directly injected into GS or embryo (if >5mm). – Tx of choice for cervical, interstitial, heterotopic and C-scar EP. – Adv: ablate only EP, spare nml IUP, preserve uterus. References • Dialani, Vandana and Levine, Deborah. Ectopic Pregnancy: A Review. Ultrasound Quarterly. 2004;20:105-117. • Kirk, E and Bourne, T. Diagnosis of ectopic pregnancy with ultrasound. Best Practice & Research Clinical Obstetrics and Gynaecology. 2009;23:501-508. • Patel, Maitray. “Rule out Ectopic”: Asking the Right Questions, Getting the Right Answers. Ultrasound Quarterly. 2006; 22:87-100. Thank you Role of MR in EP diagnosis • Increasingly used for complicated cases in whom dx is unclear. • Help plan surgical approach in abd EP. • Help assess unusual scar EP. • Help diagnose tubal EP.