Ectopic Pregnancy

1
Ectopic Pregnancy
HARVARD MEDICAL SCHOOL
BETH ISRAEL DEACONESS MEDICAL CENTER

• D. Levine, MD

2
Pseudosac
3
(No Transcript)
4
Blood in cul-de-sac
5
Blood in right flank
6
Ruptured heterotopic pregnancy in IVF patient
with intrauterine twins
7
Corpus Luteum
8
Corpus LuteumThe corpus luteum is in the ovary
an ectopic is typically in the tube
IUP
Left Ovary
9
Normal Early Pregnancy
Intradecidual Sign Double Decidual Sac
Yolk Sac
10
Case 1 empty uterus
11
Case 1 hyperstimulated ovaries
12
Case 1 ectopic
13
Case 1 live ectopic
14
Case 2 Note that the ectopic is separate from
the ovarian cyst
15
Dont be reassured by the patients dates, the
sonographic appearance is whats important
16
Case 3 In a patient with an IUD and a positive
pregnancy test, ectopic pregnancy is likely
17
Case 3 IUD and ectopic
18
Case 4 An empty uterus and blood in the
cul-de-sac ddx ectopic vs. ruptured
hemorrhagic cyst
19
Case 5 6 weeks by dates
20
Case 5 5 days later, hematosalpinx due to
ectopic pregnancy
21
Case 6 empty uterus
22
Case 6 normal ovaries
23
Case 6 ectopic adjacent to ovary
24
Case 7 IUD with free fluid
25
Case 7 blood in cul-de-sac, left ectopic
26
Case 8 blood surrounds uterus
27
Case 8 fluid up by kidney
28
Case 8 you knew it had to be there, but this
proves where the ectopic is
29
Case 9 Cervical Ectopic
30
Case 10 Isthmic Ectopic
31
Case 10 Isthmic Ectopic
32
Case 11 Abdominal Ectopic
33
Case 12 5 weeks pregnant, note the ?ectopic
pregnancy (arrow) adjacent to left ovary
34
Case 12 9 days later there is an IUP. We
presume the prior appearance was due to a bowel
loop
35
Case 13 ?ectopic? Scans 2 days apart show IUP
on follow-up. Why was a gestational sac not
visualized on the original scan?
Original scan
2 days later
36
Case 14 Scans 2 weeks apart show a ruptured
ectopic on follow-up
5/1/01
5/17/01
5/17/01
37
Case 15 Scan done at night by on-call resident,
fails to show IUP, but the fundus of the uterus
in not on the image
38
Case 15 Scan the next AM shows IUP
39
Case 16 hematosalpinx and blood in cul-de-sac
due to ruptured ectopic
40
Case 17 Twins with blood in pelvis patient was
not being treated for infertility. Managed
expectantly, and no surgery or intervention was
needed. Presumed ruptured hemorrhagic cyst
41
Case 17 (continued)
42
?-HCG

• Bioassay
• 1934 WHO First international standard
• 1964 WHO Second international standard BUT
• Reference material was contaminated
• So the value of 2nd IS 2 (1st IS)
• Gestational sac IRP 2000mIu/ml (EV) Bateman
  et al ObGyn 1990 75421-427

43
Ectopic Pregnancy

• hCG gt 2000 mIU/ml (IRP)
• no IUP on ultrasound
• treated
• DC - villi (presumed SAB)
• Methotrexate

44
If a woman is treated for ectopic pregnancy with
diagnostic laparoscopy

• Possible that women with early IUPs will be
  inappropriately treated
• Possible that women will lose an otherwise normal
  pregnancy

45
(No Transcript)
46
(No Transcript)
47
17 women with IUP, hCG gt2000 where IUP not
visualized with ultrasound

• 1 case performed at night by resident
• 1 case of triplets
• 1 case where hCG 2150 (range of error of lab
  test)
• 6 cases where possible intradecidual sign, but
  not enough to call with confidence
• 8 cases remain unexplained

48
Conclusion

• hCG of 2000 mIU/ml without a sonographic IUP,
  while suggestive of an abnormal pregnancy is NOT
  diagnostic
• If all patients with hCG gt 2000 mIU/ml are
  treated for ectopic pregnancy, then a significant
  number of potentially normal pregnancies will be
  aborted

49
Conclusion

• Since recent literature suggests that many stable
  patients with EP can be closely followed rather
  than treated, it is reasonable to follow many of
  these early cases