Usg Intensif 14. Ectopic Pregnancy Jje 20080901

ECTOPIC PREGNANCY

Judi Januadi Endjun DIVISION OF MATERNAL AND FETAL MEDICINE Department of Obstetrics and Gynecology Gatot Soebroto Army Central Hospital / Jakarta 2008

MATERI AJAR INI HANYA UNTUK DIPERGUNAKAN DALAM KEGIATAN PENDIDIKAN DAN KESEHATAN

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• Jalani hidup ini dengan sabar, jujur dan ikhlas, • Mau mengerti dan melaksanakan tatacara (adab) yang benar, dan • Mempunyai kemauan untuk selalu berbuat baik memperbaiki diri dan membuat orang lain lebih baik

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AM I PREGNANT ?

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AGENDA • • • • • •

Introduction. Normal early pregnancy. ECTOPIC PREGNANCY. Diagnostic procedures Conclusions. References.

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1

1415

LMP

Ovulation Fertilizati on

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Uterine HCG (+) Implan cavity >10 tation mIU/ml Hanya untuk Pendidikan dan Kesehatan

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USG (+) >400 mIU/ml

> 1800 mIU/ml 6

Normal early pregnancy • TVS can detect GS within the thickened choriodecidua at 5-6 W • Decidua capsularis : forms most of the GS • Decidua vera : the true decidua that surrounds the GS • Decidua basalis : and chorion frondosum form the placenta JJE-13072009

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Normal early pregnancy ∀ β-hCG > 2000 mIU/ml + GS should be sees on TVS in an IUP. β-hCG doubles every 48 hours in a normal IUP • YS should be visible in a GS that is ± 10 mm • The embryo should be visible in a 16 – 20 mm GS JJE-13072009

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Normal early pregnancy • Heart motion should be visible in an embryo ≥ 3 mm. • Normal embryos : HR > 85 bpm at 6 – 7 weeks • HR < 85 bpm can indicate impending failed pregnancy, rescan in 1 week or so • TV-CDS can be used to detect heart motion Hanya untuk Pendidikan dan JJE-13072009

Kesehatan

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AIUM Guidelines for 1st Trimester Ultrasound 1.

The uterus and adnexa should be evaluated for the presence of a gestational sac (GS). If GS is seen, its location should be documented. The presence or absence of an embryo should be noted and CRL recorded

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Presence or absence of cardiac activity should be reported

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Fetal number should be documented

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Evaluation of the uterus, adnexal structures, and culde-sac should be performed Hanya untuk Pendidikan dan

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AIUM Guidelines 1 : • CRL is a more accurate indicator of GA than GS diameter. • Identification of a YS or an embryo is definitive evidence of a GS. Intrauterine fluid collection can sometimes represent pseudogestational sac associated with ectopic pregnancy • During the late 1st trimester, BPD and other fetal measurements also may be Hanya untuk Pendidikan dan used to establish fetal age JJE-13072009 Kesehatan

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AIUM Guidelines 2 : • Real time observation is critical for this diagnosis. • With vaginal scan, cardiac motion should be appreciated by a CRL of ≥ 5 mm. If an embryo < 5 mm is seen with no cardiac activity, a follow-up scan may be needed to evaluate for fetal life. JJE-13072009

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AIUM Guidelines 3 : • Multiple pregnancies • Pseudo GS : incomplete fusion between the amnion and chorion, or elevation of the chorionic membrane by intrauterine hemorrhage

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AIUM Guidelines 4 : • Recognition of incidental findings : myomas, adnexal mass, fluid in the cul-de-sac or the flanks and subhepatic space • Correlation of serum hormonal levels with US findings often is helpful for diagnosis of EP or normal pregnancy Hanya untuk Pendidikan dan JJE-13072009

Kesehatan

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4 WEEKS PREGNANCY +

• GS 2 – 5 mm is seen within the endometrium • Spherical, regular in outline, and eccentrically situated towards the fundus • Implanted just below the surface of the endometrium (midline echo), and is surrounded by echogenic trophoblast • If YS not visible → repeated in 1 week JJE-13072009

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Trish Chudleigh, 2004 16

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5th Week of Menstrual Age (Day 15 – 21 Postconception) • Observed under microscope : IVF/ET, ICSI • Chorionic sac : 16 day post conception, 2 mm. Day 18 : 4 mm, YS can be seen

• The chorion : circular echogenic structure bordering directly on the decidua

• HRCD imaging can define maternal blood vessels between the decidua and chorion

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5th Week of Menstrual Age (Day 15 – 21 Postconception) • A hypoechoic structure in the uterine cavity can be identified as a chorionic sac only if it is surrounded by hyperplastic endometrium and displays an echogenic border, the chorion frondosum • If these signs are disregarded, a fluid collection in the uterine cavity (= pseudogestational sac) in an ectopic pregnancy may be misinterpreted as an intrauterine pregnancy • If mean GS diameter > 12 mm and YS can’t be seen → suspect anembryonic pregnancy → repeated in 1 week (Chudleigh T, 2004) JJE-13072009

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6th Week of Menstrual Age (Day 22 – 28 Postconceptional) • Fetal pole : can usually be seen adjacent to the YS, echogenic structure about 1 mm long on the surface of the YS • Notochord : pear shaped appearance in coronal section and contains a central notochord. The neural tube begins to close from the rostral direction. These process concludes on day 38 of menstrual age with closure of the inferior neuropore • Heart activity : 23rd day postconception, consistently after 26th day. The development of the cardiac pump and vascular system are parallel JJE-13072009

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6th Week of Menstrual Age (Day 22 – 28 Postconceptional) • The embryo changes from being straight line at the top of YS to being kidney-beanshaped, with the YS separated from the embryo by the vitelline duct • CRL : 4 – 10 mm • IF FHR is not detectable → miscarriage ? JJE-13072009

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CARDIAC ACTIVITY • CRL ≥ 7 mm should visible FHR • Rapid ↑ of the mean FHR between 6-9 W followed by a slight decline after 10 W • Late onset and ↓ FHR in the 1st trimester → higher rate of spontaneous abortion JJE-13072009

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7th Week of Menstrual Age (Day 22 – 28 Postconception) • Separation from the YS : 4 mm embryo, rostral pole begins to fold away from the YS, still broadly adherent to the YS. • After development of the connecting stalk, the embryo increasingly separates, the YS is extruded into the extra-amniotic coelom. • Only the vitelline duct connecting it to the embryonic vascular system JJE-13072009

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7th Week of Menstrual Age (Day 22 – 28 Postconception)

• C-shaped Embryo : at the end of 7th W, the AM still closely attached to the embryo, dominant rostral pole, and limb buds can be distinguished on the lateral aspects of the body

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7th Week of Menstrual Age (Day 22 – 28 Postconception) • CRL : 11 – 16 mm • Rhombencephalon becomes distinguishable as a diamond-shaped cavity, enabling distinction of the cephalad and caudal poles of the embryo • The spine : double echogenic parallel lines • AM and UC can also be seen JJE-13072009

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7th Week of Menstrual Age (Day 22 – 28 Postconception) • CRL 12 mm (7+3 weeks) : the head can be discriminated from the torso • Intracranial structures visible from 7 weeks onward are rhombencephalon, diancephalon, the 3rd ventricle, the hemispheres, the lateral ventricles, and the mesencephalon with the aqueduct of Sylvius (TVS : from 9 weeks) JJE-13072009

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PREGNANCY FAILURE • Pre-embryonic : > 50% • Embryonic : 28% • Fetus : 10% • 7-9 weeks : 5% • 10-12 weeks : 1 – 2%

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• GS (+) : 11,5% • YS (+) : 8,8% • Embryo ≤ 5 mm : 7,1% • Embryo 5-10% : 3,3% • Embryo ≥ 10 mm : 0,5%

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ETIOLOGY OF PREGNANCY FAILURE • Pre-embryonic : 70% chromosomal abnormalities • Embryonic : 56% chromosomal abnormality • Fetus : placentation abnormality, perfusion disturbances, uterine defect : uterus subseptus (↑ 4,7 x) , uterus arcuatus (↑ 5,8 x), uterus septus, maternal disease(s), cervical incompetent. • Antibody antinuclear : Uterine artery Pulsatility Index ↑ • Progesterone ↓ JJE-13072009

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Problems of Early Pregnancy 1. 2. 3. 4. 5. 6. 7.

Hormone measurement : hCG Miscarriage and IUFD Ectopic pregnancy Cervical pregnancy Ovarian pregnancy Abdominal pregnancy Heterotopic pregnancy

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• Pregnancies of unknown location • Twins pregnancy • Trophoblastic disease • Ovarian problems • Uterine fibroids • Pregnancy and IUD • Screening fetal anomaly • Organization of early pregnancy unit

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Hormone measurement : hCG • hCG > 25 IU/L = day 24 – 25 of a regular 28day cycle • Double approximately every 2 days • EP is suspected if hCG does not double in 2 – 3 days or cut-off 1000 IU/L can not be seen GS in TVS • Expectant management of EP if hCG < 1000 IU/L JJE-13072009

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Ectopic pregnancy (EP) • 93% are tubal pregnancy • UK : 4.9% (1970) → 9.6% (1992) (RCOG, 2000) • Pain w / wo vaginal bleeding • High risk : previous tubal pathology or surgery, with an IUD

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Ectopic pregnancy • Clinical conditions which increase risk of EP include the presence of a scarred tube from salpingitis/PID and/or previous tubal surgery • TVS : no GS within uterus. Uterus size is normal or slightly enlarged . 85% in initial US scan (Chudleigh T, 2004) • Extrauterine extraovarian adnexal mass, pseudogestational sac (10 – 29% of EP : Chudleigh T, 2004), and hemoperitoneum • The EP is usually on the side of the CL : ± 78% (Chudleigh T, 2004)

• Living embryo outside of the uterus JJE-13072009

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Ectopic pregnancy • EP may also contain a rim of increased vascularity, although this is variable, depending on the extent of trophoblastic invasion into the tubal wall • TV-CDS can distinguish distended paraovarian/uterine veins from the vascular rim of an EP • EP have variable wall vascularity and pain • A ruptured EP can be implied if there is a complex solid tubal mass, hematosalpinx, or hemoperitoneum • Fluid in the pouch of Douglas : 20 – 25% (Chudleigh T, 2004) (Arthur C. Fleischer, 2004) JJE-13072009

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Clinician’s Approach to Ectopic Pregnancy •

Clinical diagnosis

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Ultrasound sign

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Indications for workup

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Extra uterine findings

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Transvaginal ultrasound

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Indetermined sonograms

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Serum βhCG and the discriminatory zone

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EP vascular flow patterns

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Sonographic assistance in therapeutic management

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Clinical interpretation of sonographic findings

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Delayed or missed diagnosis is seen as failure of care and can result in litigation

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Rare types of ectopic pregnancy • Cornual EP : can occur within one uterine cornua, it

can enlarge because it is surrounded by myometrium. If it ruptures, catastrophic bleeding can occur

• Abdominal EP : can be diagnosed by the presence of fetus, choriodecidua, or placenta separate from uterus

• Cervical EP : GS inside the cervical area • Ovarian EP : virtually impossible to distinguish from CL if the embryo is not seen

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Interstitial EP • • • •

Interstitial portion of the fallopian tube 1.1 – 6.3% of all EP IVF and previous salpingectomy Upper lateral aspect of the uterus, outside the uterine cavity and partially surrounded by myometrium • The proximal interstitial segment of the tube joining the uterus • Severe hemorrhage and hysterectomy • MTX is effective for the treatment of early interstitial pregnancy JJE-13072009

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Cervical Pregnancy • Implanted below the IO • 1:2400 to 1:50,000 pregnancies • 0.15% of all EP US Criteria : 5. No evidence of an IUP 6. An hourglass uterine shape with ballooning of the cervical canal 7. The presence of a GS or placental tissue within the cervical canal, especially if cardiac activity is present 8. A closed internal os •

MTX : local injection or systemic or potassium chloride local injection JJE-13072009

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Ovarian Pregnancy • 1:4000 to 1:7000 deliveries US Criteria : • • • • •

Ipsilateral tube must be intact GS must be within the ovary The ovary must be connected to the uterus by the ovarian ligament Ovarian tissue must be within the sac wall GS cannot be separated from the ovary

• DD : corpus luteum, fixing fallopian tube to the ovary due to pelvic adhesion • Local excision by Laparoscopically

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Abdominal Pregnancy • 1:3400 to 1:8000 deliveries • Intraperitoneal implantation (exlusive of intratubal, ovarian, or intraligamentous sites of nidation • GS or fetal parts are usually seen behind the uterus in the pouch of Douglas or laterally within the broad ligament

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Heterotopic Pregnancy • IUP + EP • 1:6000 pregnancies • High risk : ART

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Pregnancies of Unknown Location • 8 – 31% diagnosis cannot be made by US at the initial visit • Serum hCG and progesterone

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CONCLUSIONS • TVS has a vital role in the evaluation of patients presenting with hemorrhage, distinguishing a pregnancy with subchorionic hemorrhage from an ectopic pregnancy or failed IUP. (Arthur C. Fleischer, 2004) • TVS can accurately detect ectopic gestational sacs in most cases. (Arthur C. Fleischer, 2004) • Determine the objectives of 1st trimester ultrasound.

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CONCLUSIONS • Use the appropriate transducer and the route of examination. • Minimize side effects. • CPD very important for maintaining personal competence • Good evidence that dating by ultrasound is more accurate than even a reliable menstrual history in the majority of cases (Chudleigh T, et al, 2004) • 3D and Doppler examinations should be performed if there indicated. JJE-13072009

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THANK YOU

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