History: Vaginal Bleeding
What is the first question to ask? What are the possible diagnoses? (more images to come of course!)
First question of a pelvic ultrasound is ALWAYS: Is the patient pregnant?
(+)Urine pregnancy test
Answer: Cervical Ectopic Pregnancy
Imaging is easy! -
NO IUP(endometrium opposed, no fluid or sac)
Here there is a gestation sac w/ fetal pole in cervix
1) cervical ectopic
2) spontaneous abortion
Here: Closed os, no endometrial fluid = ectopic!
***ALWAYS check pregnancy status in ANY female that COULD be pregnant.***
Ectopic is often dx of exclusion!
#1 IUP? Yes=Done. No=too early or spontaneous AB or ectopic
#2 bHCG? descrim level=3500*. >3500 =not too early
#3 bHCG trend? Decreasing =AB, Stable or Increasing = ectopic
*Some may ask bHCG of 3500?
2018 ACOG Practice bulletin rec raising descriminatory level to 3500 for a single quant bHCG when utilized with a transVAGINAL US in order to minimize the risk of overtreating o/w nl early IUPs with mtx.
-can be ANYWHERE but ~95% tubal (m/c ampulla)
-3% cornual/interstitial - present late with increased risk of bleed
-<1% "scar" (site of prior C-section)
Risks: IVF, altered anatomy (h/o PID, IUD, tubal ligation, etc), maternal age
Ectopic Pregnancy Imaging
-live extra-uterine gestation(rare)
-often see NOTHING
-complex mass adj to ovary(can resemble corpus luteum but CL is IN the ovary) -tubal ring about sac
-Doppler ring of fire -seen with CL as well!
-endometrial fluid ie pseudogestational sac
Cervical Ectopic Treatment:
Cervical Ectopic Trt -IM mtx limited effect - NO DNC due to increased risk of severe hemorrhage
-Intrasac mtx or KCL (if +hr) -IR uterine artery embo -hysterectomy