Season 9 Case 15

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

Options:

1) cervical ectopic

2) spontaneous abortion

Here: Closed os, no endometrial fluid = ectopic!

Ectopic W/U:

***ALWAYS check pregnancy status in ANY female that COULD be pregnant.***

Ectopic is often dx of exclusion!

+Pregnancy test

#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.

ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy : Obstetrics & Gynecology

management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely…

LWW

Ectopic Pregnancy

-can be ANYWHERE but ~95% tubal (m/c ampulla)

-3% cornual/interstitial - present late with increased risk of bleed

-~1% ovarian

-<1% cervical

-<1% "scar" (site of prior C-section)

-1% abdominal

Risks: IVF, altered anatomy (h/o PID, IUD, tubal ligation, etc), maternal age

Ectopic Pregnancy Imaging

-empty uterus

-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