Ectopic Pregnancy Case Study – Part 1


– Hello, my name is Phil Perrera, and I’m the emergency
ultrasound coordinator at the New York Presbyterian
Hospital in New York City, and welcome to SoundBytes Cases. Today’s module is going to
focus on ectopic pregnancy. Ectopic pregnancies constitute about 2% of all total pregnancies, although they’re commonly seen
in the emergency department. Ectopic pregnancy is more
commonly seen in women with a history of tubal ligation who are using interuterine
devices for contraception or have a history of sexually
transmitted diseases, such as pelvic inflammatory disease with scarring of the tubes. Ectopic pregnancy is also
commonly seen in women using fertility agents, which accounts for the increasing
rate of ectopic pregnancy over all. As a golden rule, we must
consider ectopic pregnancy in all women with abdominal pain and/or vaginal bleeding and
a positive pregnancy test, until ruled out by sonography. Let’s begin by reviewing
the OB/GYN anatomy that we’ll need to know to
perform bedside ultrasound of the uterus and the adnexa. We’ll begin by locating
the lower cervical region of the uterus. The portion above that, the
body, and the fundal region of the uterus above the body, which is where we define
an inter-uterine pregnancy to be located. Notice the intersticial
region of the uterus, that region of the uterus
that abuts the fallopian tube. In a cornual uterus this
is known as cornual region. Here we also see the portions
of the fallopian tube, the proximal isthmal region, the distal infindibulum, and notice the ampullary region which comprises the majority
of the fallopian tube. We also see here, the broad
ligament which encases the fallopian tube and
ovary in the lateral region of the adnexa. Remember that the ovary
is relatively mobile within the broad ligament. Now let’s review a
transvaginal long axis scan from a women who presented
with a positive pregnancy test, who had lower abdominal
pain and vaginal bleeding. Notice the fundus, as
shown here to the left, the cervix to the right. We see here the presence
of a thickened white endometrial stripe in the
midline of the uterus. Notice the pelvic cul de
sac that potential space posterior to the uterus. Notice here the absence of
an inter-uterine pregnancy. Now, confirm the absence
of an IUP by scanning in the transvaginal short axis plane. Here we have the probe marker oriented towards the patient’s right, and we’re cutting the
uterus in cross section. Notice again the thickened
endometrial stripe in the midline of the uterus, and the pelvic cul de sac posteriorly. Again, we see the absence of an IUP, and also note the absence of free fluid, dark anechoic fluid collections within the pelvic cul de sac. So, given these findings
we’re now concerned about the presence of
an ectopic pregnancy. So, lets begin our discussion
of ectopic pregnancies by reviewing the locations
that we commonly see ectopic pregnancies to be found. We see here a normal uterus to the left, and a bicornuate uterus to the right. We remember that a fundal
location is the definition of an inter-uterine pregnancy
as shown smack in the middle of the normal uterus to the left. However, we can have variants
of ectopic pregnancies within the uterus as shown
in the interstitial location in the normal uterus to the left, and in the cornual region
in the bicornuate uterus to the right. We can also have implantations low within the cervical region of the uterus, as shown in the normal uterus to the left. Now, most ectopic
pregnancies will be located within the fallopian tube and of those the majority will be found
in the ampullary region as that comprises the majority
of the fallopian tube. But we can have
implantations more proximal, within the isthmal region or distal within the infindibular region. Now, tough ectopics to
diagnose are those that implant within the ovary, within the abdominal cavity, or within the peritoneal lining. These can be very, very hard to diagnose and commonly grow to an
advanced stage before diagnosis. So, returning to our case,
given the presence of a positive pregnancy test and the absence of an IUP on bedside ultrasound, we
were very concerned about ectopic pregnancy and decided to scan out to the left adnexa. Here, notice we’re scanning
out to the left adnexa, and we have a positive finding. What we see here is a
thickened fallopian tube, comprising what is
known as the bagel sign. Notice within the
thickened fallopian tube, we have another positive finding. That is the presence of a fetal pole. So, in this patient we
were able to diagnose an ampullary ectopic
pregnancy and our next move was to call OB/GYN stat
for a consultation. So, in conclusion, ectopic
pregnancies constitute the greatest cause, overall,
of maternal mortality. We must consider an ectopic
pregnancy in all women with a positive pregnancy test where an inter-uterine
pregnancy is not visualized within the fundal part of the uterus. Most ectopic pregnancies
are going to be located in the fallopian tube, and we may actually visualize the ectopic with ultrasound evaluation of the adnexa as shown in this module. So, we’ll return with
ectopic pregnancy part two which goes over the varied manifestations of ectopics.

9 Replies to “Ectopic Pregnancy Case Study – Part 1”

  1. fantasti presentation its like spoon feeding, now I have the confidence of finding out fetal demise

  2. Sir my first pregnancy is ectopic and my second pregnancy is same that it is ectopic can you explain me why again and again my pregnancy is ectopic. I have only one tube

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