- 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.
