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Age: 35

Sex: Female

Indication: Pregnant, right lower quadrant pain

History of Cesarean section

Beta-hCG: 4510 mIU/mL

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Case #20


Findings

  • 1.4 cm gestational sac adjacent to the right ovary containing a yolk sac measuring 0.4 cm and a fetal pole measuring 0.7 cm
  • Cardiac activity is observed with heart rate of 134 beats/minute
  • Estimated gestational age by crown-rump length is 6 weeks, 4 days
  • Small amount of heterogeneous debris in the endometrial canal without discrete intrauterine gestational sac identified
  • Myometrial thickening and heterogeneity anteriorly in the uterine fundus with mild associated distortion of the endometrial canal, which may relate to a uterine fibroid or focal adenomyosis
  • Cesarean section scar in the lower uterine segment anteriorly
  • Bilateral ovarian follicles with a possible corpus luteum on the right
  • Preserved arterial and venous waveforms in both ovaries on spectral Doppler tracings
  • Trace free fluid layering in the cul-de-sac


Diagnosis

Ectopic pregnancy

Sample Report

Right adnexal (likely tubal) ectopic pregnancy with gestational age of 6 weeks, 4 days estimated based on crown-rump length. Heart rate: 134 beats/minute.

No intrauterine pregnancy is identified.

Trace free fluid layering in the cul-de-sac.


Discussion

  • While ovarian torsion is the feared gynecologic pathology in a young woman with a negative pregnancy test, ectopic pregnancy is the feared pathology with a positive pregnancy test
  • In fact, ectopic pregnancy is the leading cause for first trimester maternal death
  • Nearly all ectopic pregnancies are tubal and most of these involve the ampulla
  • Typical ultrasound findings in a tubal ectopic pregnancy include:
    • Cystic structure with a thick wall with avid peripheral vascularity on color Doppler analysis (“ring of fire” appearance) external to both the uterus and ovary
      • A corpus luteum can have an identical appearance, but is within the ovary
    • Pseudo-gestational sac sign – decidual reaction surrounds endometrial fluid creating a cyst-like appearance. This will be located centrally in the endometrial canal unlike a true gestational sac which will be eccentric to the canal within the endometrial wall
    • Free fluid may be seen. Hemoperitoneum accompanies ruptured ectopic pregnancy
  • Additional (much less common) locations for ectopic pregnancies include:
    • Interstitial – implantation of the gestational sac in the segment of the uterine tube passing through the uterine myometrium
      • These can be challenging to diagnose and typically can grow larger than tubal ectopic pregnancies before rupturing
      • Look for eccentric location of the gestational sac in the uterine fundus with an echogenic line connecting the sac to the endometrial canal
      • Also worry about this if the myometrial thickness overlying the gestational sac is < 5 mm
    • Ovarian – intraovarian growth of the gestational sac, which can be challenging to differentiate from a corpus luteum. Short followup imaging can help differentiate the two if initial workup is unclear
    • Cervical – can be confused for spontaneous abortion in process, though in spontaneous abortion, the gestational sac is not attached to the cervix and should move with gentle manipulation as well as on serial imaging
    • Cesarean section scar – look for a gestational sac in the anterior wall of the lower uterine segment in a patient with history of C-section
    • Intra-abdominal – gestational sac in the peritoneal cavity clearly separate from the ovaries and uterine tubes
      • Highest associated mortality rate
    • Heterotopic – two or more gestations, both intrauterine and extrauterine in location
      • The pseudo-gestational sac associated with tubal ectopic pregnancies can sometimes be confused for heterotopic pregnancy



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