Diagnostic Ultrasound - Abdomen and Pelvis
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Diagnostic Ultrasound - Abdomen and Pelvis

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09.07.2019 Views

Tubal Ectopic Pregnancy (Left) Sagittal transvaginal ultrasound of the uterus shows fluid in the endometrial cavity with low-level echoes st, compatible with a pseudosac. (Right) Sagittal oblique transvaginal ultrasound of the left adnexa shows an echogenic ring-like mass within a thickened tube ſt containing echogenic fluid st. Diagnoses: Female Pelvis (Left) Transverse transvaginal ultrasound of the right adnexa shows a hyperechoic tubular mass adjacent to the right ovary ſt. Note the small amount of adjacent echogenic free fluid st. (Right) Transverse color Doppler ultrasound in the same patient shows a ring of vascular flow st in the tubal mass . (Left) Sagittal transvaginal ultrasound shows pelvic free fluid with low-level echoes ſt that are compatible with moderate hemoperitoneum, which could be due to bleeding from the tube or rupture. (Right) Longitudinal oblique transabdominal ultrasound of the pelvis was repeated after transvaginal imaging showed no evidence of IUP st in a patient with hCG > 2000mIU/mL. A small echogenic ring could only be seen with transabdominal imaging above the uterus and separate from the left ovary ſt. 779

Unusual Ectopic Pregnancies Diagnoses: Female Pelvis TERMINOLOGY • Interstitial ectopic pregnancy (EP): Pregnancy occurring in intramural portion of fallopian tube • Cornual EP: Pregnancy in cornua of an anomalous uterus • Uterine scar EP: Implantation of pregnancy at site of previous uterine surgery • Cervical EP: Gestational sac (GS) in wall of the cervix • Ovarian EP: GS implanted on ovary • Abdominal EP: Implantation in peritoneal cavity • Heterotopic pregnancy: Concurrent intrauterine and ectopic pregnancies IMAGING • Best diagnostic clues on ultrasound (US) ○ Interstitial: Interstitial line sign = echogenic line from endometrium to ectopic sac ○ Cornual: Occurs with uterine mullerian duct anomaly ○ Scar EP: Eccentrically located GS at site of C-section scar ○ Cervical EP: GS eccentric to the endocervical canal KEY FACTS • 3D ultrasound: Improves visualization of gestational sac in relation to the intrauterine cavity • MR: Reserved for problem solving when US findings are equivocal or preoperative planning for large ectopics TOP DIFFERENTIAL DIAGNOSES • Intrauterine pregnancy vs. interstitial or scar EP • Tubal ectopic vs. interstitial EP • Septate uterus vs. interstitial EP • Abortion in progress vs. cervical EP • Corpus luteum vs. ovarian EP CLINICAL ISSUES • Overall, increased morbidity and mortality compared to usual tubal EP ○ Improved blood supply in setting of unusual EP often allows GS to grow larger and present later • Diagnosis of unusual ectopic pregnancy can be difficult; must have a high degree of suspicion, especially in a highrisk patient (Left) Transverse transvaginal US of an interstitial EP shows an eccentrically located GS with a fetal pole protruding from the lateral aspect of the uterus, separate from the empty endometrial cavity ſt. Note thinned overlying myometrium st. (Right) Longitudinal transvaginal ultrasound of a cervical EP shows an empty uterus ſt with a round, eccentrically located gestational sac in the anterior wall of the cervix. Note thin central curved line of the endocervical canal st and fetal pole . (Left) Longitudinal transvaginal US of a cesarean section scar ectopic, shows an eccentrically located gestation sac within the lower anterior uterine myometrium at the site of a cesarean section scar ſt. Note the yolk sac and fetal pole and empty endometrial cavity st. (Right) Longitudinal transvaginal US shows an abortion in progress with a centrally located, tear-drop shaped gestational sac spanning the lower uterine cavity and endocervical canal. Note wide open internal os st and fetal pole ſt. 780

Tubal Ectopic Pregnancy<br />

(Left) Sagittal transvaginal<br />

ultrasound of the uterus<br />

shows fluid in the endometrial<br />

cavity with low-level echoes<br />

st, compatible with a<br />

pseudosac. (Right) Sagittal<br />

oblique transvaginal<br />

ultrasound of the left adnexa<br />

shows an echogenic ring-like<br />

mass within a thickened<br />

tube ſt containing echogenic<br />

fluid st.<br />

Diagnoses: Female <strong>Pelvis</strong><br />

(Left) Transverse transvaginal<br />

ultrasound of the right adnexa<br />

shows a hyperechoic tubular<br />

mass adjacent to the right<br />

ovary ſt. Note the small<br />

amount of adjacent echogenic<br />

free fluid st. (Right)<br />

Transverse color Doppler<br />

ultrasound in the same patient<br />

shows a ring of vascular flow<br />

st in the tubal mass .<br />

(Left) Sagittal transvaginal<br />

ultrasound shows pelvic free<br />

fluid with low-level echoes ſt<br />

that are compatible with<br />

moderate hemoperitoneum,<br />

which could be due to<br />

bleeding from the tube or<br />

rupture. (Right) Longitudinal<br />

oblique transabdominal<br />

ultrasound of the pelvis was<br />

repeated after transvaginal<br />

imaging showed no evidence<br />

of IUP st in a patient with<br />

hCG > 2000mIU/mL. A small<br />

echogenic ring could only<br />

be seen with transabdominal<br />

imaging above the uterus <strong>and</strong><br />

separate from the left ovary<br />

ſt.<br />

779

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