ECTOPIC PREGNANCY

And
ABORTION

DR.SHAMIM RIMA
MBBS,DMU,FCGP
M.PHL, THESIS PART
RADIOLOGY & IMAGIMG
 ECTOPIC PREGNANCY

Any pregnancy that occurs outside of the uterine cavity

 Tubal
 Ampulla (55%)
 Isthmus (25%)
 Fimbria (17%)
 Cervical
 Ovarian
 Abdominal
 GENERAL CONSIDERATIONS

 Risk factors
- prev. tubal surgery
- prev. ectopic pregnancy
- PID, endometriosis
- prev. c/sec
- assisted reproduction: GIFT, IVF
- failed contraception
 SIGN/ SYMPTOM

Most common presentation:

 Woman of reproductive age

 Abdominal pain

 Vaginal bleeding
 Approx 7 weeks after amenorrhea
 DIAGNOSITC TESTS

Ultrasound (*test of choice)

No intrauterine gestational sac

bHCG

Do not increase appropriately

Urine pregnancy test

Pregnant / not pregnant

Progesterone level (less reliable)

 SONOGRAPHY SUSPECT ECTOPIC PREGNANCY

 Specific features:
> Live embryo in the adnexa
 Non-specific features:
> Empty uterus
> Pseudo-gestational sac of ectopic pg
> Adnexal mass
> Ectopic tubal ring
 Non-supportive features:
> live intra-uterine pregnancy
> Intra-decidual & double decidual sign of
early intra-uterine pg
> Peritropoblastic blood flow
LIVE EMBRYO
TV image: Right adnexal mass / ring gestational sac with yolk sac,
alive embryo at 7.4 weeksTV image: Embryonic cardiac activity
depicted in M-mode.
 
TV image: Embryonic cardiac activity depicted in M-mode
EMPTY UTERUS
Empty Uterus with Ectopic Pregnancy
 PSEUDO-GESTATIONAL SAC OF ECTOPIC PG

The endometrial sac does not have a surrounding chorionic ring and
free fluid is visible in the posterior cul-de-sac.
ADNEXAL MASS
TA image: uterus containing clot and decidual reaction, sm
all amount of fluid cul-de-sac
TA image: Vague right  adnexal mass
TUBAL PREGNANCY
TUBAL PREGNANCY
OVARIAN PREGNANCY
ABDOMINAL PREGNANCY
Sagittal transvaginal image shows the fetal head (h)
in the cul-de-sac, posterior to the uterus (U)
CESAREAN SCAR ECTOPIC PREGNANCY
 ECTOPIC TUBAL RING

Gestational sac surrounded by a thick chorionic ring

outside and immediately adjacent to the myometrium
 INTERSTITIAL PREGNANCY

Gestational sac with a marked eccentric location in the uterus

CORNUAL PREGNANCY
PATHOGENESIS OF ECTOPIC PREGNANCIES

 Tubal pregnancy
- ampullary > isthmic > interstitial
- secondary, tubo-ovarian, tubo-abdiminal,
broad-ligament pregnancies develop
- fertilized ovum burrows through the epith
elium
(because, tube lacks a submocosal la
yer)
 zygote comes to lie within the muscula
r wall
 rapidly proliferating trophoblast invade
s the
subjacent muscuralis
 maternal blood vessels are opened
 TUBAL RUPTURE

- the invading, expanding products of conception

may rupture the oviduct at any sites
- occur in the first few weeks in first trimester
(but, interstitial pregnancy usually occur later)
- usually, spontaneously rupture
(sometimes coitus or bimanual examination)
- rarely, undamaged conceptus into the peritoneal
cavity  lithopedion
RUPTURE ECTOPIC

Pelvis- free fluid

MORISON'S POUCH - FREE FLUID
Enlarged uterus with
grossly thickened
endometrium
(decidual cast) of
almost 15 mm. The
uterus shows
absence of any
gestation sac. No
pseudosac is seen
Transvaginal scan of
the pelvis shows a
large collection of
hemorrhagic fluid in
the cul de sac 3) A
right adnexal mass,
presumably in the
Right Fallopian tube
is also seen. A left
ovarian hemorrhagic
cyst is also present.
 HETEROTOPIC GESTATION

Also called Heterotopic pregnancy or

simultaneous intrauterine and

extrauterine pregnancy or coexistent

intrauterine and extrauterine

pregnancy
 CERVICAL ECTOPIC

•Implantation of the fertilized ovum with

subsequent development within the

cervical structure without involvement
of the corpus uteri (below the level of
internal os)
. In a typical case, the endocervix is
invaded by the trophoblast, and the
pregnancy proceeds to develop in the
fibrous cervical wall. The duration of
pregnancy is dependent upon the site
of embryo implantation. The higher it is
implanted in the cervical canal, the
greater is its capacity to grow and
cause haemorrhage .
Gestational sac in cervico- isthmic region
Transvaginal Ultrasound showing 10 week cervical ectopic gestation
ABORTION
 ABORTION

Spontaneous Abortion
Pregnancy loss at less than 20 weeks’ gestation

Threatened abortion

A pregnancy complicated by bleeding before 20 weeks’

gestation
Inevitable abortion

The cervix has dilated, but the products of conception have not
been expelled

Complete abortion

All products of conception have been passed without need for surgical
or medical intervention
 ABORTION

Incomplete abortion

Some, but not all, of the products of conception have been passed;
retained products may be part of the fetus, placenta, or membranes

Missed abortion

A pregnancy in which there is a fetal demise (usually for a number

of weeks) but no uterine activity to expel the products of conception

Septic abortion

A spontaneous abortion that is complicated by intrauterine infection

Recurrent spontaneous abortion

Three (3) or more consecutive pregnancy losses

 CAUSES

First Trimester Miscarriages

Chromosomal abnormalities
Second Trimester Miscarriages
Structural Problems
Cavity defects:
uterine fibroids
a septum
scar tissue
possibly a large polyp
Cervical insufficiency (also termed cervical incompetence)
Thrombosis
Infection
Genetic or Chromosomal Problems in the Fetus
 RISK FACTORS

Increasing maternal age

9% for a 20-24 year-old
15% for a 30-34 year-old
 51% for a 40-44 year-old
Advancing age of th[e father 
Smoking, alcohol, cocaine and heavy coffee consumption
Certain drugs, such as those used for chemotherapy
Certain medical conditions are risk factors as well. These include:
Poorly-controlled diabetes
Uncontrolled thyroid disease
High prolactin (a hormone associated with breastfeeding) levels
The polycystic ovarian syndrome.
Obesity or severely low weight.
COMPLETE MISCARRIAGE
The absence of the gestational sac and the presence of intrauterine debris
INCOMPLETE ABORTION

Empty gestational sac. 

 MISSED ABORTION

In a missed abortion, falling levels of HCG or ultrasound imaging

confirm that a miscarriage has occurred, but minimal or no
bleeding occurs and the uterus has failed to expel the
pregnancy. 
 MISSED ABORTION

The gestational sac is irregularly formed, and also the embryo is missing
from inside the gestational sac (Blighted Ovum)
Missed abortion 9Wks GA by 2D ultrasound and by using color flow
mapping to detect absence of color signals from fetal heart. The
spectral Doppler shows an artifact from maternal arterial “thump”.