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ASER 2009

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Emergency Sonography of the Pregnant Patient, American Society of Emergency Radiology (2009)

Emergency Sonography of the Pregnant Patient, American Society of Emergency Radiology (2009)

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  • 1. Emergency sonography of the pregnant patient
    Daniel Noujaim, MD
    Gabriel Werder, MD
    Tiffany Langlas, MD
    FarnooshSokhandon, MD
    Department of Radiology
    William Beaumont Hospital
    Royal Oak, Michigan
  • 2. Objectives
    Present an organized approach to the sonographic evaluation of the pregnant patient in an emergency setting
    Illustrate imaging features of various pregnancy-related conditions in an unknown-case format
    Discuss the pathogenesis, epidemiology, clinical presentation, diagnosis, & outcome of the above conditions
  • 3. Abnormal pregnancyUterine complicationsAbnormal placentationNon-obstetric complications of pregnancyConditions that mimic obstetric pathologyPostpartum complications
  • 4. Abnormal Pregnancy
    Spontaneous abortion/failed first trimester pregnancy
    Ectopic pregnancy
    Molar pregnancy
  • 5. Uterine Complications
    Cervical incompetence
    Premature rupture of membranes
    Uterine rupture
  • 6. Abnormal Placentation
    Vasa/placenta previa
    Placenta acreta/increta/percreta
    Placental abruption/subchorionic hemorrhage
    Succenturiate (accessory) lobe
    Circumvallate placenta
  • 7. Non-Obstetric Complications of Pregnancy
    Hydronephrosis
    Deep vein thrombosis
    Ruptured splenic artery aneurysm
    Hemolysis, elevated liver enzymes, low platelets (HELLP)
  • 8. Conditions that Mimic Obstetric Pathology
    Uterine (Braxton-Hicks) contraction
    Corpus luteum
    Ovarian torsion
    Tubo-ovarian abscess
    Cystic ovarian disease/endometriosis
    Acute appendicitis
  • 9. Postpartum Complications
    Retained products of conception
    Endometritis
    Ovarian vein thrombophlebitis
    Bladder flap/subfascial hematoma
  • 10. Case 1: Clinical History
    19-year-old G2,P0
    Last menstrual period: 10 weeks ago
    Beta-hCG: 230,335 mIU/ml
    Vaginal bleeding
  • 11. Case 1: Diagnosis?
  • 12. Case 1: Imaging Findings
    Heterogeneous, hyperechoic intrauterine compartment with multiple cystic elements
    “Swiss cheese endometrium”
  • 13. Case 1: Complete Molar Pregnancy
    Pathogenesis
    100% paternal genetic complement (diploid)
    Haploid sperm fertilizes “empty” ovum & duplicates to diploid
    Two sperm fertilize “empty” ovum
    Epidemiology
    5/10,000 in US
    Recurrence risk 1-2%
    Presentation
    Vaginal bleeding, hyperemesis, &/or rapid uterine enlargement
    Diagnosis
    Heterogeneous, hyperechoic intrauterine mass with cystic elements
    Markedly elevated beta-hCG
    Ovarian hyperstimulation (theca lutein cysts)
    Outcome
    12-15% progress to invasive mole
    5-8% progress to choriocarcinoma
  • 14. Case 1: Diagnosis?
    Patient presents 2 weeks after dilation & curettage with persistent vaginal bleeding & increasing beta-hCG
  • 15. Case 1: Metastatic choriocarcinoma
    Patient presents 2 weeks after dilation & curettage with persistent vaginal bleeding & increasing beta-hCG
  • 16. Case 2: Clinical History
    33-year-old G2,P0
    Last menstrual period: 3 weeks ago
    Beta-hCG: 2,256 mIU/ml
    Severe left lower abdominal quadrant pain
  • 17. Case 2: Diagnosis?
  • 18. Case 2: Imaging Findings
    Empty uterus
    Ring-like left adnexal mass
    Free fluid in cul-de-sac
  • 19. Case 2: Ruptured Tubal Ectopic Pregnancy
    Pathogenesis
    Ectopic implantation site (95% tubal; 85% same side as corpus luteum)
    Epidemiology
    1.4% (all pregnancies); 10-40% (fertility patients); 5-20% (pain/bleeding)
    Presentation
    Vaginal bleeding, pelvic pain, mass, &/or hemodynamic instability
    Diagnosis
    Positive beta-hCG
    No intrauterine pregnancy (possibly pseudogestional sac)
    Prominent echogenicendometrium
    Ring-like tubal mass with increased flow (“ring-of-fire”)
    Echogenic cul-de-sac fluid (adnexal mass + fluid: 98% sensitive)
    Outcome
    Treatment: systemic methotrexate, surgery, or US-guided injection
    80% have future intrauterine pregnancy
    15-20% have future ectopic pregnancy
  • 20. Sites & frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.
    Sepilian VP, Wood E. eMedicine: Ectopic Pregnancy. http://emedicine.medscape.com/article/258768-overview. Accessed 9/23/2009.
  • 21. Case 3: Clinical History
    35-year-old G4,P2
    Last menstrual period: 6 weeks ago
    Beta-hCG: 972 mIU/ml
    Vaginal bleeding, right lower abdominal quadrant pain, & right shoulder pain
  • 22. Case 3: Diagnosis?
  • 23. Case 3: Imaging Findings
    Thick, echogenicendometrium without evidence of intrauterine pregnancy
    Heterogeneous left adnexal mass with increased circumferential flow distinct from left ovary
  • 24. Case 3: Diagnosis?
    Evaluation of remainder of abdomen reveals the following:
  • 25. Case 3: Ruptured Tubal Ectopic Pregnancy
    Evaluation of remainder of abdomen reveals the following:
    Abnormal echogenicperihepatic fluid collection compatible with rupture…
    Patient’s right shoulder pain may represent referred pain from diaphragmatic irritation
  • 26. Case 4: Clinical History
    25-year-old G2,P0
    Last menstrual period: 2½ months ago
    Beta-hCG: 75,003 mIU/ml
    Vaginal bleeding & adnexal pain
  • 27. Case 4: Diagnosis?
  • 28. Case 4: Imaging Findings
    Extrauterine gestational sac
  • 29. Case 4: LiveAbdominalEctopic Pregnancy
  • 30. Case 4: LiveAbdominalEctopic Pregnancy
    Pathogenesis
    Direct peritoneal implantation with omental blood supply
    Most commonly implants within ovarian ligaments
    Epidemiology
    1:2,200 – 1:10,200
    Presentation
    Pelvic pain, mass, hemodynamic instability
    Diagnosis
    Gestational sac visualized separate from uterus, adnexa, & ovaries
    Outcome
    Treatment: surgery
    Maternal mortality: 0.5-18%
    Live birth is possible in rare circumstances
  • 31. Case 5: Clinical History
    19-year-old G1,P0
    Last menstrual period: 15 weeks ago
    Beta-hCG: qualitatively positive
    Pelvic pain
  • 32. Case 5: Diagnosis?
  • 33. Case 5: Imaging Findings
    Cervical length < 3 cm
    “Hourglass sign”: invagination of amniotic fluid into cervical canal
  • 34. Case 5: Cervical Incompetence
    Pathogenesis
    Premature cervical effacement which may be congenital or due to laceration, prior excessive dilation, or history of elective abortion
    Epidemiology
    1% of all pregnancies
    Presentation
    Often detected incidentally between 16th & 28th weeks of gestation
    Diagnosis
    Internal cervical os > 5mm
    Cervical length < 3cm on transvaginal/translabial US (some use 2.6cm)
    Bladder distension on transabdominal imaging falsely lengthens cervix
    Prolapse of membranes/amniotic fluid/fetal parts into cervical canal
    Outcome
    Leads to premature rupture of membranes & preterm labor
    Accounts for 15-20% of 2nd trimester loss of pregnancy
    Treatment: cervical cerclage
  • 35. Case 6: Clinical History
    32-year-old G2,P0
    Last menstrual period: 7 months ago
    Beta-hCG: 14,746 mIU/ml
    “Cramp-like” abdominal pain
  • 36. Case 6: Diagnosis
  • 37. Case 6: Imaging Findings
    “Hourglass sign”?
    Open cervical canal?
  • 38. Case 6: Diagnosis?
    Several minutes later during the same examination
  • 39. Case 6: Imaging Findings
    Closed cervical canal exceeding 3 cm in length
  • 40. Case 6: TransientUterine Contraction
    (Simulating Cervical Incompetence)
    Contraction
  • 41. Case 7: Clinical History
    19-year-old G1,P0
    Last menstrual period: 4 weeks ago
    Beta-hCG: 281 mIU/ml
    Right pelvic pain
  • 42. Case 7: Diagnosis?
  • 43. Case 7: Imaging Findings
    Empty uterus, ovarian follicle, preserved ovarian flow (normal)
  • 44. Case 7: Diagnosis?
  • 45. Case 7: Imaging Findings
    Hypoechoic blind-ending tubular structure
    Non-compressible
  • 46. Case 7: Acute Appendicitis
    Pathogenesis
    Appendiceal obstruction by appendicolith or hypertrophic Peyer’s patch
    Epidemiology
    Incidence: 7% (most common surgical problem of pregnancy)
    Perforation more likely than in non-pregnant patient
    Presentation
    Periumbilical pain that migrates to right lower abdominal quadrant
    Diagnosis
    Distended (> 7mm) non-compressible appendix with
    Increased mural vascularity on color or power Doppler interrogation
    Periappendiceal fluid collection or edema
    Nausea, vomiting, diarrhea, fever, & leukocytosis
    Outcome
    Non-perforated: surgery; perforated: percutaneous drainage
  • 47. Case 8: Clinical History
    34-year-old G4,P1
    Last menstrual period: 8 weeks ago
    Beta-hCG: 350,217 mIU/ml
    Vaginal bleeding
  • 48. Case 8: Diagnosis?
  • 49. Case 8: Imaging Findings
    Abnormal gestational sac shape
    Uterine fullness & cystic change
  • 50. Case 8: PartialMolar Pregnancy
    Pathogenesis
    Triploid with ⅔ of genetic complement paternally derived
    Two sperm fertilize a single normal ovum (diandric/monogynic)
    Epidemiology
    1/700 in US (2-3 times more common than complete molar pregnancy)
    Recurrence risk 1.7%
    Presentation
    Vaginal bleeding, missed/incomplete abortion
    Diagnosis
    Thickened placenta with focal cystic change or increased echogenicity
    Abnormal gestational sac
    Fetal parts with abnormalities (may have cardiac activity)
    Reduced amniotic fluid
    Outcome
    2-4% progress to gestational trophoblastic disease
  • 51. Case 9: Clinical History
    26-year-old G2,P0
    Last menstrual period: 11 weeks ago
    Beta-hCG: 414,566 mIU/ml
    Vaginal bleeding
  • 52. Case 9: Diagnosis?
  • 53. Case 9: Imaging Findings
    Abnormal uterine fullness & cystic change
    Multicysticadnexal structure
  • 54. Case 9: Diagnosis?
  • 55. Case 9: Molar Pregnancy
    (with Ovarian Hyperstimulation)
  • 56. Case 9: Molar Pregnancy
    (with Ovarian Hyperstimulation)
    Ovarian hyperstimulation is due to supraphysiologic beta-hCG
    Beta-hCG elicits LH- & FSH-like effects
    Results in multiple, large, bilateral theca lutein cysts
    Sonographically detectable in 46% of molar pregnancies
  • 57. Case 10: Clinical History
    41-year-old G5,P3
    Last menstrual period: 8 weeks ago
    Beta-hCG: 21,725 mIU/ml
    Left lower abdominal quadrant pain
  • 58. Case 10: Diagnosis?
  • 59. Case 10: Imaging Findings
    Pseudogestational sac
    (no double decidual sign)
  • 60. Case 10: Diagnosis?
  • 61. Case 10: Imaging Findings
    Ring-like left adnexal structure with free fluid
    Increased peripheral flow
  • 62. Case 10: Ectopic Pregnancy
    Pseudogestational sac vs. intrauterine pregnancy
    Lack of “double decidual sac sign”
    Peak systolic velocity < 0.8 cm/sec
    Dillon EH, Feyock AL, Taylor KJ. Pseudogestational sacs: Doppler US differentiation from normal or abnormal intrauterine pregnancies. Radiology. 1990 Aug;176(2):359-64.
    Nyberg DA, Laing FC, Filly RA, et al. Ultrasonographic differentiation of the gestational sac of early intrauterine pregnancy from the pseudogestational sac of ectopic pregnancy. Radiology. 1983 Mar;146(3):755-9.
  • 63. Case 11: Clinical History
    17-year-old G1,P0
    Last menstrual period: 7 weeks ago
    Beta-hCG: 137,898 mIU/ml
    Right pelvic pain
  • 64. Case 11: Diagnosis?
  • 65. Case 11: Imaging Findings
    Unremarkable intrauterine pregnancy
  • 66. Case 11: Diagnosis?
  • 67. Case 11: Imaging Findings
    Hypoechoic blind-ending tubular structure
    Non-compressible
  • 68. Case 11: Acute Appendicitis
    Pathogenesis
    Appendiceal obstruction by appendicolith or hypertrophic Peyer’s patch
    Epidemiology
    Incidence: 7% (most common surgical problem of pregnancy)
    Perforation more likely than in non-pregnant patient
    Presentation
    Periumbilical pain that migrates to right lower abdominal quadrant
    Diagnosis
    Distended (> 7mm) non-compressible appendix with
    Increased mural vascularity on color or power Doppler interrogation
    Periappendiceal fluid collection or edema
    Nausea, vomiting, diarrhea, fever, & leukocytosis
    Outcome
    Non-perforated: surgery; perforated: percutaneous drainage
  • 69. Case 12: Clinical History
    26-year-old G1,P0
    Last menstrual period: 2 months ago
    Beta-hCG: 23,051 mIU/ml
    Vaginal bleeding
  • 70. Case 12: Diagnosis?
  • 71. Case 12: Imaging Findings
    Abnormal gestational sac shape
    No fetal cardiac activity
  • 72. Case 12: Failed First Trimester Pregnancy
    Pathogenesis
    Anembryonic pregnancy (35%)
    Failure of embryo to develop vs. early demise & embryonic resorption
    Embryonic demise (54%)
    Visualization of non-viable embryo
    Molar pregnancy (11%)
    Complete (diploid): 100% paternal genetic complement
    Partial (triploid): ⅔ paternal genetic complement
    Epidemiology
    30-60% of documented beta-hCG elevations result in failed pregnancy
    Presentation
    Vaginal bleeding, pelvic pain, uterine contractions
    Diagnosis
    Discriminitory levels critical to accurate diagnosis (see next slide)
  • 73. Case 12: Failed First Trimester Pregnancy
    Discriminatory Levels
  • 74. Case 13: Clinical History
    26-year-old G1,P0
    Last menstrual period: 4 weeks ago
    Beta-hCG: qualitatively positive
    Sharp left-sided pelvic pain
  • 75. Case 13: Diagnosis?
  • 76. Case 13: Imaging Findings
    Multiple small peripherally-oriented cysts in enlarged ovary
  • 77. Case 13: Ovarian Torsion
    Pathogenesis
    Twisting of ovary around vascular pedicle
    Initial venous/lymphatic compromise, followed by arterial compromise
    Increased risk
    Rapid uterine growth (e.g. gestational weeks 8-16)
    Rapid uterine involution (e.g. immediate postpartum period)
    Large ovarian mass (e.g. corpus luteum cyst)
    Epidemiology
    17-24% of torsion occur in pregnancy (0.06% of all pregnancies)
    5th most common gynecologic emergency
    Presentation
    Acute sharp pelvic pain, nausea, vomiting, fever
    Diagnosis
    Enlarged heterogeneous ovary (60% right) with small peripheral cysts
    Decreased or absent flow on Doppler interrogation; free pelvic fluid
    Outcome
    Treatment: surgical detorsion or excision (ovarian salvage rate: 10-30%)
  • 78. Case 14: Clinical History
    42-year-old G5,P3
    Last menstrual period: 4 weeks ago
    Beta-hCG: qualitatively positive (home pregnancy test)
    Acute right lower abdominal quadrant pain, 1½ week history of vaginal discharge
  • 79. Case 14: Diagnosis?
  • 80. Case 14: Imaging Findings
    Heterogeneous complex predominantly hypoechoic mass
    Posterior shadowing
    Increased peripheral flow with complex central fluid collection devoid of flow
  • 81. Case 14: Tubo-Ovarian Abscess
    Pathogenesis
    Most commonly a consequence of pelvic inflammatory disease (PID)
    Rarely arises following appendicitis, diverticulitis, or pelvic surgery
    Epidemiology
    100,000 cases annually in the US
    Presentation
    Pelvic pain, fever, history of PID
    Diagnosis
    Palpable adnexal mass
    Leukocytosis & elevated erythrocyte sedimentation rate
    Complex adnexal mass/fluid collection with increased peripheral flow
    Posterior shadowing if gas is present; complex free pelvic fluid (pus)
    Outcome
    Treatment: transvaginal/transgluteal drainage & systemic antibiotics
  • 82. Case 15: Clinical History
    30-year-old G3,P2
    Last menstrual period: 10 weeks ago
    Beta-hCG: 76,489 mIU/ml
    Right lower abdominal quadrant pain
  • 83. Case 15: Diagnosis?
  • 84. Case 15: Imaging Findings
    Left uterine cornu
    Eccentrically located gestational sac high in right uterine fundus
    with myometrial thinning
  • 85. Case 15: Interstitial Ectopic Pregnancy
    Pathogenesis
    Implantation in uterine cornu (intramural portion of fallopian tube)
    Epidemiology
    2-4% of ectopic pregnancies
    Presentation
    Pelvic pain, vaginal bleeding, hemodynamic instability
    Diagnosis
    Gestational sac located eccentrically in superior uterine fundus
    Interstitial line sign: echogenic line from endometrium to gestational sac
    Surrounding myometrial thickness < 5mm
    Outcome
    Treatment: surgery
    Maternal mortality: 2-2.5% (significantly higher than tubal pregnancy)
    Uterine rupture most commonly occurs 9-12 weeks
  • 86. Case 16: Clinical History
    28-year-old G4,P2
    Last menstrual period: 2½ months ago
    Beta-hCG: 225 mIU/ml
    Pelvic pain, vaginal bleeding, history of elective termination of pregnancy 2 weeks ago
  • 87. Case 16: Diagnosis?
  • 88. Case 16: Imaging Findings
    Thickened
    endometrium
    with focal area
    of increased flow
  • 89. Case 16: Retained Products of Conception
    Pathogenesis
    Incomplete expulsion of fetal/embryonic/placental material
    Epidemiology
    1% of all pregnancies
    Increased following termination & with placenta acreta
    Presentation
    Delayed postpartum bleeding
    Diagnosis
    Persistent endometrial thickening (> 1cm)
    Echogenic endometrial mass
    Intrauterine fluid
    Irregular interface between endometrium & myometrium
    High-velocity, low-resistance flow on Doppler interrogation (> 21cm/sec)
    Outcome
    Treatment: dilation & curettage
  • 90. Case 17: Clinical History
    32-year-old G1,P1
    Last menstrual period: pre-pregnancy
    Beta-hCG: qualitatively negative
    Pelvic pain, vaginal bleeding, history of spontaneous vaginal delivery 3½ months ago
  • 91. Case 17: Diagnosis?
  • 92. Case 17: Imaging Findings
    Echogenic endometrial mass with posterior shadowing
  • 93. Case 17: Endometritis
    Pathogenesis
    Ascending vaginal/cervical infection
    Secondary to retained products of conception or chorioamnionitis
    Epidemiology
    1-3% of vaginal deliveries
    15-20% of cesarean section (50-60% without antibiotic prophylaxis)
    70-90% of patients with PID have coexistent endometritis
    Presentation
    Pelvic pain, fever, uterine tenderness
    Diagnosis
    Thickened heterogeneous endometrium
    Echogenic endometrial mass
    Intrauterine fluid & gas (gas seen in 21% of normal postpartum patients)
    Increased endometrial flow on Doppler interrogation
    Outcome
    Treatment: systemic antibiotics
  • 94. Case 18: Clinical History
    26-year-old G2,P0
    Last menstrual period: 3 months ago
    Beta-hCG: 83,757 mIU/ml
    Pelvic pain, vaginal bleeding
  • 95. Case 18: Diagnosis?
  • 96. Case 18: Imaging Findings
    Crescentichypoechoic collection between placenta & myometrium
  • 97. Case 18: Marginal Placental Abruption
    (Subchorionic Hemorrhage)
    Pathogenesis
    Hemorrhage into deciduabasalis layer with resultant premature separation of placenta from uterus
    Marginal > retroplacental > preplacental
    Epidemiology
    1% of all pregnancies
    17x risk in patients with prior placenta abruptio
    Presentation
    Vaginal bleeding, pelvic pain
    Diagnosis
    Hypoechoiccrescentic fluid collection between placenta & myometrium
    Outcome
    Excellent prognosis if small
    Placental detachment > 50% -> fetal death > 50%
  • 98. Case 19: Clinical History
    27-year-old G1,P0
    Last menstrual period: 5½ months ago
    Beta-hCG: qualitatively positive
    Right upper abdominal quadrant pain
  • 99. Case 19: Diagnosis?
  • 100. Case 19: Imaging Findings
    Persistence on postvoid imaging
    Collecting system prominence
    Absent right ureteral jet
  • 101. Case 19: Diagnosis?
  • 102. Case 19: Imaging Findings
    Resistive indices not significantly different
  • 103. Case 19: MaternalHydronephrosis
    (Physiologic Caliectasis)
    Pathogenesis
    Non-obstructive dilation due to ureteral compression by gravid uterus
    Smooth muscle relaxation due to progesterone also contributes
    Epidemiology
    90% of all pregnancies by 3rd trimester
    Right more common than left
    Presentation
    Asymptomatic
    Diagnosis
    Unilateral dilatation of collecting system
    No significant difference between kidney resistive indices
    Ureteral jet rules out obstruction, but absent jet is an unreliable finding
    Outcome
    Resolution with parturition
  • 104. Case 20: Clinical History
    33-year-old G3,P0
    Last menstrual period: 7 weeks ago
    Beta-hCG: 110,780 mIU/ml
    Right lower abdominal quadrant pain, history of fertility treatments
  • 105. Case 20: Diagnosis?
  • 106. Case 20: Imaging Findings
    Fluid in open cervical canal
    Gestational sac in uterus
    Gestational sac in right adnexa
    Echogenic fluid in cul-de-sac
  • 107. Case 20: Heterotopic Pregnancy
    (with Threatened Abortion of Intrauterine Pregnancy)
    Pathogenesis
    Simultaneous intrauterine & ectopic pregnancies
    Epidemiology
    1:7000 spontaneous pregnancies
    1-2% of in vitro fertilization pregnancies
    Presentation
    Vaginal bleeding, pelvic pain
    Diagnosis
    Visualization of both intrauterine & ectopic pregnancies
    Outcome
    Treatment: surgery, systemic methotrexate, US-guided local injection
    Local injection agents: methotrexate, KCl, hyperosmolar glucose
    If patient stable, intrauterine pregnancy can be delivered vaginally
  • 108. Case 21: Clinical History
    18-year-old G1,P0
    Last menstrual period: 8 months ago
    Beta-hCG: 11,811 mIU/ml
    Painless vaginal bleeding
  • 109. Case 21: Diagnosis?
  • 110. Case 21: Imaging Findings
    Placenta
    Cervical canal
  • 111. Case 21: Placenta Previa
    Pathogenesis
    Implantation of blastocyst in lower uterine segment
    Epidemiology
    Decreased incidence as pregnancy progresses
    5% at 15th-16th weeks of gestation; 0.5% at full term
    Presentation
    Painless 3rd trimester vaginal bleeding
    Diagnosis
    Complete: placenta completely covers internal cervical os
    Partial: placenta partially covers internal cervical os
    Marginal: placental edge within 2cm of internal cervical os
    Outcome
    Early in pregnancy, most resolve with uterine growth
    After 34th week of gestation, unlikely to resolve (cesarean section)
  • 112. Case 22: Clinical History
    32-year-old G1,P0
    Last menstrual period: 7½ weeks ago
    Beta-hCG: 8,252 mIU/ml
    Vaginal bleeding
  • 113. Case 22: Diagnosis?
  • 114. Case 22: Imaging Findings
    Empty uterus
    Free fluid in cul-de-sac
  • 115. Case 22: Diagnosis?
  • 116. Case 22: (L) Corpus Luteum, (R) Ectopic Pregnancy
    Echogenicity greater than ovary
    Bilateral “rings-of-fire”
    (not shown)
  • 117. Case 22: Ruptured Ectopic Pregnancy
    Ring-like adnexal mass of ectopic pregnancy vs. corpus luteum
    Higher velocity/lower impedance flow on Doppler interrogation
    Extreme resistive indices (> 0.7 & < 0.4)
    Independent mobility of mass relative to ovary on palpation
    Echogenicity greater than ovarian parenchyma on grayscale imaging
    85% of ectopic pregnancies are ipsilateral to corpus luteum
    Atri M. Ectopic pregnancy versus corpus luteum cyst revisited: best Doppler predictors. J Ultrasound Med. 2003 Nov;22(11):1181-4.
    Rottem S, Thaler I, Levron J, et al. Criteria for transvaginalsonographic diagnosis of ectopic pregnancy. J Clin Ultrasound. 1990 May;18(4):274-9.
  • 118. Case 22: Ruptured Ectopic Pregnancy
  • 119. Acknowledgements & Contact Information
    The authors acknowledge significant contributions from & extend their gratitude to the following individuals:
    Dr. HanhNghiem, Dept. of Radiology
    Dr. Charles Cash, Dept. of Radiology
    Dr. Richard Bronsteen, Dept. of Maternal-Fetal Imaging
    Dr. Christine Comstock, Dept. of Maternal-Fetal Imaging
    Contact Information:
    Daniel Noujaim, MD
    Department of Radiology
    William Beaumont Hospital
    3601 W Thirteen Mile Rd
    Royal Oak, MI 48073
    Daniel.Noujaim@beaumont.edu