ASER 2009

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

Published in: Health & Medicine

ASER 2009

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

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