This document provides new terminology and classifications for ectopic pregnancies according to consensus recommendations from an ESHRE working group. Key points include:
- Pregnancies are classified as normally located (eutopic), ectopic, or of unknown location (PUL).
- Ectopic pregnancies can be further specified as uterine (cervical, caesarean scar, intramural) or extrauterine.
- Uterine ectopic pregnancies involve trophoblast invasion beyond the endometrial-myometrial junction. They can be partial or complete.
- The terms "angular pregnancy" and "tubal miscarriage" should be abandoned in the new terminology.
Traditionally Vaginal vault suturing is done Laparoscopically in TLH, but vaginal suturing by vaginal route is simple, easy and has less learning curve
Traditionally Vaginal vault suturing is done Laparoscopically in TLH, but vaginal suturing by vaginal route is simple, easy and has less learning curve
Cervical incompetence is the inability for the cervix to retain an intra-uterine pregnancy till term as a result of structural and functional defects of the cervix
Testicular cancer for public awareness by Dr RubzDr. Rubz
A presentation prepared for Charity Dinner with Fun Charity. All the profits of the event will go to FReHA (a NGO which supports women's and reproductive health.)
In this presentation we will focus on aetiological factors that cause infirtility. Our focus is on US depiction of these aetiological factors to help physician in the management of infirtility.
We have nothing to do with direct radiological intervention in the management of infirtility in this presentation.
The presentation highlights on the spinning process, sewing thread and the defects in making a yarn. The basic knowledge that a FD student should be clear.
Most pregnant women who carry group B streptococcus (GBS) bacteria have healthy babies.
But there's a small risk that GBS can pass to the baby during childbirth.
Sometimes GBS infection in newborn babies can cause serious complications that can be life threatening, but this is not common.
Extremely rarely, GBS infection during pregnancy can also cause miscarriage, early (premature) labour or stillbirth.
GBS is one of many bacteria that can be present in our bodies. It does not usually cause any harm.
When this happens, it's called carrying GBS, or being colonised with GBS.
It's estimated about 1 pregnant woman in 5 in the UK carries GBS in their digestive system or vagina.
Around the time of labour and birth, many babies come into contact with GBS and are colonised by the bacteria.
Most are unaffected, but a small number can become infected.
If a baby develops GBS infection less than 7 days after birth, it's known as early-onset GBS infection.
Most babies who become infected develop symptoms within 12 hours of birth.
Symptoms include:
• being floppy and unresponsive
• not feeding well
• grunting
• a high or low temperature
• fast or slow heart rates
• fast or slow breathing rates
irritability
Late-onset GBS infection
Late-onset GBS infection develops 7 or more days after a baby is born. This is not usually associated with pregnancy.
The baby probably became infected after the birth. For example, they may have caught the infection from someone else.
GBS infections after 3 months of age are extremely rare.
Breastfeeding does not increase the risk of GBS infection and will protect your baby against other infections.
Cervical incompetence is the inability for the cervix to retain an intra-uterine pregnancy till term as a result of structural and functional defects of the cervix
Testicular cancer for public awareness by Dr RubzDr. Rubz
A presentation prepared for Charity Dinner with Fun Charity. All the profits of the event will go to FReHA (a NGO which supports women's and reproductive health.)
In this presentation we will focus on aetiological factors that cause infirtility. Our focus is on US depiction of these aetiological factors to help physician in the management of infirtility.
We have nothing to do with direct radiological intervention in the management of infirtility in this presentation.
The presentation highlights on the spinning process, sewing thread and the defects in making a yarn. The basic knowledge that a FD student should be clear.
Most pregnant women who carry group B streptococcus (GBS) bacteria have healthy babies.
But there's a small risk that GBS can pass to the baby during childbirth.
Sometimes GBS infection in newborn babies can cause serious complications that can be life threatening, but this is not common.
Extremely rarely, GBS infection during pregnancy can also cause miscarriage, early (premature) labour or stillbirth.
GBS is one of many bacteria that can be present in our bodies. It does not usually cause any harm.
When this happens, it's called carrying GBS, or being colonised with GBS.
It's estimated about 1 pregnant woman in 5 in the UK carries GBS in their digestive system or vagina.
Around the time of labour and birth, many babies come into contact with GBS and are colonised by the bacteria.
Most are unaffected, but a small number can become infected.
If a baby develops GBS infection less than 7 days after birth, it's known as early-onset GBS infection.
Most babies who become infected develop symptoms within 12 hours of birth.
Symptoms include:
• being floppy and unresponsive
• not feeding well
• grunting
• a high or low temperature
• fast or slow heart rates
• fast or slow breathing rates
irritability
Late-onset GBS infection
Late-onset GBS infection develops 7 or more days after a baby is born. This is not usually associated with pregnancy.
The baby probably became infected after the birth. For example, they may have caught the infection from someone else.
GBS infections after 3 months of age are extremely rare.
Breastfeeding does not increase the risk of GBS infection and will protect your baby against other infections.
Cord prolapse is a frightening and life-threatening event that occurs in labor. Rapid identification and immediate appropriate response may well save the life of a neonate. Therefore, clinicians should be knowledgeable in its recognition and management.
types of breech
how you can manage a woman with breech baby?
what is External cephalic version and who can do it ?
what is the risks of vaginal breech birth ?
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. AGENDA
Background
Flow diagram of early pregnancy
Pregnancy of unknown location
Normally sited pregnancy
Angular pregnancy
Uterine ectopic pregnancy
Extra-uterine ectopic pregnancy
Rudimentary horn pregnancy
Residual ectopic pregnancy
Qualitative and Quantitative description of ectopic
3. BACKGROUND
A working group of members of the ESHRE Special Interest Group in Implantation and Early
Pregnancy (SIG-IEP) and selected experts in ultrasound was formed in order to write
recommendations on the classification of ectopic pregnancies.
The working group (WG) included nine members of different nationalities with internationally
recognised experience in ultrasound and diagnosis of ectopic pregnancies on ultrasound.
This document is developed according to the manual for development of ESHRE
recommendations for good practice. The recommendations were discussed until consensus
by the working group, supported by a survey among the members of the ESHRE SIG-IEP.
The present ESHRE document provides 17 consensus recommendations on how to describe
normally sited and different types of ectopic pregnancies on ultrasound.
5. PREGNANCY OF UNKNOWN LOCATION ( PUL)
All pregnancies can be described as either normally sited, ectopic or of unknown location.
Regarding pregnancy of unknown location (PUL), this term is reserved for when no
pregnancy is visualised on transvaginal scan in clinically stable women with a positive urine
pregnancy test.
It is essential that the ultrasound examination is carried out in a systematic manner and all
possible locations for an implanted pregnancy are examined.
6. NORMALLY SITED PREGNANCY
Consensus: A pregnancy which is
located within the uterine cavity should be
described as a normally sited (eutopic)
pregnancy.
7. VIABILITY
• Consensus: A pregnancy which is located within the uterine cavity with embryonic/foetal
heart pulsations should be described as a live normally sited (eutopic) pregnancy.
• Consensus: A pregnancy which is located within the uterine cavity without a visible
embryo which has the potential to develop normally should be described as an early normally
sited (eutopic) pregnancy.
8. MISCARRIAGE
Consensus:
• The term miscarriage should be used to describe a normally sited (eutopic) pregnancy <22
weeks’ gestation with abnormal development resulting in embryonic/fetal loss.
• The term ‘tubal miscarriage’ should be abandoned to facilitate the use of the term miscarriage
for a normally sited (eutopic) pregnancy with abnormal development resulting in
embryonic/fetal loss.
9. ECTOPIC PREGNANCY
Live and failing ectopic pregnancy
Location of ectopic pregnancy
Partial or complete ectopic pregnancy
10. LIVE AND FAILING ECTOPIC PREGNANCY
Consensus:
An ectopic pregnancy which contains an embryo/foetus with evidence of heart pulsations
should be described as a live ectopic pregnancy.
The term miscarriage should not be used for an ectopic pregnancy. Ectopic pregnancy with
clinical, ultrasound and/or biochemical signs of regression should be described as a failing
ectopic pregnancy
11. LOCATION OF ECTOPIC PREGNANCY
Consensus:
Ectopic pregnancies should be classified as uterine or extrauterine.
• Previous classification of ectopic pregnancies as tubal and non-tubal should be abandoned.
12. PARTIAL VERSUS COMPLETE ECTOPIC PREGNANCY
Consensus: Cervical, caesarean scar, intramural and interstitial ectopic pregnancies should
be described as partial or complete.
The Working group (WG) agreed that uterine ectopic pregnancies which are completely
confined to the myometrium with no visible connection with the uterine cavity should be
described as complete.
Those which are involving the myometrium to some extent but are also in part within the
uterine cavity should be labelled as partial.
Following on from this, it was agreed that interstitial ectopic pregnancies could also be
classified as partial or complete.
Partial interstitial pregnancies are those which are implanted within the interstitial part of the
Fallopian tube, but also partially protruding through the uterine tubal ostium into the uterine
cavity.
13. ANGULAR PREGNANCY
The term ‘angular pregnancy’ was initially defined surgically as ‘implantation of the embryo
just medial to the utero-tubal junction, in the lateral angle of the uterine cavity’
In a recent prospective study which included 42 cases, the authors found that 80% of these
pregnancies resulted in a live birth and 20% in miscarriage.
There were no cases of uterine rupture, maternal death, abnormal placentation or
hysterectomy.
It was concluded that angular pregnancy is a variation of a normally implanted intrauterine
pregnancy, rather than a form of ectopic pregnancy
The WG agreed that angular pregnancy is not a clinical entity and it is synonymous with a
pregnancy which is normally implanted in the upper lateral aspect of the uterine cavity
Consensus: The term angular pregnancy should be abandoned.
15. UTERINE ECTOPIC PREGNANCIES
The junctional zone or inner myometrium surrounds basal layer of the endometrium. On
ultrasound scan, it appears hypoechoic and it is particularly easy to visualise on 3D ultrasound. It
is a useful anatomical landmark as the placental invasion should not extend beyond the
endometrial–myometrial junction into the outer myometrium.
In view of that, only pregnancies which are located within the uterine cavity with placental invasion
not extending beyond the endometrial–myometrial junction should be considered normally
implanted.
All uterine ectopic pregnancies are defined by evidence of trophoblast invasion beyond the
endometrial–myometrial junction, but not outside the uterine visceral/broad ligament peritoneum.
Depending on the previous history and location, this can be further specified to either a scar
pregnancy, cervical pregnancy or intramural pregnancy.
In many uterine ectopic pregnancies, the gestational sac is only partially invading the myometrium
and these cases should be described as partial scar, partial cervical or partial intramural
pregnancy, regardless of the depth of invasion.
16. CAESAREAN SCAR PREGNANCY
A caesarean scar pregnancy is a pregnancy implanted in the transverse lower segment
caesarean section scar.
CSP is defined by the following features: gestational sac located low in the uterus close to the
internal os and anterior implantation with trophoblast invading into the myometrium.
Most caesarean scar pregnancies are partial which facilitates their transcervical surgical
evacuation.
Complete scar pregnancies are relatively rare, and they tend to bulge into the broad ligament
or into the vesico-uterine space.
19. CERVICAL PREGNANCY
A cervical pregnancy is implanted into the myometrium below the level of the internal os.
Ultrasound criteria :
o A gestational sac present below the level of the internal cervical os.
o The absence of the ‘sliding sign’
o Blood flow around the gestational sac using colour Doppler.
All pregnancies implanted into posterior cervix should be described as cervical ectopic
pregnancies regardless of women’s previous history of delivery by caesarean section.
In cases of anterior implantation in women who have had a caesarean in the past, the
differential diagnosis includes caesarean scar ectopic pregnancy.
Cervical ectopic can also be classified as partial or complete depending on the presence or
absence of their communication with the cervical canal.
22. INTRAMURAL PREGNANCY
Intramural pregnancies are relatively rare.
They are located above the level of internal os which differentiates them from cervical and caesarean section
scar pregnancies.
They typically occur after previous myomectomy, but they can also be caused by scarring following uterine
perforation or after classical (upper segment vertical) caesarean section.
In some cases, intramural pregnancy can develop in a focus of adenomyosis.
They do not involve the interstitial portion of the tubes which facilitate differential diagnosis from interstitial
tubal pregnancies.
They could be located anywhere within the uterine corpus which makes it harder to detect them compared to
cervical and lower transverse caesarean section scar pregnancies.
The defining feature is extension beyond the endometrial–myometrial junction above the level of the internal
os.
They can also be classified as complete or partial .
Adenomyosis and cystic fibroids could sometimes resemble an empty gestational sac on B-mode ultrasound
scan. In such cases, colour Doppler could be used to demonstrate increased vascularity surrounding
gestational sac which is typically absent in adenomyosis and relatively sparse in fibroids
25. UTERINE ECTOPIC PREGNANCIES
Consensus:
The term intramural pregnancy should be used to describe a pregnancy which is located
within the uterus, but breaches the endometrial–myometrial junction and invades the
myometrium of the uterine corpus above the internal os.
The terms caesarean scar and cervical pregnancies should be used to describe pregnancies
which invade myometrium in the vicinity or below the level of the internal os.
Caesarean scar pregnancies are implanted anteriorly at the visible or presumed site of
transverse lower segment uterine scar, whilst cervical pregnancies could be located either
anteriorly or posteriorly.
27. TUBAL ECTOPIC PREGNANCIES
Anatomically, the Fallopian tube is a hollow structure which extends from the uterine tubal
orifice to the lateral opening at the fimbrial end.
A gestational sac can implant in any part of the Fallopian tube.
Depending on their location, tubal ectopic pregnancies can be divided into interstitial, isthmic,
ampullary.
Fimbrial ectopic has also been described, but they can only be diagnosed at surgery and on
ultrasound scan they are indistinguishable from ampullary ectopic pregnancies.
The management of ampullary and fimbrial ectopic pregnancies is essentially the same and
therefore the panel has decided to retain only ampullary tubal ectopic in the classification.
28. INTERSTITIAL TUBAL ECTOPIC PREGNANCY
Tubal pregnancies located closer to the uterus have a higher potential to grow larger and to
contain a live embryo/fetus which increases the risk of serious complications.
In view of this, interstitial ectopic pregnancies used to be seen as a separate entity to more
distal isthmic and ampullary ectopic pregnancies.
In addition, as they develop, most interstitial pregnancies tend to grow laterally into the
proximal segment of the tube and ectopic pregnancies which are confined to the interstitial
segment of the tube only are relatively rare.
A critical diagnostic feature of interstitial ectopic pregnancies is visualisation of a thin
intramural/interstitial segment of Fallopian tube adjoining the medial aspect of the gestational
sac and the lateral aspect of the uterine cavity, often referred to as the interstitial line sign.
In addition, the gestational sac has to be at least partially enveloped by the myometrium.
30. TUBAL ECTOPIC PREGNANCY
Isthmic tubal ectopic pregnancy Ampullary tubal ectopic pregnancy
A pregnancy close to the uterus but not surrounded by myometrium could be described as isthmic whilst the
pregnancy located further away and close to the ovary could be labelled as ampullary tubal ectopic
31. TUBAL ECTOPIC PREGNANCY
Consensus: Tubal ectopic pregnancies should be described as either interstitial, isthmic or
ampullary.
The WG noted that there may be some concern about re-classifying interstitial ectopic as
tubal as this is a departure from current clinical practice. However, during discussion, it was
very clear that all WG members favored this change as it is more logical taking into account
anatomical structure of the Fallopian tube.
There was a consensus that re-classification of interstitial pregnancy would facilitate more
conservative surgical approach to treat this type of ectopic pregnancy and discourage
surgeons from performing uterine wedge resection which is associated with an increased risk
of both intra- and post-operative complications
32. OVARIAN PREGNANCY
An ovarian pregnancy is located completely or partially within the ovarian parenchyma.
In the majority of cases, ovarian pregnancy is ipsilateral to the corpus luteum.
The key diagnostic feature is the inability to separate the pregnancy from the ovary on
palpation with the ultrasound probe during the examination. However, this finding is not
entirely specific as it may also be present in tubal pregnancies which are firmly adhered to the
uterus or ovary.
Small ovarian pregnancies are easier to diagnose correctly than larger or ruptured
pregnancies. However, some very small ovarian pregnancies with no embryo or a yolk sac
may resemble a corpus luteum.
Although, trophoblastic tissue tends to be more echogenic than corpus luteum these
differences are not always obvious. In view of that, it is important to utilise colour Doppler in
suspected ovarian pregnancies which facilitates detection of corpus luteum and
demonstration of another area of increased vascularity within the ovary representing peri-
trophoblastic blood flow of an ovarian ectopic
34. ABDOMINAL PREGNANCY
An abdominal pregnancy results from implantation in the peritoneal cavity, outside of the
uterus, ovaries and Fallopian tubes.
In a primary abdominal pregnancy, the original site of implantation is the peritoneal cavity.
Secondary abdominal pregnancies are the result of tubal rupture or expulsion of pregnancy
through the fimbrial end of the tube and its re-implantation into the abdominal cavity.
The most common sites for implantation are the broad ligament, pouch of Douglas,
uterovesical pouch and surfaces of the tubes and uterus.
Early abdominal pregnancies are often difficult to diagnose. There will be usually an empty
uterine cavity and no evidence of a dilated Fallopian tube or an adnexal mass.
The diagnosis should be suspected if a gestational sac is seen in an unusual location such
as the pouch of Douglas or vesico-uterine pouch or if surrounded by loops of bowel.
Doppler examination is helpful to confirm the presence of peri-trophoblastic blood flow.
36. RUDIMENTARY HORN PREGNANCY
This term refers to a pregnancy in the rudimentary horn of a unicornuate uterus.
The RCOG classifies this pregnancy as ‘cornual pregnancy’. However, as mentioned
previously, the term cornual pregnancy has been used in clinical practice to describe
pregnancies in various locations, both normally sited and ectopics, and we decided to
abandon this term.
Rudimentary horn pregnancy is rare, with a reported incidence of 1 in 75 000–150 000
pregnancies.
If not diagnosed in early pregnancy, they can advance well into the second trimester, when
they often present with severe pain and rupture.
Ultrasound criteria :
o Visualisation of a single interstitial portion of Fallopian tube in the main unicornuate uterine
body.
o Gestational sac/products of conception seen mobile and separate from the unicornuate
cavity and completely surrounded by myometrium.
o A vascular pedicle adjoining the gestational sac to the unicornuate uterus
37. RUDIMENTARY HORN PREGNANCY
Consensus: All pregnancies within the confines of the uterine cavity should be classified as normally
sited regardless whether the uterus in normally formed or anomalous. The only exception is a
pregnancy located in a rudimentary horn of a unicornuate uterus which should be classified as a
rudimentary horn ectopic pregnancy
38. RESIDUAL ECTOPIC PREGNANCY
An ectopic pregnancy can remain visible also after decline of serum hCG to pre-pregnancy
levels. On ultrasound scan, they initially appear hyperechoic, but with time they tend to turn
into more solid, hypoechoic lesions which are poorly vascularised on Doppler examination.
Consensus:
o The term ‘residual ectopic pregnancy’ should be used for an ectopic pregnancy which
presents as a discrete mass on ultrasound in a woman with a negative pregnancy test.
o The term ‘chronic ectopic’ should not be used in clinical practice.
40. QUALITATIVE AND QUANTITATIVE DESCRIPTIONS OF
ECTOPIC PREGNANCY
Morphology of ectopic pregnancy
Measuring an ectopic pregnancy
Semi-quantitative grading of hemoperitoneum
41. MORPHOLOGY OF ECTOPIC PREGNANCY
Further assessment on the clinical aspects is to be considered, but this is outside the scope
of this terminology paper.
42. MEASURING AN ECTOPIC PREGNANCY
Ectopic pregnancies should also be measured in three perpendicular planes using the following
protocol:
43. MEASURING AN ECTOPIC PREGNANCY
How to measure an ectopic on ultrasound scan:
1. The outer to outer margins of the trophoblast should be measured in all cases to include the
full size of trophoblastic tissue
2. In ectopic pregnancies presenting with a well-defined gestational sac, the inner to inner
margins of the coelomic cavity should also be measured in a manner similar to the
measurement of ‘gestational sac’ size in normally implanted pregnancies and
3. In women with evidence of haematosalpinx, the measurements should be taken between the
inner margins of the Fallopian tube distended with blood. This technique ensures better
correlation between the pre-operative ultrasound and surgical findings.
44. MEASURING AN ECTOPIC PREGNANCY
The measurements of all three planes should be reported and the mean diameter may be
calculated. The size of the gestational sac in normally sited pregnancies is usually measured
from the inner sac wall/chorionic fluid interface which corresponds to the size of coelomic
cavity in early and the amniotic cavity in later pregnancies.
In many ectopic pregnancies, the size of the coelomic cavity is very small in comparison to
the size of trophoblastic ring or haematosalpinx. This may encourage inappropriate use of
conservative management and in some cases create an impression of discordance between
pre-operative ultrasound and surgical findings.
45. SEMI-QUANTITATIVE GRADING OF HEMOPERITONEUM
The exact amount blood in the pelvis is difficult to measure on ultrasound.
Haemoperitoneum should be categorised semi-quantitatively as :
o Mild when there is only echogenic fluid present in the pouch of Douglas.
o Moderate when there are visible blood clots.
o Severe when there were blood clots and echogenic fluid present both in the pouch of Douglas
and in the utero-vesical space. Presence of blood in the Morrison’s pouch (hepato-renal
space) is also an indication of severe intra-abdominal bleeding
46. SEMI-QUANTITATIVE GRADING OF HEMOPERITONEUM
Semi-quantitative grading of haemoperitoneum. (a) Mild; (b) moderate; (c) severe. F, fluid; C,
blood clot; PoD, pouch of Douglas; VUP, vesico-uterine pouch.
47. QUALITATIVE AND QUANTITATIVE DESCRIPTION OF
ECTOPIC
Consensus: In all ectopic pregnancies, measurements of the gestational sac size and
trophoblastic mass should be routinely carried out. In tubal ectopic pregnancies, the size of
haematosalpinx should be reported when present. All measurements should be performed in
three perpendicular planes. The haemoperitoneum should be estimated semi-quantitatively.
48. REFERENCE
Terminology for describing normally sited and ectopic pregnancies
on ultrasound: ESHRE recommendations for good practice;Human
Reproduction; December 2020