Bleeding

Case: Ectopic Pregnancy - Part 1

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This video details how bedside transvaginal ultrasound can help emergency medicine professionals evaluate OB/GYN anatomy to diagnose possible ectopic pregnancies.

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Pseudogestational Sac

Tubal Ectopic Abdominal Ectopic

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- Hello, my name is Phil Perrera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
Today's module is going to focus on ectopic pregnancy.
Ectopic pregnancies constitute
about 2% of all total pregnancies,
although they're commonly seen in the emergency department.
Ectopic pregnancy is more commonly seen in women
with a history of tubal ligation
who are using interuterine devices for contraception
or have a history of sexually transmitted diseases,
such as pelvic inflammatory disease
with scarring of the tubes.
Ectopic pregnancy is also commonly seen in women
using fertility agents,
which accounts for the increasing rate of ectopic pregnancy
over all.
As a golden rule, we must consider ectopic pregnancy
in all women with abdominal pain
and/or vaginal bleeding and a positive pregnancy test,
until ruled out by sonography.
Let's begin by reviewing the OB/GYN anatomy
that we'll need to know to perform bedside ultrasound
of the uterus and the adnexa.
We'll begin by locating the lower cervical region
of the uterus.
The portion above that, the body, and the fundal region
of the uterus above the body,
which is where we define an inter-uterine pregnancy
to be located.
Notice the intersticial region of the uterus,
that region of the uterus that abuts the fallopian tube.
In a cornual uterus this is known as cornual region.
Here we also see the portions of the fallopian tube,
the proximal isthmal region,
the distal infindibulum,
and notice the ampullary region
which comprises the majority of the fallopian tube.
We also see here, the broad ligament which encases
the fallopian tube and ovary in the lateral region
of the adnexa.
Remember that the ovary is relatively mobile
within the broad ligament.
Now let's review a transvaginal long axis scan
from a women who presented with a positive pregnancy test,
who had lower abdominal pain and vaginal bleeding.
Notice the fundus, as shown here to the left,
the cervix to the right.
We see here the presence of a thickened white
endometrial stripe in the midline of the uterus.
Notice the pelvic cul de sac that potential space
posterior to the uterus.
Notice here the absence of an inter-uterine pregnancy.
Now, confirm the absence of an IUP by scanning
in the transvaginal short axis plane.
Here we have the probe marker
oriented towards the patient's right,
and we're cutting the uterus in cross section.
Notice again the thickened endometrial stripe
in the midline of the uterus,
and the pelvic cul de sac posteriorly.
Again, we see the absence of an IUP,
and also note the absence of free fluid,
dark anechoic fluid collections
within the pelvic cul de sac.
So, given these findings we're now concerned
about the presence of an ectopic pregnancy.
So, lets begin our discussion of ectopic pregnancies
by reviewing the locations that we commonly see
ectopic pregnancies to be found.
We see here a normal uterus to the left,
and a bicornuate uterus to the right.
We remember that a fundal location is the definition
of an inter-uterine pregnancy as shown smack in the middle
of the normal uterus to the left.
However, we can have variants of ectopic pregnancies
within the uterus as shown in the interstitial location
in the normal uterus to the left,
and in the cornual region in the bicornuate uterus
to the right.
We can also have implantations low
within the cervical region of the uterus,
as shown in the normal uterus to the left.
Now, most ectopic pregnancies will be located
within the fallopian tube and of those
the majority will be found in the ampullary region
as that comprises the majority of the fallopian tube.
But we can have implantations more proximal,
within the isthmal region
or distal within the infindibular region.
Now, tough ectopics to diagnose are those that implant
within the ovary,
within the abdominal cavity,
or within the peritoneal lining.
These can be very, very hard to diagnose
and commonly grow to an advanced stage before diagnosis.
So, returning to our case, given the presence of a positive
pregnancy test and the absence of an IUP
on bedside ultrasound, we were very concerned about
ectopic pregnancy and decided to scan out
to the left adnexa.
Here, notice we're scanning out to the left adnexa,
and we have a positive finding.
What we see here is a thickened fallopian tube,
comprising what is known as the bagel sign.
Notice within the thickened fallopian tube,
we have another positive finding.
That is the presence of a fetal pole.
So, in this patient we were able to diagnose
an ampullary ectopic pregnancy and our next move
was to call OB/GYN stat for a consultation.
So, in conclusion, ectopic pregnancies constitute
the greatest cause, overall, of maternal mortality.
We must consider an ectopic pregnancy in all women
with a positive pregnancy test
where an inter-uterine pregnancy is not visualized
within the fundal part of the uterus.
Most ectopic pregnancies are going to be located
in the fallopian tube,
and we may actually visualize the ectopic
with ultrasound evaluation of the adnexa
as shown in this module.
So, we'll return with ectopic pregnancy part two
which goes over the varied manifestations
of ectopics.

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5750491404001

https://youtube.com/watch?v=iui0HF95XAw

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Case: Ectopic Pregnancy - Part 1

Case: Ectopic Pregnancy - Part 1

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