OVARIAN ECTOPIC PREGNANCY.5% To 1% Of Ectopic Pregnancies

A woman who is capable of conceiving is capable of having a pregnancy in a

location other than the uterine cavity .

COMPLEX EXOPHYTIC OVARIAN LUTEAL CYST VERSUS OVARIAN ECTOPIC.

1. Follow up – cyst has rapid change 2. Complex fluid in the POD

supports ectopic as possibility .

MERCURY IMAGING INSTITUTE SCO 172-173 SEC 9C CHANDIGARHMERCURY IMAGING CENTRE SCO 16-17 SEC 20D CHANDIGARH

Case details• 27 yr old female in late secretery

phase of the menstrual cycle presented with pain left illiac fossa and chronic low back ache.

• Rebound tenderness in the left iliac fossa apprecaiated.

• USG –TVS - ? PID • Repeat – USG –Transvesicle

? Tubal ectopic ( Adnexal mass appreciated betwen the left side uterine cornu and left ovary . Left ovary could not be seen separate from the lesion. The mass has heterogenous chaotic arterial flow around it . Probe tenderness was appreciated on the lesion.)

• Heteroegnous echogenic areas in the POD were thought to be adynamic gut – Finally proved to be Blood clots .

• hCG was done and it was >2000 . There was no intrauterine G sac – Possibility of ectopic pregnancy in the ampullary region of he tube was given.

Trans vesicle USG

Endometrial lining is homogenous with no decidual cyst , pseudogestational sac . Mass is appreciated in the left adnexal region between the corunal end and left ovary .

Trans vesicle USG

Left adnexal mass is well defined with an anechoic central crescent shaped area s/o ? G sac

in the extra uterine location.

Trans vesicle USG

Rt ovary is normal. Central endometrium is normal.

Trans vesicle USG

Mass is seen medial to the left ovary and on further sagittal views mass can not be discretely

separated from left ovary.

Follow up.....................

• Laproscopic removal of the adnexal mass done . Moderate amount of haemoperitoneum present .

• Either side tubes were normal.• Initial histopathological assesement –

Corpus luteal cyst .• Follow up beta HCG VALUES DROP

DOWN.• Possibility of ? Tubal abortion with

ruptured corpus luteal cyst is kept.

• Further sections through the ovarian tissue revealed chorionic villi

• Diagnosis of ovarian ectopic was confirmed.

Ectopic pregnancy

• SALPHINGITIS TREATMENT• TUBAL SCARRING ,

TUBOPLASTY.• ASSISTIVE REPRODUCTIVE

TECHNIQUES• OVULATION INDUCTION.

All the above mentioned situations raise the possibility of ectopic

gestation.

Some facts• Beta Hcg ( International reference ) –

Value of more than 2000 – usually the sac is seen in the normal pregnancy.

• In normal intrauterine Pregnancy the doubling time of beta Hcg is 2 days .

• Intrauterine sac should grow at a rate of .8mm / day.

• Ectopic pregnancy has lower S PROGESTERONE LEVEL when compared with the normal intrauterine gestation.

Triad in ectopic ...... Pain in ectopic........

• Pain , adnexal mass , bleeding P/V , positive pregnancy test.

• Amenorrhoea, abdominal pain and appearance of the vaginal bleeding ( only 45 % cases have this triad).

• Pain site is non specific – Ipsilateral to the ectopic , Contralateral to ectopic – corpus luteal cyst , Shoulder , Back , vaginal pain.

This patient had chronic low back ache with pain and rebound tenderenss in the left iliac fossa. Adnexal mass was appreciated on USG and she was in late secretery phase of her menstrual cycle.

Signs in early intrauterine gestation.

• INTRA DECIDUAL SIGN Small anechoic focus with

echogenic rim around it with location eccenteric to the endometrial stripe is suggestive of early intrauterine gestation . ( seen 4.5 wks of gestation) ( Size as small as 2.2mm)

D/D – Decidual cysts, Pseudogestational sac , Small endometrial fluid collection.

• DOUBLE DECIDUAL SAC SIGN

Seen later than the intradecidual sign.

Yolk sac and embroy if appreciated in the SAC - increase the confidence level of the intrauterine gestation.

Choroiniv villi , endometrial fluid , decidua vera - All three constitue the double decidual sac sign.

Abnormal intrauterine G sac versus

Pseudogestational sac • Appreciating an intrauterine

sac of size approximately 13mm with no secondary yolk sac raises the suspicion of the abnormal intrauterine gestation. Post D&C if presence of the chorionic villi is demonstrated – Nothing to worry . If No chorionic villi demonstrated – still chances of ectopic are high and Serial monitoring with beta Hcg has to be done.

• Combine – Trans vaginal with trans abdominal – Vaginal probe has better resolution because of the proximity to area of interest but limited field of view is a limitation hence transabdominal should be combined with trans vaginal .

• Look above and below the ovaries . Look between the ovaries and uterus

• Keep in mind haematosalphinx.

Diagnostic criteria of ectopic pregnancy ( in patient with positive pregnancy test no intrauterine

pregnancy.)

• Extrauterine sac with Yolk sac/embryo

• Adnexal ring• Complex adnexal mass

separate from the ovary.• Fluid ( Moderate or

large amount of the fluid / complex fluid- echogenic fluid ).

• Decidual cyst.

This patient had an adnexal mass with minimal amount of fluid and no intrauterine G sac/ endometrail fuid collection.

The echogenic contents in the POD were assumed to be adynamic gut which were blood clots due to haemoperitoneum.

Differences between Early intrauterine gestation and pseudosac.

EARLY INTRAUTERINE PREGNANCY

• Round • Eccenteric• Margins – Well defined• Decidual reaction –Well

defined • Intradecidual sign• Double decidual sac sign• Growth rate= .8mm/ day.

PSEUDO SAC

• Ovoid• Central• Poorly defined margins• Absent Decidual reaction• Single decidual layer – no

double decidual sac sign.

Endometrium in ectopic pregnancy

• Endometrium in ectopic pregnancy – Thick , thin

• Decidual cyst may or may not be present at endometrial/ myometrial junction.

D/D of haematosalphinx

• Retrograde flow of the blood in spontaneous abortion.

• Pedunculated fibroid• Exophytic corpus luteal cyst • Tubo-ovarian abscess• Tubal cyst • Adjacent bowel

ASSESS PERITROPHOBLASTIC FLOW

1. Corpus luteal cyst 2. Implantation site of normal

pregnancy3. Extrautreine ectopic pregnancy

All these will have low impedence high diastolic flow component . Hence in situation

where corpus luteal cyst has to be differentiated from the ectopic

pregnancy – extra –ovarian location is very important.

Color doppler helps to assess viability of the tissue – No flow in an ectopic supports dead non viable tissue and hence instead of surgical - more conservative plans can be thought of.

Brief about cervical and interstitial ectopic

CERVICAL ECTOPIC

DIFFERENTIATE FROM CERVICAL ABORTION.

• Sac in abortion changes it’s shape quite fast

• Sac in ectopic is round to hour glass in shape

• Peritrophoblsatic flow is appreciated in the cervix in case of ectopic gestation and not in the cervical abortions.

• Profuse bleeding in cervical ectopic

INTERSTITIAL PREGNANCY

Pregnancy with less than 5mm myometrial cover at one or more places and stationed

in the vicnity of the fundus / cornual region is taken as

interstitial pregnancy.

Non invasive approach

• TVS with Beta Hcg – Non invasive preffered test .

• Combine TVS with Trans abdominal USG.

• Doppler suggestion of no flow in the ectopic pregnancy suggests non viable / dead ectopic and conservative approach can be thought in this situation.

Lesson learnt

• Differentiate exophytic corpus luteal cyst from the ectopic pregnancy ( be sure about intraovarian / extra ovarian location)

• Echogenic complex signal in the POD – Think of haem products ,

• Beta Hcg- take international reference levels into considerations

Trophoblsatic flow – Low impedence and high diatolic component in an extrauterine / extra ovarian mass supports ectopic as diagnosis.

Decidual cysts , small endometrial fluid collections – these observations should be given importance in similar way as other direct positive signs.