Ultrasound Imaging: Usual and Atypical Findings of the Extrauterine Pregnancy

Introduction The most important way to reduce maternal mortality and preserve fertility related to EP is the diagnosis and early treatment. Transvaginal pelvic US is the first diagnostic tool in hemodinamically stable patients with suspected EP. Recently studies have shown that in 73, 9% of the cases it is possible to make a diagnosis by transvaginal US and in 94% of the cases EP is diagnosed even before the surgery. The ß-hcg values are another important mark to help the ultrasonographic evaluation. In particular EP is characterized by lower levels of ß-hcg, that increase less than the IUP; in presence of a ß-hcg around 500-1000 mUI/ml, the gestational sac is visible in the uterus, in the 80% of cases. Every time there is a clinical suspicion of ectopic pregnancy or when the ß-hcg levels lay down for a pathological pregnancy, the ultrasound evaluation is recommended. In these cases ultrasounds may be essential to determine the location of intraor extra-uterine gestation. A series of ultrasound criteria, those relate to endometrium, tubal pattern, ovaries, aspect of uterine cornua and cervix and the pouch of Douglas, are the most relevant factors to establish a diagnosis. Furthermore in case of PUL, a term used to classify a pregnancy before the final clinical outcome is known, the US exam is fundamental to an exclusion diagnosis. Citation: Giulia Gagliardi., et al. “Ultrasound Imaging: Usual and Atypical Findings of The Extrauterine Pregnancy”. EC gynaecology 1.1S1 (2016): 36-47. Ectopic pregnancy (EP) occurs when the blastocyst implants outside the uterine cavity. In developed countries, the incidence of this disease ranges from 11 to 20% for every 1000 live births [1, 2,3] and it remains the leading cause of maternal death during the first trimester of pregnancy, with a mortality rate equal to 9-14% [4,5]. It is evident that the diagnosis and early treatment of ectopic pregnancy are essential to reduce maternal mortality and preserve fertility. Most of the ectopic pregnancies is localized at the level of the Fallopian tubes. Almost all ectopic pregnancies are not progressive and often are absorbed before the manifestation of any kind of symptoms. The trophoblast is able to erode the tubal wall causing intra-tubal (hematosalpinx) and extra-tubal (hemoperitoneum) bleeding. Sometimes it’s possible to see an embryo with cardiac activity in the ectopic gestational sac. EP is often suspected when vaginal bleeding occurs along with abdominal or pelvic pain associated with sore and tender adnexal mass in patients at 5-9 weeks’ gestation [6,7]. The greatest risk for the patient is the rupture of the Fallopian tube. The risk is not always easily related to the severity of pain, in fact the pain may even decrease or disappear following tubal rupture [7]. Any clinical suspicion as hypovolemic shock and shoulder pain, as indirect sign of diaphragmatic injury, should raise the suspicion of an ectopic pregnancy complicated by rupture of the tube and the management must include surgery in emergency conditions. Fortunately, these situations are not very common and the trans-vaginal pelvic ultrasound looks to be the first diagnostic tool in hemodynamically stable patients with suspected ectopic pregnancy [8]. In recent years studies show that in about 73.9% of the cases it is possible to make a diagnosis by trans-vaginal ultrasound [9] and that 94% are diagnosed even before the surgery [10]. Abbreviations: EP: Ectopic pregnancy; PUL: Pregnancy of unknown location; IUP: intrauterine pregnancy