IwouldliketothankDr.FrankSandersonforjoiningusforroundstodayaswellasfortheexpertopinionhehasofferedinpreparationforthispresentation

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SothepatientisbroughtintoRAZ…

Recall:heterotopicis1:7000to1:30 000naturallyconceivedpregnancies,upto1%withassistedreproductivetechnologies

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SothepatientisbroughtintoRAZ…

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Soyoudoatransabdominal bedsideultrasoundandthisiswhatyousee…asmallintrauterinegestationalsac(actuallythisimageistransvaginal,butforthecasewe’llcallittransabdominalJ )

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SothepatientisbroughtintoRAZ…

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\Anindepthreviewofthemanagementofectopicpregnancyisbeyondthescopeoftoday’stalk.

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So itscriticaltodeterminenotonlywhenectopicisapossiblediagnosis,butalsonottojumptothisdiagnosisprematurely.Thechallengeisthatthereisaperiodoftimeduringpregnancywhenitmaynotbepossibletodefinitivelydeterminethelocationofpregnancy– thissubsetofpatientsrepresentsadiagnosticandmanagementdilemma

1.HahnSA,Promes SB,BrownMD.ClinicalPolicy:CriticalIssuesintheInitialEvaluationandManagementofPatientsPresentingtotheEmergencyDepartmentinEarlyPregnancy.AnnEmergMed.2017;69:241-250.

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Clinical suspicion– suspectectopicpregnancyevenwhensignsandsymptomsaresubtle,includingpv bleedingwithnoabdominalpain(RESOURCE??)

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Anormalgestationalsacisrounded,withathickechogenicrim, knownasthedoubledecidual sign

Worthnoting,whileemergencyphysiciansusetheyolksactodefineanIUP<radiologyliteratureusesthepresenceofagestationsactodefineIUP.

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Complex adnexalmasses- includethetubalringsign:ahyperechoic ringaroundatubalgestationalsac

Pseudogestational saconcethoughttobeverycommon,upto20%.Nowthoughtabout10%ofectopics haveapseudogestational sac.Seeinganyfluidintheuteruscarriesa99.5%chanceofintrauterinepregnancy– allcomers,notEDpopulation

Ofwomenwithconfirmedectopicpregnancy,15to25%ofinitialscansarenegative– emptyuterus,noadnexalmass,nofreefluid

2.MorinLetal.UltrasoundEvaluationofFirstTrimesterComplicationsofPregnancy.JObstetGynaecolCan2016;38(10):982-9887.DeCrespignyLC.Demonstrationofectopicpregnancybytransvaginalultrasound.BritishJObstetGynaecol1988;95:1253-68. RichardsonAetal.Accuracyoffirsttrimesterultrasounddiagnosisoftubalpregnancyintheabsenceofanobviousextrauterineembryo:systematicreviewandmeta-analysis.UltrasoundObstetGynaecol2016;477:28-37

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Complexadnexalmass,distinctfromuterusSeetheendometrialstripe,anddistinctseparatemassImportanttolookcarefully,maybetemptedtocallitIUPonceyouseethefetaltissue

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βHCGlevelsinviableIUP,nonviableIUPandectopicpregnancyhaveconsiderableoverlap - AsingleserumβHCGcannotdistinguishWhataboutthediscriminatoryzone? Conceptually,βHCGbelowwhichpregnancynotvisibleonUSAnnals2011Forpatientswithnondiagnosticbedsideultrasonography,usingadiscriminatoryhCGlevelof3,000mIU/mLtofurtherassessforectopicpregnancyshowedsensitivityof35%(95%confidenceinterval[CI]18%to54%)andspecificityof58%(95%CI48%to67%). Overallsensitivityofbedsidepelvicultrasonographyforthedetectionofintrauterinepregnancywas71%(95%CI63%to78%),andthespecificitywas99%(95%CI94%to100%).

6.WangRetal.Useofab-HCGdiscriminatoryzonewithbedsidepelvicultrasonography.AnnEmergMed2011;58(1):12-203. CampionEWetal.DiagnosticCriteriaforNon-ViablePregnancyEarlyintheFirstTrimester.NEnglJMed2013;369(15):1443-14514. KadarN,DeVoreG,RomeroR.DiscriminatoryhCGzone:itsuseinthesonographicevaluationforectopicpregnancy.ObstetGynecol1981;58:156-615. BreeRL,EdwardsM,Bohm-VelezM,BrylerS,RoberstJ,MendelsonEB.Transvaginalsonographyintheevaluationofearlypregnancy:correleationwithhCGlevel.AJRAmJRoentgenol1989:153:75-9.(plusrelpicatiedbyabout3morestudiesinearly90’s...)

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Sohowcanweusetheb-HCG?... Inthesettingofasymptomaticpatientwithemptyuterus,alowβHCG<1000doesnotruleoutectopicpregnancyIfanything,thesefigures futhersupporttheneedtobesuspiciousofectopicinpregnancyofunknownlocationwithlowbHCG

9.ShaunikAetal.Utilityofdialationandcurettageinthediagnosisofpregnancyofunknownlocation.AmJObstetGynecol2011;204(2):130.....thisstudyhad173women10.BensonDB,DoubiletPM,PetersHE,FratesMC.Intrauterinefluidwithectopicpregnancy:areappraisal.JUltrasoundMed2013;32:389-93

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TheAmericanCollegeofEmergencyPhysiciansrecommends:ProceedtoTVUSinsymptomaticpatientswithbHCG lessthan 1000If youhangyourhatontheconceptofadiscriminatoryzone,youmayadvocateavoidingordeferringultrasoundforbHCG <1000.Particularlyforuslocally,onemayperformatransabdominalscanwithNodefinitiveIUPandbHCG =1000.Arewedone?….ACEP’s2017updatedpolicyonpatientspresentingtoEDinearlypregnancywouldrecommendtomoveforwardwithTVUS

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Onehundredandseventeencasesofectopicpregnancywerereviewed.Thirty-sevencasesmetpredeterminedcriteriaof'clinicalstability'atfirstpresentation.Thesepatientswaitedamedian14hfordiagnosticultrasoundwith62%waitingmorethan12h.Noadverseeventsoccurredwhilewaitingforthisdiagnosticstudy.CONCLUSIONS: Preliminaryresultssuggestthatpregnantpatientswithabdominalpainandvaginalbleedinginthefirsttrimesterwhomeetspecificlow-riskclinicalcriteriacouldpotentiallyhaveultrasounddelayed12-18hwithoutriskofadverseevent.Furtherprospectivestudiesarewarrantedtoconfirmthesafetyofthisstrategy. Theyfoundnoadverseevents,definedasdeathorneedforfluidbolusbecauseofhemodynamicinstability,in37patientsdespiteamediandelaytoultrasoundof14hours(range0to126hours),with62%ofpatientswaiting12hoursorlonger.Themeanb-hCG levelinthisgroupwas2,887mIU/mL(range85to26,000mIU/mL),butthenumberofpatientswithab-hCG levellessthanthediscriminatorythresholdwasnotprovided.

11:HendryJN,Naidoo Y.Delayedultrasoundinpatientswithabdominalpainandvaginalbleedingduringthefirsttrimesterofpregnancy.EmergMed(Fremantle).2001;13:338-343.12:BarnhartK,Mennuti MT,BenjaminI,etal.Promptdiagnosisofectopicpregnancyinanemergencydepartmentsetting.Obstet Gynecol.1994;84:1010-1015.

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AccordingtotheAssociationofEarlyPregnancyUnitsguidelines, ifnointrauterineorectopicpregnancyorretainedproductsofconceptionareseenontransvaginalultrasoundandthewomanisasymptomaticatinitialassessment,shecanbemanagedconservatively.ThisisirrespectiveofthehCG discriminatoryzoneandadditionalultrasoundfindings,suchasasuspiciousadnexalmass3cm.Conservativemanagementinvolvesre-estimationofserumhCG levelsat48hourstodeterminethepatternofhCG changefromtheinitialassessment.Furtherfollow-upwithhCGandtransvaginal ultrasoundcanbearrangedortherapeuticinterventionmade.1513.Sagili H&MohamedK.Review:Pregnancyofunknownlocation:anevidence-basedapproachtomanagement.TheObstetrician&Gynaecologist 2008;10:224-230.

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3.CampionEWetal.DiagnosticCriteriaforNon-ViablePregnancyEarlyintheFirstTrimester.NEnglJMed2013;369(15):1443-1451

13.Sagili H&MohamedK.Review:Pregnancyofunknownlocation:anevidence-basedapproachtomanagement.TheObstetrician&Gynaecologist 2008;10:224-230.

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Thisconceptissupportedinthe 2016SOGCGuidelineonUltrasoundEvaluationofFirstTrimesterComplicationsofPregnancy

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Inthepregnantpatientwithvaginalbleedingand/orabdominalpain:

WhenTVUSisdelayedorremainsnon-diagnostic,involveobstetriciantoaidinriskstratificationandmanagement

Reliable,hemodynamicallystablepatientsmaybedischargedwithfollowupExpeditedTVUS(nextday)RepeatβHCGin48h

Thepatientwillrequireappropriate dischargeinstructions,advisingofthecontinuingpossibilityofectopicpregnancy.SheshouldbeadvisedtoreturntoEDimmediatelyifbleedingorabdominalpainorpresyncope occur.Forpatientspresentingfromremotelocationsorthosewhomaynotbereliable,consideradmissionwhileawaitingrepeatb-HCG

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Thepatientisreliable andwillbegoinghometoherpartner,shelivesnearthehospital

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Inthefirsttrimester,theterms spontaneousabortion,miscarriageandearlypregnancylossareusedinterchangeably

Thereisriskassociatedwithdiagnosingearlypregnancylosstooearlyduetoriskoffalsepositive– riskofinterveningonaviablepregnancy

Earlypregnancylossisdiagnosedusingultrasound,withattentiontoserialbHCG andtime-basedcriteriafordoagnosis

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Anormalgestationalsacisrounded,withathickechogenicrim, knownasthedoubledecidual sign

Worthnoting,whileemergencyphysiciansusetheyolksactodefineanIUP<radiologyliteratureusesthepresenceofagestationsactodefineIUP.

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CRL=5mmhasafals pos rateof8.3%, gestsacof16mmhasfalsepos rateof4.4%

15.Abdallah Y,Daemen A,KirkE,Pexsters A,Naji O,Stalder C,etal.Limitationsofcurrentdefinitionsofmiscarriageusingmeangestationalsacdiameterandcrown-rumplengthmeasurements:amulticenterobser- vational study.UltrasoundObstetGynecol 2011;38:497–502.

16.Abdallah Y,Daemen A,Guha S,SyedS,Naji O,Pexsters A,etal.Gestationalsacandembryonicgrowtharenotusefulascriteriatodefinemiscarriage:amulti- centerobservationalstudy.UltrasoundObstet Gynecol 2011;38:503–9.

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Criteriaare fromtheSocietyofRadiologistinUltrasound(American)in2011andendorsedbybothACOGandSOGC

TheFHRistypicallyvisible assoonasembryovisible,thereforeCRL<7mmwithnoFHRissuggestivebutnotdiagnosticofearlypregnancyloss

TheMeansacdiameterof25mmwithnoembryois100%specificforEPL

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CriteriaarefromtheSocietyofRadiologistsinUltrasoundMultispecialtyConsensusConferenceonEarlyFirstTrimesterDiagnosisofMiscarriageandExclusionofaViableIntrauterinePregnancy,October2012.

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PanelAshowsanembryowithacrown–rumplength(betweentheplussigns,indicatingcalipers)of7.1mm.Nocardiac activitywasseenonrealtimeultrasonography.

Forreflection– thisisameasurementofmillimeters,sosubjecttointer-observervariability

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PanelsBandCshowagestationalsacwithameandiameterof27.7mm(averageof35.4mm,19.7mm,and28.1mm),withnovisibleembryo.SAGdenotessagittalview,andCORcoronalview.

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Timebasedcriteriainclude:Absenceofembryowithheartbeat7–13daysafterascanthatshowedagestationalsacwithoutayolksacAbsenceofembryowithheartbeat7–10daysafterascanthatshowedagestationalsacwithayolksacAbsenceofembryo≥6wk afterlastmenstrualperiodPanelDshowsanintrauterinegestationalsacwithayolksac,andPanelE(ascanobtained2weekslater)showsayolksacbutnoembryowithinthegestationalsac.

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SerumβHCGbecomespositiveatimplantationDay21or22postLMPDay8postconceptionPositiveserumβHCG>15Note:urinepreg+atβHCG=30

ASingleorserialβHCGmaybeusedtoaddsupporttoUSdiagnosisofnonviablepregnancy

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Note:Spontaneousabortionismedicallycommon,anditsimpactisoftenunderestimated. Weoftendealwiththesepatientsinthetime-pressuredenvironmentofRAZ,andwhilewemaybegladthatthepatientdoesnothaveanectopicpregnancy,tothepatientitmaybeoneoftheworstdaysofherlife.

Soit’sessentialthatwehavetheseconversationsinatactful,empathicmanner.–andvitalthatweareabletoprovideupfrontinfoontreatmentoption.Evenbetter–printahandoutforthepatient.

ACOGhandout:http://www.acog.org/-/media/For-Patients/faq090.pdf

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Limitedtofirsttrimesterupto12w6dC/Iif:infection,hemorrhage,severeanemia,bleedingdisorderSuccessfultocompeteexpulsionin80%women - PossiblymoreeffectiveinwomenalreadyexperiencingbleedingExpectmoderatetoheavybleeding - CounselthatsurgeryormedicationmaybenecessaryifcompleteexpulsionnotachievedConfirmation:typicallywithUS - Absenceofgestationalsacandendometrialthickness<30mm, SerialβHCGalternativeiflimitedUSaccess

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Samecriteriaasexpectant(<12w6d,medicallystable) –Successrateofmedical mgmt about95%forimcomplete abortion,88%forfetaldeathand80%foranembryonic pregnancyGoodoptionforwomanwishingtoshortendurationtoexpulsionbutwishingtoavoidsurgicalevacuation - Alsomorecontroloverwhenbleedingoccurs, ReducesneedforD&Cby60%Sampleprotocol - Misoprosol 800mcgpv,Onerepeatdoseprn,noearlierthan3hafterfirstdoseandwithin7d, Ibuprofen forpaincontrol,RhoGAM within72hoffirstdoseifRh(-)USin7-14dtodocumentcompleteexpulsion - OrserialβHCGCounselre:whatistoomuchbleeding?Soaking2maxipadsperhoursfor2consecutivehours– ifthisoccursreturntoEDIfmisoprstol fails,patientmayoptforexpectantorsurgicalmanagement

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SuccessrateofD&C approaches99%Suctioncurettagemaybeperformedinanofficesetting

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Preventionofallo-immunizationforRh(-)mother: - RhoGAM 50mcgwithin72hofdxofmiscarriage Orimmediatelyfollowingsurgicalmanagement, If50mcgdosenotavailable,usefull300mcgdose

Delayedconception?à nobenefitAvoidintercourse1-2wk afterpassageoftissuetoreduceinfection

(notevidencebased)

MayresumecontraceptionimmediatelyaftercompletionofspontaneousabortionIUDmaybeplacedattimeofsurgicalevauation

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Diagnosisofearlypregnancylossismadeasshehasabsenceofembryowithheartbeat7–13daysafteranultrasoundscanthatshowedagestationalsacwithoutayolksacAdditionally,bHCG is falling

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Addedtakehome point:- Itcantake3to4visitsover1– 2weekstomakeafinaldiagnosisofectopic

pregnancyorearlypregnancyloss- Thesecasesrequireteamworkwiththepatient’sobstetricalprovider

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