Diagnostic ultrasound ( PDFDrive )

1076 PART IV Obstetric and Fetal Sonography
A
B
FIG. 30.36 Left Ectopic Pregnancy Failed Medical Management. A 38-year-old woman with pain and bleeding from left ectopic pregnancy
treated with methotrexate. (A) At initial diagnosis, left extraovarian ectopic mass (black arrow) was found adjacent to the left ovary (white arrows).
HCG levels continued to rise. (B) Repeat scan 2 weeks later shows growth of adnexal mass now containing a gestational sac with embryonic pole.
The ectopic pregnancy was then treated successfully with salpingectomy.
ultimate goal is to diagnose the ectopic pregnancy before tubal
rupture and to treat it so as to minimize tubal scarring while
maintaining tubal patency.
Laparoscopy is oten used for deinitive diagnosis in ectopic
pregnancy and for the more conservative surgical procedures
such as salpingotomy. 125 he diseased tube is incised and microdissection
used to remove the gestational sac. he incision is then
let to heal by secondary intention. he rate of subsequent IUP
in these surgical patients is 61.4%, with a 15% rate of recurrent
ectopic pregnancy. 126
Medical management has also been successful in the treatment
of early ectopic pregnancy. Cell growth inhibitors such as
methotrexate are injected systemically (intravenous, intramuscular,
or oral administration) and the serum β-hCG levels followed
closely. he methotrexate kills the rapidly dividing trophoblastic
cells, which are then reabsorbed, resulting in falling β-hCG levels
and, ideally, preservation of the tubal lumen. 127 Success rates
range from 61% to 93% for local injection 128 and from 65% to
94% for intramuscular treatment. 129 he rate of side efects is
21% with parenteral administration and 2% with local injection
under ultrasonic guidance.
Medical treatment is most successful in tubal pregnancies
(vs. interstitial ectopic pregnancy or cervical ectopic pregnancy),
those cases with smaller ectopic masses, less free luid, and those
without embryonic cardiac activity.
Barnhart et al. 130 reviewed studies of multidose and single-dose
regimens of methotrexate and found an overall success rate of
89% (1181 of 1327 women). he single dose was used more
oten but was associated with a signiicantly greater chance of
failure than multidose therapy, although it had fewer side efects.
Hajenius et al. 128 compared treatment options of laparoscopy,
laparotomy, methotrexate (local vs. systemic, single vs. multiple
dose), and expectant management (where patients are monitored
without treatment). Multidose intramuscular methotrexate is
most cost-efective in patients with low serum β-hCG than
laparoscopic salpingostomy. In all cases, both therapies had similar
results, with laparoscopy having a higher cost and longer
hospital stay.
Nazac et al. 129 studied 137 women with an unruptured ectopic
pregnancy and hematosalpinx seen on TVS. hey found that in
cases with an hCG level less than 1000 mIU/mL, local injection
of methotrexate (1 mg/kg) directly into the sac ater irst aspirating
the contents had a 92.5% success rate compared with 67% for
intramuscular administration. he local injection was performed
vaginally using the same technique as for follicle aspiration during
oocyte retrieval in IVF.
A common complication of methotrexate therapy is a rupture
of the ectopic pregnancy, with increased pelvic pain and tenderness
and the appearance of a hemorrhagic mass. Usually these
will resolve with conservative management but occasionally will
require surgical intervention. Even with successful treatment of
an ectopic pregnancy, an adnexal mass may increase in size as
a result of edema and hemorrhage. However, any evidence of
further continuation of growth of the ectopic pregnancy is
evidence of failure of the therapy (Fig. 30.36).
Conservative management is becoming more common for
the stable patient with low or declining levels of β-hCG. Success
rates of up to 69.2% have been reported. 126
EVALUATION OF THE EMBRYO
he diagnosis of speciic fetal anomalies in the irst trimester is
discussed in the chapters pertaining to the involved organ system.
Nuchal translucency screening is discussed in the Chapter 31.
his discussion is limited to general principles of assessment of
the embryo in the irst trimester. Current trends in irst-trimester
diagnosis, including widespread acceptance of TVS, nuchal
translucency screening, maternal serum markers, and cell free
DNA testing, combined with improved sonographic resolution,
have resulted in the potential diagnosis of a wide range of defects
in the irst trimester. As the resolution of ultrasound equipment
improves, visualization of embryologic structures becomes
possible. It is critical that incorrect decisions are not made on
the basis of incomplete understanding of normal and abnormal
embryonic and fetal anatomy in the irst trimester. herefore if
any uncertainty surrounds the indings in an early scan,