1. Ectopic Pregnancy Susana Smith Harbutt February, 2013 Dr. Joy Sclamberg

2. HPI: The patient is a 36 year old G10P6030 at 8 weeks by LMP with PMH of 2 ectopic pregnancies treated with MTX who presents 7 days follow-up of medical management of ectopic pregnancy. She originally presented to OSH on 1/27/10 for 10/10 abdominal pain and was found to have +beta HCG and right adnexal mass. She presented to Rush for second opinion. She received MTX for medical management of the ectopic pregnancy and her beta-HCG have continued to trend upwards. Physical Exam: Vitals: BP: 111/68 mmHg Pulse: 74 Temp: 98.4 °F (36.9 °C) Resp: 18 General: alert and oriented, NAD Lungs: Clear bilaterally Heart: S1, S2+, RRR Abdomen- soft, minimal suprapubic ttp, no rebound or guarding Bimanual exam- mild suprapubic tenderness, no CMT, no adnexal tenderness Clinical History and Physical Exam 2

3. Ectopic Pregnancy Hemorrhagic Cyst – key findings clot retraction and fibrin strands Ovarian torsion – findings include enlarged edematous ovary. Doppler findings can vary, lack of doppler makes the diagnosis. Pelvic Inflammatory Disease – findings include thickened tubal wall, hyperemia or increased vascularity of the fallopian tube. Appendicitis Paratubal cyst Working Diagnosis

4. Discriminatory HCG: level at which an intrauterine pregnancy should be detected by ultrasound. If not present than abnormal or ectopic gestation is likely. Beta HCG

5. Ultrasound MRI CT Diagnostic Imaging Options

6. ACR Criteria

7. Ultrasound

8. Double Decidua Sign Normal Pregnancy

9. Yolk Sac and Embryo Yolk Sac at 5 weeks

10. Uterus Transvaginal Ultrasound 5193474

11. Cervix Transvaginal Ultrasound

12. Right Adnexa Transvaginal Ultrasound

13. Right Ovary Transvaginal Ultrasound

14. Right Ovary Transvaginal Ultrasound

15. Left Adnexa Transvaginal Ultrasound

16. Left Adnexa Transvaginal Ultrasound

17. Left Adnexa Transvaginal Ultrasound

18. Gestational Sac Transvaginal Ultrasound

19. Gestational Sac Transvaginal Ultrasound

20. Yolk Sac Transvaginal Ultrasound

21. Embryo – Fetal Pole Transvaginal Ultrasound

22. Left Adnexa Transvaginal Ultrasound

23. “Ring of Fire” Transvaginal Doppler Ultrasound

24. Operative laparoscopy with removal of ectopic pregnancy and salpingectomy Pathology Report: Treatment

25. MRN: 9003501 Accession: 5193474 Adam, Andy. Grainger & Allison's Diagnostic Radiology, 5th ed. Chapter 53 Imaging in Obstetrics and Infertility. Churchill Linvingstone 2008 Barnhart, Kurt T., M.D., M.S.C.E Ectopic Pregnancy. N Engl J Med 2009; 361:379-3 July 23, 2009DOI: 10.1056/NEJMcp0810384July 23, 2009DOI: 10.1056/NEJMcp0810384 Levine, Deborah. Ectopic Pregnancy. Radiology. 2007.245: 385-397 Case and References 25