Emergency Sonography of the Pregnant Patient, American Society of Emergency Radiology (2009)

1. Emergency sonography of the pregnant patient Daniel Noujaim, MD Gabriel Werder, MD Tiffany Langlas, MD FarnooshSokhandon, MD Department of Radiology William Beaumont Hospital Royal Oak, Michigan

2. Objectives Present an organized approach to the sonographic evaluation of the pregnant patient in an emergency setting Illustrate imaging features of various pregnancy-related conditions in an unknown-case format Discuss the pathogenesis, epidemiology, clinical presentation, diagnosis, & outcome of the above conditions

3. Abnormal pregnancyUterine complicationsAbnormal placentationNon-obstetric complications of pregnancyConditions that mimic obstetric pathologyPostpartum complications

4. Abnormal Pregnancy Spontaneous abortion/failed first trimester pregnancy Ectopic pregnancy Molar pregnancy

5. Uterine Complications Cervical incompetence Premature rupture of membranes Uterine rupture

6. Abnormal Placentation Vasa/placenta previa Placenta acreta/increta/percreta Placental abruption/subchorionic hemorrhage Succenturiate (accessory) lobe Circumvallate placenta

7. Non-Obstetric Complications of Pregnancy Hydronephrosis Deep vein thrombosis Ruptured splenic artery aneurysm Hemolysis, elevated liver enzymes, low platelets (HELLP)

8. Conditions that Mimic Obstetric Pathology Uterine (Braxton-Hicks) contraction Corpus luteum Ovarian torsion Tubo-ovarian abscess Cystic ovarian disease/endometriosis Acute appendicitis

9. Postpartum Complications Retained products of conception Endometritis Ovarian vein thrombophlebitis Bladder flap/subfascial hematoma

10. Case 1: Clinical History 19-year-old G2,P0 Last menstrual period: 10 weeks ago Beta-hCG: 230,335 mIU/ml Vaginal bleeding

11. Case 1: Diagnosis?

12. Case 1: Imaging Findings Heterogeneous, hyperechoic intrauterine compartment with multiple cystic elements “Swiss cheese endometrium”

13. Case 1: Complete Molar Pregnancy Pathogenesis 100% paternal genetic complement (diploid) Haploid sperm fertilizes “empty” ovum & duplicates to diploid Two sperm fertilize “empty” ovum Epidemiology 5/10,000 in US Recurrence risk 1-2% Presentation Vaginal bleeding, hyperemesis, &/or rapid uterine enlargement Diagnosis Heterogeneous, hyperechoic intrauterine mass with cystic elements Markedly elevated beta-hCG Ovarian hyperstimulation (theca lutein cysts) Outcome 12-15% progress to invasive mole 5-8% progress to choriocarcinoma

14. Case 1: Diagnosis? Patient presents 2 weeks after dilation & curettage with persistent vaginal bleeding & increasing beta-hCG

15. Case 1: Metastatic choriocarcinoma Patient presents 2 weeks after dilation & curettage with persistent vaginal bleeding & increasing beta-hCG

16. Case 2: Clinical History 33-year-old G2,P0 Last menstrual period: 3 weeks ago Beta-hCG: 2,256 mIU/ml Severe left lower abdominal quadrant pain

17. Case 2: Diagnosis?

18. Case 2: Imaging Findings Empty uterus Ring-like left adnexal mass Free fluid in cul-de-sac

19. Case 2: Ruptured Tubal Ectopic Pregnancy Pathogenesis Ectopic implantation site (95% tubal; 85% same side as corpus luteum) Epidemiology 1.4% (all pregnancies); 10-40% (fertility patients); 5-20% (pain/bleeding) Presentation Vaginal bleeding, pelvic pain, mass, &/or hemodynamic instability Diagnosis Positive beta-hCG No intrauterine pregnancy (possibly pseudogestional sac) Prominent echogenicendometrium Ring-like tubal mass with increased flow (“ring-of-fire”) Echogenic cul-de-sac fluid (adnexal mass + fluid: 98% sensitive) Outcome Treatment: systemic methotrexate, surgery, or US-guided injection 80% have future intrauterine pregnancy 15-20% have future ectopic pregnancy

20. Sites & frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%. Sepilian VP, Wood E. eMedicine: Ectopic Pregnancy. http://emedicine.medscape.com/article/258768-overview. Accessed 9/23/2009.

21. Case 3: Clinical History 35-year-old G4,P2 Last menstrual period: 6 weeks ago Beta-hCG: 972 mIU/ml Vaginal bleeding, right lower abdominal quadrant pain, & right shoulder pain

22. Case 3: Diagnosis?

23. Case 3: Imaging Findings Thick, echogenicendometrium without evidence of intrauterine pregnancy Heterogeneous left adnexal mass with increased circumferential flow distinct from left ovary

24. Case 3: Diagnosis? Evaluation of remainder of abdomen reveals the following:

25. Case 3: Ruptured Tubal Ectopic Pregnancy Evaluation of remainder of abdomen reveals the following: Abnormal echogenicperihepatic fluid collection compatible with rupture… Patient’s right shoulder pain may represent referred pain from diaphragmatic irritation

26. Case 4: Clinical History 25-year-old G2,P0 Last menstrual period: 2½ months ago Beta-hCG: 75,003 mIU/ml Vaginal bleeding & adnexal pain

27. Case 4: Diagnosis?

28. Case 4: Imaging Findings Extrauterine gestational sac

29. Case 4: LiveAbdominalEctopic Pregnancy

30. Case 4: LiveAbdominalEctopic Pregnancy Pathogenesis Direct peritoneal implantation with omental blood supply Most commonly implants within ovarian ligaments Epidemiology 1:2,200 – 1:10,200 Presentation Pelvic pain, mass, hemodynamic instability Diagnosis Gestational sac visualized separate from uterus, adnexa, & ovaries Outcome Treatment: surgery Maternal mortality: 0.5-18% Live birth is possible in rare circumstances

31. Case 5: Clinical History 19-year-old G1,P0 Last menstrual period: 15 weeks ago Beta-hCG: qualitatively positive Pelvic pain

32. Case 5: Diagnosis?

33. Case 5: Imaging Findings Cervical length < 3 cm “Hourglass sign”: invagination of amniotic fluid into cervical canal

34. Case 5: Cervical Incompetence Pathogenesis Premature cervical effacement which may be congenital or due to laceration, prior excessive dilation, or history of elective abortion Epidemiology 1% of all pregnancies Presentation Often detected incidentally between 16th & 28th weeks of gestation Diagnosis Internal cervical os > 5mm Cervical length < 3cm on transvaginal/translabial US (some use 2.6cm) Bladder distension on transabdominal imaging falsely lengthens cervix Prolapse of membranes/amniotic fluid/fetal parts into cervical canal Outcome Leads to premature rupture of membranes & preterm labor Accounts for 15-20% of 2nd trimester loss of pregnancy Treatment: cervical cerclage

35. Case 6: Clinical History 32-year-old G2,P0 Last menstrual period: 7 months ago Beta-hCG: 14,746 mIU/ml “Cramp-like” abdominal pain

36. Case 6: Diagnosis

37. Case 6: Imaging Findings “Hourglass sign”? Open cervical canal?

38. Case 6: Diagnosis? Several minutes later during the same examination

39. Case 6: Imaging Findings Closed cervical canal exceeding 3 cm in length

40. Case 6: TransientUterine Contraction (Simulating Cervical Incompetence) Contraction

41. Case 7: Clinical History 19-year-old G1,P0 Last menstrual period: 4 weeks ago Beta-hCG: 281 mIU/ml Right pelvic pain

42. Case 7: Diagnosis?

43. Case 7: Imaging Findings Empty uterus, ovarian follicle, preserved ovarian flow (normal)

44. Case 7: Diagnosis?

45. Case 7: Imaging Findings Hypoechoic blind-ending tubular structure Non-compressible

46. Case 7: Acute Appendicitis Pathogenesis Appendiceal obstruction by appendicolith or hypertrophic Peyer’s patch Epidemiology Incidence: 7% (most common surgical problem of pregnancy) Perforation more likely than in non-pregnant patient Presentation Periumbilical pain that migrates to right lower abdominal quadrant Diagnosis Distended (> 7mm) non-compressible appendix with Increased mural vascularity on color or power Doppler interrogation Periappendiceal fluid collection or edema Nausea, vomiting, diarrhea, fever, & leukocytosis Outcome Non-perforated: surgery; perforated: percutaneous drainage

47. Case 8: Clinical History 34-year-old G4,P1 Last menstrual period: 8 weeks ago Beta-hCG: 350,217 mIU/ml Vaginal bleeding

48. Case 8: Diagnosis?

49. Case 8: Imaging Findings Abnormal gestational sac shape Uterine fullness & cystic change

50. Case 8: PartialMolar Pregnancy Pathogenesis Triploid with ⅔ of genetic complement paternally derived Two sperm fertilize a single normal ovum (diandric/monogynic) Epidemiology 1/700 in US (2-3 times more common than complete molar pregnancy) Recurrence risk 1.7% Presentation Vaginal bleeding, missed/incomplete abortion Diagnosis Thickened placenta with focal cystic change or increased echogenicity Abnormal gestational sac Fetal parts with abnormalities (may have cardiac activity) Reduced amniotic fluid Outcome 2-4% progress to gestational trophoblastic disease

51. Case 9: Clinical History 26-year-old G2,P0 Last menstrual period: 11 weeks ago Beta-hCG: 414,566 mIU/ml Vaginal bleeding

52. Case 9: Diagnosis?

53. Case 9: Imaging Findings Abnormal uterine fullness & cystic change Multicysticadnexal structure

54. Case 9: Diagnosis?

55. Case 9: Molar Pregnancy (with Ovarian Hyperstimulation)

56. Case 9: Molar Pregnancy (with Ovarian Hyperstimulation) Ovarian hyperstimulation is due to supraphysiologic beta-hCG Beta-hCG elicits LH- & FSH-like effects Results in multiple, large, bilateral theca lutein cysts Sonographically detectable in 46% of molar pregnancies

57. Case 10: Clinical History 41-year-old G5,P3 Last menstrual period: 8 weeks ago Beta-hCG: 21,725 mIU/ml Left lower abdominal quadrant pain

58. Case 10: Diagnosis?

59. Case 10: Imaging Findings Pseudogestational sac (no double decidual sign)

60. Case 10: Diagnosis?

61. Case 10: Imaging Findings Ring-like left adnexal structure with free fluid Increased peripheral flow

62. Case 10: Ectopic Pregnancy Pseudogestational sac vs. intrauterine pregnancy Lack of “double decidual sac sign” Peak systolic velocity < 0.8 cm/sec Dillon EH, Feyock AL, Taylor KJ. Pseudogestational sacs: Doppler US differentiation from normal or abnormal intrauterine pregnancies. Radiology. 1990 Aug;176(2):359-64. Nyberg DA, Laing FC, Filly RA, et al. Ultrasonographic differentiation of the gestational sac of early intrauterine pregnancy from the pseudogestational sac of ectopic pregnancy. Radiology. 1983 Mar;146(3):755-9.

63. Case 11: Clinical History 17-year-old G1,P0 Last menstrual period: 7 weeks ago Beta-hCG: 137,898 mIU/ml Right pelvic pain

64. Case 11: Diagnosis?

65. Case 11: Imaging Findings Unremarkable intrauterine pregnancy

66. Case 11: Diagnosis?

67. Case 11: Imaging Findings Hypoechoic blind-ending tubular structure Non-compressible

68. Case 11: Acute Appendicitis Pathogenesis Appendiceal obstruction by appendicolith or hypertrophic Peyer’s patch Epidemiology Incidence: 7% (most common surgical problem of pregnancy) Perforation more likely than in non-pregnant patient Presentation Periumbilical pain that migrates to right lower abdominal quadrant Diagnosis Distended (> 7mm) non-compressible appendix with Increased mural vascularity on color or power Doppler interrogation Periappendiceal fluid collection or edema Nausea, vomiting, diarrhea, fever, & leukocytosis Outcome Non-perforated: surgery; perforated: percutaneous drainage

69. Case 12: Clinical History 26-year-old G1,P0 Last menstrual period: 2 months ago Beta-hCG: 23,051 mIU/ml Vaginal bleeding

70. Case 12: Diagnosis?

71. Case 12: Imaging Findings Abnormal gestational sac shape No fetal cardiac activity

72. Case 12: Failed First Trimester Pregnancy Pathogenesis Anembryonic pregnancy (35%) Failure of embryo to develop vs. early demise & embryonic resorption Embryonic demise (54%) Visualization of non-viable embryo Molar pregnancy (11%) Complete (diploid): 100% paternal genetic complement Partial (triploid): ⅔ paternal genetic complement Epidemiology 30-60% of documented beta-hCG elevations result in failed pregnancy Presentation Vaginal bleeding, pelvic pain, uterine contractions Diagnosis Discriminitory levels critical to accurate diagnosis (see next slide)

73. Case 12: Failed First Trimester Pregnancy Discriminatory Levels

74. Case 13: Clinical History 26-year-old G1,P0 Last menstrual period: 4 weeks ago Beta-hCG: qualitatively positive Sharp left-sided pelvic pain

75. Case 13: Diagnosis?

76. Case 13: Imaging Findings Multiple small peripherally-oriented cysts in enlarged ovary

77. Case 13: Ovarian Torsion Pathogenesis Twisting of ovary around vascular pedicle Initial venous/lymphatic compromise, followed by arterial compromise Increased risk Rapid uterine growth (e.g. gestational weeks 8-16) Rapid uterine involution (e.g. immediate postpartum period) Large ovarian mass (e.g. corpus luteum cyst) Epidemiology 17-24% of torsion occur in pregnancy (0.06% of all pregnancies) 5th most common gynecologic emergency Presentation Acute sharp pelvic pain, nausea, vomiting, fever Diagnosis Enlarged heterogeneous ovary (60% right) with small peripheral cysts Decreased or absent flow on Doppler interrogation; free pelvic fluid Outcome Treatment: surgical detorsion or excision (ovarian salvage rate: 10-30%)

78. Case 14: Clinical History 42-year-old G5,P3 Last menstrual period: 4 weeks ago Beta-hCG: qualitatively positive (home pregnancy test) Acute right lower abdominal quadrant pain, 1½ week history of vaginal discharge

79. Case 14: Diagnosis?

80. Case 14: Imaging Findings Heterogeneous complex predominantly hypoechoic mass Posterior shadowing Increased peripheral flow with complex central fluid collection devoid of flow

81. Case 14: Tubo-Ovarian Abscess Pathogenesis Most commonly a consequence of pelvic inflammatory disease (PID) Rarely arises following appendicitis, diverticulitis, or pelvic surgery Epidemiology 100,000 cases annually in the US Presentation Pelvic pain, fever, history of PID Diagnosis Palpable adnexal mass Leukocytosis & elevated erythrocyte sedimentation rate Complex adnexal mass/fluid collection with increased peripheral flow Posterior shadowing if gas is present; complex free pelvic fluid (pus) Outcome Treatment: transvaginal/transgluteal drainage & systemic antibiotics

82. Case 15: Clinical History 30-year-old G3,P2 Last menstrual period: 10 weeks ago Beta-hCG: 76,489 mIU/ml Right lower abdominal quadrant pain

83. Case 15: Diagnosis?

84. Case 15: Imaging Findings Left uterine cornu Eccentrically located gestational sac high in right uterine fundus with myometrial thinning

85. Case 15: Interstitial Ectopic Pregnancy Pathogenesis Implantation in uterine cornu (intramural portion of fallopian tube) Epidemiology 2-4% of ectopic pregnancies Presentation Pelvic pain, vaginal bleeding, hemodynamic instability Diagnosis Gestational sac located eccentrically in superior uterine fundus Interstitial line sign: echogenic line from endometrium to gestational sac Surrounding myometrial thickness < 5mm Outcome Treatment: surgery Maternal mortality: 2-2.5% (significantly higher than tubal pregnancy) Uterine rupture most commonly occurs 9-12 weeks

86. Case 16: Clinical History 28-year-old G4,P2 Last menstrual period: 2½ months ago Beta-hCG: 225 mIU/ml Pelvic pain, vaginal bleeding, history of elective termination of pregnancy 2 weeks ago

87. Case 16: Diagnosis?

88. Case 16: Imaging Findings Thickened endometrium with focal area of increased flow

89. Case 16: Retained Products of Conception Pathogenesis Incomplete expulsion of fetal/embryonic/placental material Epidemiology 1% of all pregnancies Increased following termination & with placenta acreta Presentation Delayed postpartum bleeding Diagnosis Persistent endometrial thickening (> 1cm) Echogenic endometrial mass Intrauterine fluid Irregular interface between endometrium & myometrium High-velocity, low-resistance flow on Doppler interrogation (> 21cm/sec) Outcome Treatment: dilation & curettage

90. Case 17: Clinical History 32-year-old G1,P1 Last menstrual period: pre-pregnancy Beta-hCG: qualitatively negative Pelvic pain, vaginal bleeding, history of spontaneous vaginal delivery 3½ months ago

91. Case 17: Diagnosis?

92. Case 17: Imaging Findings Echogenic endometrial mass with posterior shadowing

93. Case 17: Endometritis Pathogenesis Ascending vaginal/cervical infection Secondary to retained products of conception or chorioamnionitis Epidemiology 1-3% of vaginal deliveries 15-20% of cesarean section (50-60% without antibiotic prophylaxis) 70-90% of patients with PID have coexistent endometritis Presentation Pelvic pain, fever, uterine tenderness Diagnosis Thickened heterogeneous endometrium Echogenic endometrial mass Intrauterine fluid & gas (gas seen in 21% of normal postpartum patients) Increased endometrial flow on Doppler interrogation Outcome Treatment: systemic antibiotics

94. Case 18: Clinical History 26-year-old G2,P0 Last menstrual period: 3 months ago Beta-hCG: 83,757 mIU/ml Pelvic pain, vaginal bleeding

95. Case 18: Diagnosis?

96. Case 18: Imaging Findings Crescentichypoechoic collection between placenta & myometrium

97. Case 18: Marginal Placental Abruption (Subchorionic Hemorrhage) Pathogenesis Hemorrhage into deciduabasalis layer with resultant premature separation of placenta from uterus Marginal > retroplacental > preplacental Epidemiology 1% of all pregnancies 17x risk in patients with prior placenta abruptio Presentation Vaginal bleeding, pelvic pain Diagnosis Hypoechoiccrescentic fluid collection between placenta & myometrium Outcome Excellent prognosis if small Placental detachment > 50% -> fetal death > 50%

98. Case 19: Clinical History 27-year-old G1,P0 Last menstrual period: 5½ months ago Beta-hCG: qualitatively positive Right upper abdominal quadrant pain

99. Case 19: Diagnosis?

100. Case 19: Imaging Findings Persistence on postvoid imaging Collecting system prominence Absent right ureteral jet

101. Case 19: Diagnosis?

102. Case 19: Imaging Findings Resistive indices not significantly different

103. Case 19: MaternalHydronephrosis (Physiologic Caliectasis) Pathogenesis Non-obstructive dilation due to ureteral compression by gravid uterus Smooth muscle relaxation due to progesterone also contributes Epidemiology 90% of all pregnancies by 3rd trimester Right more common than left Presentation Asymptomatic Diagnosis Unilateral dilatation of collecting system No significant difference between kidney resistive indices Ureteral jet rules out obstruction, but absent jet is an unreliable finding Outcome Resolution with parturition

104. Case 20: Clinical History 33-year-old G3,P0 Last menstrual period: 7 weeks ago Beta-hCG: 110,780 mIU/ml Right lower abdominal quadrant pain, history of fertility treatments

105. Case 20: Diagnosis?

106. Case 20: Imaging Findings Fluid in open cervical canal Gestational sac in uterus Gestational sac in right adnexa Echogenic fluid in cul-de-sac

107. Case 20: Heterotopic Pregnancy (with Threatened Abortion of Intrauterine Pregnancy) Pathogenesis Simultaneous intrauterine & ectopic pregnancies Epidemiology 1:7000 spontaneous pregnancies 1-2% of in vitro fertilization pregnancies Presentation Vaginal bleeding, pelvic pain Diagnosis Visualization of both intrauterine & ectopic pregnancies Outcome Treatment: surgery, systemic methotrexate, US-guided local injection Local injection agents: methotrexate, KCl, hyperosmolar glucose If patient stable, intrauterine pregnancy can be delivered vaginally

108. Case 21: Clinical History 18-year-old G1,P0 Last menstrual period: 8 months ago Beta-hCG: 11,811 mIU/ml Painless vaginal bleeding

109. Case 21: Diagnosis?

110. Case 21: Imaging Findings Placenta Cervical canal

111. Case 21: Placenta Previa Pathogenesis Implantation of blastocyst in lower uterine segment Epidemiology Decreased incidence as pregnancy progresses 5% at 15th-16th weeks of gestation; 0.5% at full term Presentation Painless 3rd trimester vaginal bleeding Diagnosis Complete: placenta completely covers internal cervical os Partial: placenta partially covers internal cervical os Marginal: placental edge within 2cm of internal cervical os Outcome Early in pregnancy, most resolve with uterine growth After 34th week of gestation, unlikely to resolve (cesarean section)

112. Case 22: Clinical History 32-year-old G1,P0 Last menstrual period: 7½ weeks ago Beta-hCG: 8,252 mIU/ml Vaginal bleeding

113. Case 22: Diagnosis?

114. Case 22: Imaging Findings Empty uterus Free fluid in cul-de-sac

115. Case 22: Diagnosis?

116. Case 22: (L) Corpus Luteum, (R) Ectopic Pregnancy Echogenicity greater than ovary Bilateral “rings-of-fire” (not shown)

117. Case 22: Ruptured Ectopic Pregnancy Ring-like adnexal mass of ectopic pregnancy vs. corpus luteum Higher velocity/lower impedance flow on Doppler interrogation Extreme resistive indices (> 0.7 & < 0.4) Independent mobility of mass relative to ovary on palpation Echogenicity greater than ovarian parenchyma on grayscale imaging 85% of ectopic pregnancies are ipsilateral to corpus luteum Atri M. Ectopic pregnancy versus corpus luteum cyst revisited: best Doppler predictors. J Ultrasound Med. 2003 Nov;22(11):1181-4. Rottem S, Thaler I, Levron J, et al. Criteria for transvaginalsonographic diagnosis of ectopic pregnancy. J Clin Ultrasound. 1990 May;18(4):274-9.

118. Case 22: Ruptured Ectopic Pregnancy

119. Acknowledgements & Contact Information The authors acknowledge significant contributions from & extend their gratitude to the following individuals: Dr. HanhNghiem, Dept. of Radiology Dr. Charles Cash, Dept. of Radiology Dr. Richard Bronsteen, Dept. of Maternal-Fetal Imaging Dr. Christine Comstock, Dept. of Maternal-Fetal Imaging Contact Information: Daniel Noujaim, MD Department of Radiology William Beaumont Hospital 3601 W Thirteen Mile Rd Royal Oak, MI 48073 Daniel.Noujaim@beaumont.edu