Ectopic p agement

Expectant Medical Surgical

Procedure (None) Methotrexate: dose= 50 mg/m 2 laparoscopy v. laparotomy
salpingectomy v. salpingotomy
Success rates 48-100% 65-95% : 1 dose: 68% ; 2 doses: 84%
Advantages • Can be performed on • Can be performed on an outpatient • Definitive 1-stop management
outpatient basis basis • No prolonged follow-up
• Avoids risks of surgery • Avoids the risks of surgery • Avoids risks of rupture
• Avoids risks of MTX • <10% require surgical intervention • Potentially shortens the time until
next conception can occur
Disadvantages Side effects: abdominal pain (75%), Potential surgical complications -
conjunctivitis, stomatitis, GI upset including bowel/ bladder I ureteric
7% experience tubal rupture during injury or adhesions
follow-up; 14% requ ire >1 dose

Higher risk of unplanned admission and intervention compared to

surgical management

Kirk E et al , HRUpdate. 2014, 20(2):250-61 . Kirk E et al, Hum Reprod , 2007 . ' ,. 1
 Complete Partial
46, XX only paternal 69 XXX or 69 XXY (triploidy)
Classic 'snowstorm' or 'bunch of grapes' Paternal & maternal (dispermic fertilisation)
appearance Often has embryo
95% diagnosed via US 20% diagnosed via US
Kirk E et al. Ultrasound Obstet Gynecol. 2007 ;29(1 ):70-5 /1.,...&.:. - - \ A f ' _ _J ___ , _
 Key points
1. The first evidence of an intrauterine pregnancy can be seen at
around 4 weeks, using the transvaginal approach
2. At 4 weeks, the mean sac diameter is 2mm
3. The normal gestation sac grows at -1 mm/day
4. The correct terminology should be used when describing early
pregnancy events
5. The strict criteria used to diagnose miscarriage should always be
followed
6. The most common ultrasound appearance of an ectopic pregnancy
is of a heterogenous mass
ISUOG Basic Training
Cervical Assessment
Vaginal sonography of the cervix
I

A 1 • \ & I ' I
Normal cervix & short cervix
The Fetal Medicine Foundation Pulsa ~ para salir del modo de pantalla completa al assessment
• Patient in gynecological position, empty bladder
• Vaginal probe> 5 MHz in a lubricated disposable sheath
• Gently place the probe in the anterior vaginal fornix and ensure a
sagittal view of the cervix is obtained
• Large image(> 75% of screen)
• Identify the internal os, external os, cervical canal & endocervical
mucosa. Beware segmental contractions of the lower uterus
• Avoid excessive pressure with the probe because it may cause
inaccurate estimation of cervical length
• Take time, at least three measurements and use the shortest
The Fetal Medicine Foundation Pulsa ~ para salir del modo de pantalla completa al assessment
• Patient in gynecological position, empty bladder
• Vaginal probe> 5 MHz in a lubricated disposable sheath
• Gently place the probe in the anterior vaginal fornix and ensure a
sagittal view of the cervix is obtained
• Large image(> 75% of screen)
• Identify the internal os, external os, cervical canal & endocervical
mucosa. Beware segmental contractions of the lower uterus
• Avoid excessive pressure with the probe because it may cause
inaccurate estimation of cervical length
• Take time, at least three measurements and use the shortest
 Segmental t wer uterus:
be careful not t e cervical length
Cervix is s I Pulsa ~ para salir del modo de pantalla completa
e pressure
Cervical length & preterm delivery
in asymptomatic patients t:> TheFetalMedicineFoundation
Ultrasound Obstet Gyneco/ 2008; 31: 549-554
Published online in Wilev InterScience (www.interscience.wilev.com). DOI: 10.1002/uog.5333

Cervical length and obstetric history predict spontaneous

preterm birth: development and validation of a model to
provide individualized risk assessment
E. CELIK>:·, M. TO*, K. GAJEWSKA,.'", G. C. S. SMITHt and K. H. NICOLAIDES,.~ on behalf of The
Fetal Medicine Foundation Second Trimester Screening Group

Screening by a combination of obstetric history and cervical length

provides a higher detection rate than either method alone. For a screen- I
positive rate of 10%, the respective detection rates are about 80% and
60% in identifying extreme and early preterm birth.
 A

ISUOG Basic Training

Assessing normal and abnormal findings
between 10 & 14 weeks in • singleton and twin
pregnancies
- - -•--,•tti U,tU- II
,...,.,.,._._ • • ..,,
lu l _ , .. ....._., ,.._,.,., l \.•H Hl

~ isuog"9 GUIDELINES
Ultra "" Pu Isa ~ para salir del modo de pantalla completa
of gestational age
I UOC rr.101icc Guidelines: pcrlonnoncc of ftrs1-1rinia1cr
I
fctol ultr.i ound n

Pregnant women should be offered an early ultrasound scan between 10 + 0 and 13 + 6 weeks to
establish accurate gestational age. (Grade A recommendation)

It is recommended that CRL should be used to determine gestational age < 84 mm

After this stage, HC can be used, as it becomes slightly more precise than the BPD.
(GOOD PRACTICE POINT)
 ~
G : Pulsa para salir del modo de pantalla completa
es

Gestational age Terminology

1-10 weeks Embryo

>10 weeks Fetus

 Pregnancy d : a practical

..
I

Pregnancy resulting from assisted Spontaneous pregnancy

reproductive technology (ART) ~
Reliable last menstrual period
?
ART- derived gestational age should
be used to assign the EDD
No Yes

~ ..
Pregnancy dating by
'~
Change EDD only if
ultrasound difference> 5-?days
 Expected date of delivery {EDD) should
be clearly documented
I
Weeks of
12+3 • ... fetal dimensions
amenorrhea
correspond to the
menstrual age
EDD (amenorrhea) 15/01/2019
OR
Gestational weeks • ... fetal dimensions show
11+0
(US) discrepancy of +/- X days
in respect to amenorrhea
EDD (US) 25/01/2019
-
13 + 6-week scan

Organ/anatomical
*
Table 2 Suggested anatomical assessment at rime of 11 to

area Present and/or normal?

Present
Cranial bones
Midline folx
Choroid-plexu -filled ventricle
I
Normal appearance
Nuchal translucency thickness (if acx:epted
after informed consent and

e trained/certified operator available)~

Eyes with lens•
Nasal bone•
Normal profile/mandible •
Intact lips 11
Vertebrae (longirudinal and axial)•
Intact overlying skin•
Symmetrical lung fields
No effusions or masses
Ca rdi ac regular activity
Four symmetrical chambers•
Stomach present in left upper quadrant
Bladder•
Kidneys.,
Normal cord insertion
No umbilical defects
Four limbs each with three segments
Hands and feet with normal orientation•
Size and texture
Three-vessel cord•

• Optional structures. Modified from Fong et al. 28 , McAuliffe

d al.87 , Taipale et al.'° and von Kaiscnbcrg et al. 88 •
ut,,_,iow.,,,c,,....,uou.•1, 101-11J
Pll~l.lza!anlmC' lD 11,ry<nluielabr (W\Jrroal• bn.ty.am).. OOtlO.IOOlAaag..12.Ml

@lisuog .. GUIDELINES

ISUOG Practice Guidelines: performance of first-trimester

fetal ultra ound can

I
Neck
• Normal appearance
• Nuchal translucency thickness flt
accepted after informed consent
and trained/certified operator
available)*
* OPTIONAL
111n--,ow.,,,c,,....,uou. •1, 102-11J
Pll~l.lza! anlmC' ID 'IJ""dr7 Osluie Labr (W\Jr,-ml• bnry.am).. lX)t 10.1002Axlg..12.}4l

@lisuog .. GUIDELINES

ISUOG Practice Guidelines: performance of first-trimester

fetal ultra ound can

Spine
I
• Vertebrae (longitudinal and axial)*
• Intact overlying skin*
~isuog,.
ISUOG Practice Guidelines: performance of first-trimester
fetal ultra ound can

Chest
• Symmetrical lung fields I
• No effusions or masses
1Jln-.uo-dOWM1C)WIIHll)I 1013. .. 1: IOl-lU
PlabUi.'i:a! mlmc-10 'IJ""dr7 o.J:me Lahr (W\Jrraal• briuy.am),. 001: 10. IOOlA.Kig.1"'4.!

@lisuog ..
ISUOG Practice Guidelines: performance of first-trimester
fetal ultra ound can

Kidneys
Abdomen
• Stomach present in left upper
quadrant I
• Bladder*
• Kidneys*
~1n--,ow,,,c,,...,,uou... , 101-1u
PllbU~ mlant la ~ uty o.llllC Labruy (W\Jr,-aala br.uy.am),. OOt: I0,1002A,ag.1"4l

@lisuog ..
ISUOG Practice Guidelines: performance of first-trimester
fetal ultra ound scan

Abdominal wall
• Normal cord insertion
• No umbilical defects
I
 Accuracy of Ultrasonography at 11-14 Weeks of Gestation for Detection of Fetal
Structural Anomalies: A Systematic Review. Rossi & Prefumo, Obstet & Gynecol 2013
High percentage detection rate
• Acrania, anencephaly, ectopia cordis,
ence halocele
50-99% detection rate
• Cystic hygroma
• Double-outlet right ventricular flow,
Fallot's, hypoplastic left heart
syndrome, septal defects, transposition
of great vessels, valvular disease
• Gastroschisis, omphalocele
• Holoprosencephaly, megacystis
• Limb reduction , polydactyly
1-49% detection rate
• Spina bifida, hydrocephalus, skeletal
dysplasia, facial cleft, Dandy-Walker,
aortic coarctation, arthrogryposis
0% detection rate
• Corpus callosum agenesis, cerebellar
hypoplasia
I
• Duplex kidneys, hydronephrosis, renal
agenes1s
• Congenital pulmonary adenomatoid
malformation, extralobar sequestration
• Duodenal atresia, bowel obstruction
I\ - • · - . \A.I" -J-···-
 Detection rate of structural
abnormalities by gestational age

100

90
80
---!!
~ 70
~

~
e......
i)' 60
C
Q)

6- 50
II'
/
....Q)
u. 40

30

20
I
10

0 I I I
11 12 13 14
Gestational age (weeks)

Rossi & Prefumo, Obstetrics & Gynecology, 2013

Pu Isa ~ para salir del modo de pantalla completa
 Exomphalos Physiological bowel
(om phalocele) herniation (<11 weeks)

I
Abdominal wall defect: gastroschisis
 ~
Sac Pulsa para salir del modo de pantalla completa
ma