09.12.2013

Pregnant baby in double sac

Understand diagnostic and treatment algorithms to make appropriate dispositions for patients suspected of having an ectopic pregnancy.
Patients at greatest risk for developing an ectopic pregnancy are those with anatomic abnormalities impairing the ability of a fertilized egg to implant in the uterus. Symptoms of an ectopic pregnancy develop as the fetus grows by distorting surrounding tissue or rupturing causing peritoneal irritation. All women of childbearing age presenting to the ED with abdominal or pelvic pain should have a urine pregnancy test performed immediately on arrival.
Stable patients in the first trimester of pregnancy with abdominal pain and vaginal bleeding can be further evaluated in the ED.
The earliest sign of an IUP by transvaginal ultrasound is the double decidual sac sign (click on Figure to the left), occurring at around 4.5-5 weeks after the last menstrual period (LMP).
The β-hCG is a glycoprotein hormone produced by trophoblasts that doubles approximately every 48-72 hours in the first trimester.
Any patient strongly suspected of having an ectopic pregnancy needs to be medically or surgically managed in conjunction with OB-GYN. Methotrexate is the most successful method to medically manage a patient with ectopic pregnancy and may preserve fertility better than surgical interventions.
All patients suspected of having an ectopic pregnancy are managed in conjunction with OB-GYN. The presentation of ectopic pregnancy can be highly variable, so maintaining a high index of suspicion is paramount to making the diagnosis. An ectopic pregnancy can be 'ruled out' in the presence of an IUP in a patient not undergoing infertility treatment.
Ectopic pregnancy is managed surgically in cases of clinical instability, contraindications to medical therapy, or failure of medical therapy. Any patient discharged from the ED with a potential ectopic pregnancy should understand "ectopic precautions" and have the means to return immediately to the ED.
One of the problems with sonography of the early pregnancy is the inability to clearly determine if the gestation sac is intrauterine or extrauterine (ectopic) in nature. Ectopic pregnancy is defined as any pregnancy implanted outside the uterus, with approximately 97% occurring in the fallopian tube. Tubal factors including history of salpingitis, tubal surgery, and previous ectopic pregnancy are the most important risk factors for ectopic pregnancy.


The classic triad of abdominal pain, delayed menses, and vaginal bleeding is neither sensitive nor specific for ectopic pregnancy. A pregnancy test should be obtained on all female patients of childbearing age (consider ages 10-60) who present to the ED with complaint of abdominal pain, amenorrhea, or vaginal bleeding. The combination of positive FAST and positive pregnancy test should prompt an immediate call to OB-GYN to take the patient to the OR for a presumptive diagnosis of ruptured ectopic pregnancy. If you have a strong suspicion of pregnancy and the patient provides a dilute urine, a serum pregnancy test should be considered. A yolk sac (click the Figure just below the one to the left) is typically identified at 5-6 weeks and the presence of a yolk sac has 100% predictive value for an intrauterine pregnancy. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience.
Clinical Policy: Critical issues in the initial evaluiation and mananagement of patients presenting to the emergency department in early pregnancy. It is a life threatening condition complicating 1 in 80 pregnancies presenting to emergency departments. It is important to recognize that many ectopic pregnancies occur in women without any recognized risk factors, so maintaining a high index of suspicion is paramount to making an accurate diagnosis. If an IUP is visualized, a concurrent ectopic pregnancy (heterotopic pregnancy) is statistically unlikely unless the patient has received fertility treatments.
An ectopic pregnancy cannot be excluded until the patient has a yolk sac demonstrated within the gestational sac.
ACEP's clinical policy on patients presenting to the ED in early pregnancy states that a transvaginal ultrasound should be performed on all patients in whom the diagnosis of ectopic pregnancy is considered despite the β-hCG level, as both IUP's and ruptured ectopics have been diagnosed at very low levels. Greater than 2ml of nonclotting blood is suggestive of hemoperitoneum and ruptured ectopic pregnancy.
Of course there is a very small chance of a co-existing intra and extra uterine pregnancy (hetero topic pregnancy). This occurs spontaneously at a rate of only 1 in 10,000 pregnancies, but the incidence is much higher for women using infertility drugs or assisted reproductive technologies . An ectopic pregnancy is highly likely in patients with a β-hCG level greater than 1500 with the absence of intrauterine pregnancy on transvaginal ultrasound. It works by interfering with syntheses of DNA and cell replication of fetal cells, resulting in involution of the pregnancy.


Clinically stable patients with an ectopic pregnancy may be managed medically with methotrexate if they have an excellent follow up plan.
Despite the improved diagnostic modalities, ectopic pregnancy is still frequently misdiagnosed on initial presentation with up to 40-50% of patients correctly diagnosed on repeat visits. Amenorrhea is present in almost 75% of women with ectopic pregnancies, and irregular vaginal bleeding occurs in 56.4%, but may be minimal even in the critically ill patient.
For those hemodynamically stable patients with inconclusive ultrasound findings where the diagnosis is in doubt, they may be managed as an outpatient with serial ultrasound examinations and β-hCG levels. Overall, it accounts for about 9% of all pregnancy-related maternal deaths, and is one of the leading causes of maternal death in the first trimester. The yolk sac should be seen at 5 to 6 weeks of gestation whilst the embryo is visualized at a little under 6 weeks with its characteristic cardiac activity. The diagnosis of ectopic pregnancy should be considered in female patients presenting to the ED with syncope or unexplained hypotension. All patients discharged from the ED who have the potential to have an ectopic pregnancy must receive and understand the "ectopic precautions" and be instructed to return to the ED immediately if they develop worsening pain, vaginal bleeding, dizziness, syncope, or weakness. The gestation sac in normal circumstances is seen as an anechoic space surrounded by a hyperechoic rim measuring around 2mm. The majority of patients with an ectopic pregnancy have normal vital signs until they have experienced significant blood loss.
Paradoxic bradycardia can occur in ectopic pregnancy, thus vital signs should not be reassuring and all patients with ectopic pregnancy should be considered potentially unstable. At this stage the gestation sac is too small to deform the uterine cavity line.A little later, around just after 5 weeks, the double decidual sac sign is seen.
Also, they believe that very often the double decidual sac sign may be visualized much later than 6 weeks, in many instances, by which time the embryo or yolk sac are clearly visualized.



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