Figure 419 large irregularly shaped gestational sac

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Figure 4.19 Large, irregularly shaped gestational sac. Because no yolk sac or fetal pole is seen, this is likely embryonic resorption and a missed abortion. However, pseudogestational sac of ectopic pregnancy cannot be ruled out on this image alone, and proper consultation should be obtained. B, bladder; GS, gestational sac; U, uterus. Figure 4.17 Heterotopic pregnancy. Two gestational sacs are seen (*). The sac in the lower right-hand corner of the screen is outside the uterine cavity. Courtesy of Dr. Greg Press, University of Texas – Houston, Hermann Memorial Hospital, Houston, TX. Diagnostic ultrasound 107 First trimester ultrasound
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Figure 4.21 Intrauterine device (IUD) for contraception. Reverberation artifact is seen. Placement is normal (mid- uterus at endometrial stripe). B, bladder. Figure 4.22 Twin gestation. Figure 4.20 Molar pregnancy. The large uterus appears filled with heterogeneous material in the form of hundreds of tiny follicles. Because a significant number of such patients have high hCG levels and undergo malignant transformation of this tissue, they should pursue formal consultation. 108 Diagnostic ultrasound First trimester ultrasound
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Sample clinical protocol Algorithms using transvaginal sonography and a beta-hCG discriminatory zone ( Table 4.1 ) have been developed to improve diagnostic accuracy and clinical consistency. There are several variations of this algorithm, although the recommendations are generally similar ( 1 –3, 12 ). The protocol illustrated in Figure 4.24 is a typical algorithm incorporating several key decision points (pelvic ultrasound, Rh type, hCG level, etc.) into a care plan for patients with possible ectopic pregnancy. Table 4.1 Discriminatory zone findings on transabdominal (TA) and transvaginal (TV) scanning TA TV hCG level Gestational sac 5.5–6 weeks 4.5–5 weeks 1700–6000 Yolk sac 6–6.5 weeks 5–5.5 weeks 8000–15 000 Fetal pole 7 weeks 5.5–6 weeks 13 000–15 000 Cardiac activity 7 weeks 6 weeks 16 000–25 000 Fetal parts > 8 weeks 8 weeks 29 000–39 000 Figure 4.23 Cornual or interstitial ectopic. Pregnancy is implanted at the edge of the myometrium. A pseudogestational sac is seen just anterior to the uterus (U). Free fluid is also noted. B, bladder. Courtesy of Dr. Robert Miller, North Shore Medical Center, Salem, MA. Diagnostic ultrasound 109 First trimester ultrasound
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Literature review Female patient with + uhCG FAST exam Immediate resuscitation with fluids, type and cross for blood, gynecology consult for ? OR Transabdominal US followed by transvaginal pelvic US if TA is negative +IUP seen on US No IUP seen on US IVF patient Gynecology consult Hemodynamically (HD) unstable Hemodynamically (HD) stable yes no Serum hCG level hCG < 1000, formal consultation but likely DC with 48 hour follow- up arranged, ectopic precautions hCG > 1000, formal US obtained and gynecology consultation Home with obstetric followup Large amount of pelvic free fluid +/– pelvic mass yes no Positive Figure 4.24 Sample clinical protocol for evaluation of possible ectopic pregnancy.
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