Ultrasound Findings of
Ectopic Pregnancy
Claudia Diaz, HMS III
Radiology - BIDMC
May 2008
Objectives
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Index case
„ DDX of abdominal pain
„ Clinical presentation
Diagnostic Tests
Transvaginal Ultrasonography
Female Reproductive Anatomy
Imaging of index case
Transvaginal sonographic findings
Additional patient cases
Ectopic pregnancy locations
Ectopic pregnancy facts & management
Take-home points
Image: http://www.aafp.org/afp/20051101/1707.pdf
Patient Index Case
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HPI: 32-year-old G1P1 with LMP 8 wks ago, presenting with
3 weeks of ongoing LLQ pain. Reports mild vaginal bleeding for the
last 10 days. Negative pregnancy test and normal ultrasound
3 weeks ago.
EXAM:
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VITALS: T 98.4 HR 100 RR 20 BP 123/67
ABDOMEN: Tender to palpation in LLQ with radiation to RLQ.
PELVIC: No active bleeding. Mild cervical motion tenderness, left
adnexal tenderness.
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LABS:
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HCG: 3610
Differential diagnosis
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DDX for abdominal pain in women of reproductive age
includes:
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Pregnancy-related: Ectopic pregnancy, spontaneous abortion.
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Gynecologic: Endometritis, pelvic inflammatory disease, tubo-
ovarian abscess, endometriosis, ovarian neoplasm, ovarian
torsion/rupture/hemorrhage, uterine fibroids.
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Non-gynecologic: Appendicitis, bowel obstruction, diverticulitis,
IBD, UTI, pyelonephritis, nephrolithiasis.
Clinical Correlates
Clinical
Triad
Abdominal
Pain
Vaginal
Bleeding
Amenorrhea
These clinical findings are non-specific and also occur in
patients who spontaneously abort.
Physical exam findings
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Enlarged uterus.
Vaginal bleeding.
Pelvic pain with manipulation of cervix.
Palpable adnexal mass.
Æ Red flags for ruptured ectopic pregnancy:
Significant abdominal tenderness, hypotension,
guarding and rebound tenderness.
Diagnostic Tests
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Urine pregnancy test.
B-hCG measurement.
Less commonly used: diagnostic curettage
& serum progesterone levels.
Radiologic test of choice:
Transvaginal ultrasound.
Human Chorionic Gonadotropin
(B-hCG) Levels
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Normal intrauterine pregnancy: B-hCG levels
should rise by at least 66% over 48hrs.
Levels of hCG that plateau in first 8wks of
pregnancy indicate abnormal pregnancy (SAB or
ectopic).
Transvaginal ultrasonography should detect an
intrauterine pregnancy when B-hCG level is
>1500mIU/mL (~1500-2000mIU/mL).
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Risk of ectopic pregnancy high if hCG above
discriminatory factor without an intrauterine
gestational sac.
Transvaginal ultrasonography:
the modality of choice
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How does it work?
High-frequency sound waves directed into the
body and manner in which sound is reflected back to
transducer is recorded.
Æ Advantages: no ionizing radiation, inexpensive,
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minimal invasive.
Disadvantages: operator dependent, moderate
resolution.
Transabdominal US is no longer considered to be
sufficient for proper diagnosis.
Transvaginal US is the imaging of choice for evaluation
of ectopic pregnancy:
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Intrauterine pregnancies are reliably diagnosed earlier.
Sensitivity: 67 to 100.
Specificity: 100 (virtual certainty).
Image: http://www.stjohnsmercy.org/ healthinfo/test/gyn/TP124.asp#
Diagnosing suspected ectopic
following TVS
Image: http://www.aafp.org/afp/20051101/1707.html
Female Reproductive Anatomy
http://infertility.health-info.org/reproductive-anatomy-physiology/reproductive-anatomy-physiology-home.html
Index Case
U
RO
U - Uterus measuring approximately
7.2 x 4.8 x 4.9 cm.
RO - Right ovary.
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PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Index Case
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RIGHT ADNEXA: 1.4-cm ring-shaped structure containing a yolk sac
and living embryo.
PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Index Case
Embryonic crown-rump length
(CRL) consistent with a 6w3d
pregnancy. Embryonic cardiac
activity measuring 120 beats
per minute is documented.
CRL
Patient underwent operative laparoscopy
with right salpingectomy.
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PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
“Double Sac” Sign
Earliest sonographic sign of IUP is “double
sac” sign:
Æ True gestational sac – double echogenic rings
surrounding hypoechoic fluid (sac).
- inner ring: decidua capsularis.
- outer ring: decidua parietalis.
Æ Visible at 4-5wks of gestation.
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Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography. Seminars in Roentgenelogy,
Vol XXXIII, No 4(Oct), 1998: pp 339-343.
Likelihood of Ectopic pregnancy based
on transvaginal sonographic findings
Ultrasound Finding
Likelihood of ectopic pregnancy (+B-hCG,
vaginal pain or bleeding, no IUP)
Extrauterine embryo with cardiac activity
100%
Adnexal fluid w/ yolk sac or apparent embryo w/out
heartbeat
100%
Tubal ring
95%
Complex or solid adnexal mass w/out tubal ring,
yolk sac, or embryo (excluding masses w/in ovary)
92%
No significant adnexal abnormality
5%
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OTHER COMMON RADIOLOGIC FINDINGS:
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Free fluid in pelvis and/or abdomen.
“Ring of fire” – mass in adnexa surrounded by hypervascular flow
on doppler.
Pseudogestational sac in uterus.
Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography.
Ultrasonography. Seminars in Roentgenelogy,
Vol XXXIII, No 4(Oct), 1998: pp 339339-343.
Patient Case #2
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HPI: 31-year-old G1P0 at 7 weeks GA by LMP with ultrasound
findings suspicious for ectopic pregnancy. Treated with
methotrexate, admitted for severe RLQ pain, and subsequent
ruptured ectopic pregnancy. Patient underwent operative
laparoscopy and right salpingectomy.
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LABS:
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HCG: 3523 (day 1) Æ 1964 (day 3) Æ 1400 (day 4)
Patient Case #2
Transvaginal Ultrasound I: day 1
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No evidence of intrauterine
gestational sac.
Adjacent to right ovary, complex
echogenic area thought to be empty
sac (E).
E
E
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Transvaginal Ultrasound II: day 3
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Slight interval increase in size of right
ectopic pregnancy (E).
PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Patient Case #2
Transvaginal Ultrasound III: day 4 --> RUPTURED ECTOPIC
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Adjacent to right ovary, heterogeneously echoic structure (ectopic
(ectopic pregnancy - RE) increased in size.
Large amount of new free fluid.
RE
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PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Patient Case #2
FF
FF – free fluid in pelvis.
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PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Patient Case #3
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HPI: 32-year-old G8P2 at unknown GA with lower abdominal pain
and vaginal bleeding, and amenorrhea x1 year. Positive pregnancy
test previously but no IUP on recent ultrasound.
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EXAM:
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VITALS: T 97.6 HR 76 RR 18 BP 104/68
ABDOMEN: Diffusely tender to palpation suprapubically, no R/G.
PELVIC: Blood at cervical os. Mild cervical motion tenderness, left
adnexal tenderness.
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LABS:
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HCG: 2413 Æ 1794 (drop in last 3 days).
Patient Case #3
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Transabdominal & Transvaginal Ultrasound:
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Large adnexal mass and moderate amount of complex free fluid within
within the pelvis.
No evidence of IUP, possible pseudosac.
U
B
U
FF
B – bladder
U - uterus
CF – cul-de-sac free fluid
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PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Patient Case #3
Patient underwent left salpingectomy
via laparotomy.
A
B
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A: Complex, heterogeneous left adnexal mass with internal echoes on
on left adnexa.
B: Small oval structure with anechoic center within the uterine fundus
fundus without characteristic intrauterine
gestational sac (no true dedidual reaction) Æ Pseudosac.
PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Patient Case #4
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HPI: 22-year-old G1P0 at 8w1d by LMP presenting with 4-weeks of ongoing
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EXAM:
light vaginal bleeding and severe lower abdominal pain.
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guarding, + rebound.
PELVIC: Deferred.
LABS:
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VITALS: T 98.4 HR 101 RR 18 BP 142/79
ABDOMEN: Rigid, tender to palpation in lower quadrants b/l, +involuntary
HCG: 488
Transabdominal Ultrasound:
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No IUP visible.
Large heterogeneous mass without definite color flow posterior to uterus
(11.6 x 7.4 x 11 cm).
Moderate free fluid in abdomen/pelvis, extending into Morrison’s pouch and
spleen, low level echoes concerning for blood.
Patient Case #4
U
U: uterus.
M: heterogenous mass.
RK: Kidney.
L: Liver.
Arrow: Morrison’s pouch, hepato-renal space.
L
M
RK
Patient underwent laparotomy and right
salpingectomy.
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PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Ectopic pregnancy locations
Ectopic pregnancy results if the blastocyst implants anywhere outside of the uterine
cavity. The vast majority of ectopic pregnancies occur in:
Ampulla Ectopic Pregnancy --- 75% - 90%
Isthmic Ectopic Pregnancy --- 5% - 15%
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Heterotopic pregnancy (one embryo in the uterus and one ectopic embryo): 1/7000
(incidence in heterotopic pregnancies has increased due to assisted reproductive
technologies – 1%).
http://www.ectopicpregnancyfoundation.org/ectopicpregnancyplacementdiagram.htm
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Predisposing factors
**Any factor that interferes with the normal fallopian tube function**
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Previous tubal surgery.
Previous ectopic pregnancy.
In-utero diethylstilbestrol exposure.
Previous gynecologic infections (PID).
Treatment of infertility.
Current cigarette smoking.
Previous intrauterine device use.
Ectopic pregnancy facts
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Ectopic pregnancies make up 1.9% of all
reported pregnancies (0.5% of all pregnancies in
1970 to 2% in 1992).
Incidence increasing due to increase in pelvic
inflammatory disease and ART.
10-15% of all maternal deaths are due to
ectopic pregnancies.
Infertility occurs in 10-15% of women who have
had an ectopic pregnancy.
Management
of Ectopic
Pregnancy
MEDICAL (MTX)
EXPECTANT
MANAGEMENT
1. Small tubal
diameter (<3.5cm).
2. No fetal cardiac activity.
1. Low & declining
hCG levels.
3. hCG concentration
<5000mIU/mL.
Æ Serial hCG measurements!
SURGICAL
1. Ruptured ectopic/
hemodynamically unstable.
2. Contraindications
to medical therapy.
3. Lack of timely access to
medical institution.
4. Failed medical therapy.
Take-home points
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Ectopic pregnancy should always be considered in women of
reproductive age presenting with abdominal pain.
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The classic triad of ectopic pregnancy includes abdominal pain,
vaginal bleeding, and amenorrhea.
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Transvaginal ultrasound is the modality of choice when diagnosing
an ectopic pregnancy.
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With hCG level>1500mIU/mL and no IUP identified on transvaginal
ultrasound, this is high-risk for ectopic pregnancy.
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Transvaginal ultrasound is diagnostic if a true gestational sac, yolk
sac, embryo, or cardiac activity is found inside or outside of the
uterus.
Ectopic pregnancy is the leading cause of pregnancy related death
in 1st trimester of pregnancy.
References
Bhatt, Shweta; Hamad Ghazale, Vikram S. Dogra. Sonographic evaluation of ectopic pregnancy.
Radiologic clinics of North America. 45 (2007) 549-560.
Derchi, Lorenzo E. et al. Ultrasound in gynecology. Eur Radiol. (2001) 11:2137-2155.
Doubilet, Peter M. & Carol B. Benson. Emergency Obstetrical Ultrasonography. Seminars in
Roentgenelogy, Vol XXXIII, No 4(Oct), 1998: pp 339-343.
Lozeau, M.D., M.S., Anne-Marie & Beth Potter, M.D. Diagnosis and Management of Ectopic
pregnancy. American Family Physician. Volume 72, No 9; Nov. 2005.
Nelson AL, DeUgarte CM, Gambone JC. Ectopic pregnancy. In: Hacker NF, Moore JG, Gambone
JC. Essentials of obstetrics and gynecology, 4th ed. Philadelphia: Saunders, 2004: 325-333.
Novelline, Robert A. Ultrasound imaging & Ectopic pregnancy. Squire’s Fundamentals of
Radiology. Sixth edition. Pgs. 34-35 & 430-431.
Toy, MD, Eugene C., Benton Baker, MD, MSC, Patti Jayne Ross, MD, Larry C. Gilstrap, MD.
Case Files: Obstetrics & Gynecology. Pgs. 63-69, 211-218, 329-333.
Yudin, MD, Mark H. MSc, FRCSC, & Harold C. Wiesenfeld, MDCM. Current Diagnosis &
Treatment of Sexually Transmitted Diseases. Chapter 5: Lower Abdominal Pain in Women.
Images References
1. http://www.aafp.org/afp/20051101/1707.pdf
2. http://www.stjohnsmercy.org/ healthinfo/test/gyn/TP124.asp#
3. http://www.aafp.org/afp/20051101/1707.html
4. http://infertility.health-info.org/reproductive-anatomy-physiology/reproductive-anatomy-physiology-home.html
5. http://radiology.rsnajnls.org/cgi/content/full/210/2/579/F2
6. http://www.ectopicpregnancyfoundation.org/ectopicpregnancyplacementdiagram.htm
7. Cases: PACS, BIDMC. Courtesy of BIDMC-ultrasound recorded case files.
Acknowledgements
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Dr. James Kang
Dr. Jay Pahade
Dr. Rola Shaheen