Diagnostic Clues to Ectopic Pregnancy

Published Online:https://doi.org/10.1148/rg.286085506

Ectopic pregnancy accounts for approximately 2% of all pregnancies and is the most common cause of pregnancy-related mortality in the first trimester. Initial evaluation consists of hormonal assays and pelvic ultrasonography (US). A history of pelvic pain along with an abnormal β human chorionic gonadotropin level should trigger an evaluation for an ectopic pregnancy. The fallopian tube is the most common location for an ectopic pregnancy. An adnexal mass that is separate from the ovary and the tubal ring sign are the most common findings of a tubal pregnancy. Other types of ectopic pregnancy include interstitial, cornual, ovarian, cervical, scar, intraabdominal, and heterotopic pregnancy. Interstitial pregnancy occurs when the gestational sac implants in the myometrial segment of the fallopian tube. Cornual pregnancy refers to the implantation of a blastocyst within the cornua of a bicornuate or septate uterus. An ovarian pregnancy occurs when an ovum is fertilized and is retained within the ovary. Cervical pregnancy results from an implantation within the endocervical canal. In a scar pregnancy, implantation takes place within the scar of a prior cesarean section. In an intraabdominal pregnancy, implantation occurs within the intraperitoneal cavity. Heterotopic pregnancy occurs when an intrauterine and an extrauterine pregnancy occur simultaneously. A spectrum of intra- and extrauterine findings may be seen on US images. Although many of the US findings are nonspecific by themselves, when several of them are seen, the specificity of US in depicting an ectopic pregnancy substantially improves.

© RSNA, 2008

References

  • 1 Centers for Disease Control and Prevention (CDC). Ectopic pregnancy: United States, 1990–1992. MMWR Morb Mortal Wkly Rep 1995; 44: 46–48.
  • 2 LozeauAM, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician2005; 72: 1707–1714.
  • 3 LipscombGH, Stovall TG, Ling FW. Nonsurgical treatment of ectopic pregnancy. N Engl J Med2000; 343: 1325–1329.
  • 4 AttarE. Endocrinology of ectopic pregnancy. Obstet Gynecol Clin North Am2004; 31: 779–794.
  • 5 DayaS. Human chorionic gonadotropin increase in normal early pregnancy. Am J Obstet Gynecol1987; 156: 286–290.
  • 6 PittawayDE, Reish RL, Wentz AC. Doubling times of human chorionic gonadotropin increase in early viable intrauterine pregnancies. Am J Obstet Gynecol1985; 152: 299–302.
  • 7 EyvazzadehAD, Levine D. Imaging of pelvic pain in the first trimester of pregnancy. Radiol Clin North Am2006; 44: 863–877.
  • 8 BirkenS, Berger P, Bidart JM, et al. Preparation and characterization of new WHO reference agents for human chorionic gonadotropin and metabolites. Clin Chem2003; 49: 144–154.
  • 9 SeeberBE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol2006; 107: 399–413.
  • 10 McCordML, Muram D, Buster JE, Arheart KL, Stovall TG, Carson SA. Single serum progesterone as a screen for ectopic pregnancy: exchanging specificity and sensitivity to obtain optimal test performance. Fertil Steril1996; 66: 513–532.
  • 11 DartR, Ramanujam P, Dart L. Progesterone as a predictor of ectopic pregnancy when the ultrasound is indeterminate. Am J Emerg Med2002; 20: 575–579.
  • 12 LevineD. Ectopic pregnancy. Radiology2007; 245: 385–397.
  • 13 MorinL, Van den Hof MC. SOGC clinical practice guidelines: ultrasound evaluation of first trimester pregnancy complications. Int J Gynaecol Obstet2006; 93: 77–81.
  • 14 RussellSA, Filly RA, Damato N. Sonographic diagnosis of ectopic pregnancy with endovaginal probes: what really has changed? J Ultrasound Med1993; 12: 145–151.
  • 15 NybergDA, Hill LM. Normal early intrauterine pregnancy: sonographic development and HCG correlation. In: Patterson AS, ed. Transvaginal ultrasound. St Louis, Mo: Mosby, 1992; 64–85.
  • 16 PaspulatiRM, Bhatt S, Nour S. Sonographic evaluation of first-trimester bleeding. Radiol Clin North Am2004; 42: 297–314.
  • 17 BanerjeeS, Aslam N, Zosmer N, Woelfer B, Jurkovic D. The expectant management of women with early pregnancy of unknown location. Ultrasound Obstet Gynecol1999; 14: 231–236.
  • 18 BouyerJ, Coste J, Fernandez H, Pouly JL, Job-Spira N. Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod2002; 17: 3224–3230.
  • 19 WebbEM, Green GE, Scoutt LM. Adnexal mass with pelvic pain. Radiol Clin North Am2004; 42: 329–348.
  • 20 DialaniV, Levine D. Ectopic pregnancy: a review. Ultrasound Q2004; 20: 105–117.
  • 21 AtriM, Leduc C, Gillett P, et al. Role of endovaginal sonography in the diagnosis and management of ectopic pregnancy. RadioGraphics1996; 16: 755–774.
  • 22 BlaivasM, Lyon M. Reliability of adnexal mass mobility in distinguishing possible ectopic pregnancy from corpus luteum cysts. J Ultrasound Med2005; 24: 599–603.
  • 23 PelleritoJS, Taylor KJ, Quedens-Case C, et al. Ectopic pregnancy: evaluation with endovaginal color flow imaging. Radiology1992; 183: 407–411.
  • 24 DurfeeSM, Frates MC. Sonographic spectrum of the corpus luteum in early pregnancy: gray-scale, color, and pulsed Doppler appearance. J Clin Ultrasound1999; 27: 55–59.
  • 25 BhattS, Ghazale H, Dogra VS. Sonographic evaluation of ectopic pregnancy. Radiol Clin North Am2007; 45: 549–560.
  • 26 YehHC, Rabinowitz JG. Amniotic sac development: ultrasound features of early pregnancy—the double bleb sign. Radiology1988; 166: 97–103.
  • 27 HammoudAO, Hammoud I, Bujold E, Gonik B, Diamond MP, Johnson SC. The role of sonographic endometrial patterns and endometrial thickness in the differential diagnosis of ectopic pregnancy. Am J Obstet Gynecol2005; 192: 1370–1375.
  • 28 DograV, Paspulati RM, Bhatt S. First trimester bleeding evaluation. Ultrasound Q2005; 21: 69–85.
  • 29 de BoerCN, van Dongen PW, Willemsen WN, Klapwijk CW. Ultrasound diagnosis of interstitial pregnancy. Eur J Obstet Gynecol Reprod Biol1992; 47: 164–166.
  • 30 MalinowskiA, Bates SK. Semantics and pitfalls in the diagnosis of cornual/interstitial pregnancy. Fertil Steril2006; 86: 1764.e11–e14.
  • 31 AckermanTE, Levi CS, Dashefsky SM, Holt SC, Lindsay DJ. Interstitial line: sonographic finding in interstitial (cornual) ectopic pregnancy. Radiology1993; 189: 83–87.
  • 32 LauS, Tulandi T. Conservative medical and surgical management of interstitial ectopic pregnancy. Fertil Steril1999; 72: 207–215.
  • 33 TulandiT, Saleh A. Surgical management of ectopic pregnancy. Clin Obstet Gynecol1999; 42: 31–38.
  • 34 Timor-TritschIE, Monteagudo A, Matera C, Veit CR. Sonographic evolution of cornual pregnancies treated without surgery. Obstet Gynecol1992; 79: 1044–1049.
  • 35 HiroseM, Nomura T, Wakuda K, Ishiguro T, Yoshida Y. Combined intrauterine and ovarian pregnancy: a case report. Asia Oceania J Obstet Gynaecol1994; 20: 25–29.
  • 36 MelilliGA, Avantario C, Farnelli C, Papeo R, Savona A. Combined intrauterine and ovarian pregnancy after in vitro fertilization and embryo transfer: a case report. Clin Exp Obstet Gynecol2001; 28: 100–101.
  • 37 HerbertssonG, Magnusson SS, Benediktsdottir K. Ovarian pregnancy and IUCD use in a defined complete population. Acta Obstet Gynecol Scand1987; 66: 607–610.
  • 38 SpiegelbergO. Zur casuistic der ovarialschwangerschaft. Arch Gynaekol1878; 13: 73.
  • 39 SergentF, Mauger-Tinlot F, Gravier A, Verspyck E, Marpeau L. Ovarian pregnancies: reevaluation of diagnostic criteria [in French]. J Gynecol Obstet Biol Reprod (Paris)2002; 31: 741–746.
  • 40 VelaG, Tulandi T. Cervical pregnancy: the importance of early diagnosis and treatment. J Minim Invasive Gynecol2007; 14: 481–484.
  • 41 HofmannHM, Urdl W, Höfler H, Hönigl W, Tamussino K. Cervical pregnancy: case reports and current concepts in diagnosis and treatment. Arch Gynecol Obstet1987; 241: 63–69.
  • 42 KungFT, Lin H, Hsu TY, et al. Differential diagnosis of suspected cervical pregnancy and conservative treatment with the combination of laparoscopy-assisted uterine artery ligation and hysteroscopic endocervical resection. Fertil Steril2004; 81: 1642–1649.
  • 43 JurkovicD, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively. Ultrasound Obstet Gynecol1996; 8: 373–380.
  • 44 AshA, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG2007; 114: 253–263.
  • 45 GodinPA, Bassil S, Donnez J. An ectopic pregnancy developing in a previous caesarean section scar. Fertil Steril1997; 67: 398–400.
  • 46 LiSP, Wang W, Tang XL, Wang Y. Cesarean scar pregnancy: a case report. Chin Med J (Engl)2004; 117: 316–317.
  • 47 ParekhVK, Bhatt S, Dogra VS. Abdominal pregnancy: an unusual presentation. J Ultrasound Med2008; 27: 679–681.
  • 48 RojanskyN, Schenker JG. Heterotopic pregnancy and assisted reproduction: an update. J Assist Reprod Genet1996; 13: 594–601.
  • 49 AtrashHK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol1987; 69: 333–337.
  • 50 FernandezH, Gervaise A. Ectopic pregnancy after infertility treatment: modern diagnosis and therapeutic strategy. Hum Reprod Update2004; 10: 503–513.

Article History

Published in print: Oct 2008