The Institute for Advanced Medical Education designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

These credits are accepted by the American Registry for Diagnostic Medical Sonography (ARDMS).

Faculty: Lyndon M. Hill, MD Professor of OB-GYN Medical Director, Ultrasound Magee Women's Hospital Pittsburgh, PA

Course: Sonographic Evaluation of Ectopic Pregnancies

Target Audience: Physicians, sonographers and others who perform and/or interpret OB ultrasound.

• Identify the risk factors associated with an ectopic gestation.
• Summarize the medical and surgical management of ectopic pregnancies.
• Correlate the B-hCG levels with gestational age and ultrasound findings in the evaluation of ectopic pregnancies.
• Improve sensitivity and specificity in identifying ectopic pregnancy.

System requirements: In order to complete this program you must have a computer with a recent version of Internet Explorer or Netscape, and a printer, which is configured to print from the browser.

Estimated Time for Completion of tutorial: approximately 50 minutes
Date of Release: January 31, 2001
Date of Last Review: September 29, 2006
Expiration Date: September 29, 2009

Disclosure: In compliance with the Essentials and Standards of the ACCME, the author of this CME tutorial is required to disclose any significant financial or other relationships they may have with the manufacturer(s) of any commercial product(s) or provider(s) of any commercial service(s) discussed in this program.

Dr. Lyndon M. Hill has indicated that no such relationships exist.

IAME discloses no relevant financial relationships with commercial interests. 

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Sonographic Evaluation of Ectopic Pregnancies

Lyndon M. Hill, MD
Professor of OB-GYN
Medical DirectorUltrasound
Magee Women's Hospital
Pittsburgh, PA

(Direct to Quiz)

 

Introduction

The incidence of ectopic pregnancies has steadily increased from 4.5/1,000 in 1970 to 20/1,000 in 1992(NCHS, 1992). While this increase is for the most part real, earlier diagnosis also plays a role by identifying ectopic pregnancies that would have spontaneously resolved. Quantitiative B-hCG levels and transvaginal sonography have been responsible for a shifting in the presentation of ectopic pregnancies from a medical emergency to a more benign condition. Prior to 1978 only 28% (Kim, 1987) of ectopics were diagnosed prior to rupture; this figure had changed to 85% by 1988 (Senterman, 1988). Despite these improvements ectopic pregnancies still account for 9% of all maternal deaths in the United States (NCHS, 1992). The maternal mortality associated with an ectopic pregnancy is ten times greater than that associated with childbirth (Filly, 1987).

Risk Factors

The risk factors associated with an ectopic pregnancy are generally self-evident. A history of a prior ectopic pregnancy increases a patient's risk to 12%-18% (Stabile, 1990). Women undergoing invitro fertilization have a 3% to 4% incidence of ectopic pregnancy (Nazari, 1993; Stabile, 1990). The rate of heterotopic pregnancies approaches 1% after assisted reproduction (Frates, 1995)

(Figure 1). Other risk factors are listed in Table 1.

Figure 1. A hetrotopic pregnancy (an intrauterine pregnancy and left ectopic) at 7.2 weeks' gestation

To view an enlargement, click on the image.

Table 1
Risk Factors for Ectopic Pregnancy

Prior ectopic
In-vitro fertilization
Tubal ligation
Intra-uterine contraceptive device
Cigarette smoking
Multiple sex partners
Pelvic inflammatory disease
Endometriosis

Location of Ectopic Pregnancies

Approximately 80% of ectopic pregnancies occur in the ampullary portion of the fallopian tube; 10% are in the isthmus; 5% are fimbrial in location and 2-4% are cornual. Ovarian, cervical and abdominal pregnancies are rare (Breen, 1970).

Clinical Findings

Historically, pelvic pain was the most common symptom of an ectopic pregnancy. Initially, the pain may be localized to the side of the ectopic. After rupture, the pain becomes more diffuse. With the earlier diagnosis of ectopic pregnancies, a skipped menstrual cycle or early first trimester spotting may be a patient's only initial complaint. The classic triad of vaginal bleeding, adnexal tenderness, and an adnexal mass is present in less than 30% of ectopic pregnancies (Kim, 1987).

Quantitative B-hCG Levels

Serum B-hCG can be detected by 6 days after conception (Daya, 1987). While the B-hCG of ectopic pregnancies are generally lower than for normal pregnancies, there is significant overlap. The B-hCG level of unruptured (1190mIU/ml) and ruptured (4160 mIU/ml) ectopic pregnancies are significantly different (Ackerman, 1982). Ectopic pregnancies with very low B-hCG levels are unlikely to rupture and may spontaneously resolve (Hay, 1989). However, in cases when gestational age is uncertain, a chronic ectopic pregnancy should be considered. Recurrent small episodes of bleeding result in a gradual disintegration of the tubal wall; a pelvic mass eventually forms. Since the trophoblastic tissue may have died, the B-hCG level may be low to absent (Abramov, 1997).

There is a direct correlation between gestational sac size and the exponential rise in B-hCG during the first 5 weeks of pregnancy. Hence, by comparing ultrasound findings with B-hCG levels, the concept of a "discriminatory zone" was developed. With transvaginal sonography a gestational sac is usually visualized at a serum B-hCG level between 1000 and 2000 mIU/ml. However, technical factors (multiple gestation, leiomyomas, subchorionic hemorrhage) and biologic variability in singleton gestations may result in a normal intrauterine gestational sac not being detected until a greater B-hCG level is obtained. In general, the 95% confidence interval for the detection of a normal intrauterine gestational sac is 3000 mIU/ml (Kadar, 1994; Shapiro, 1992).

Sonographic Findings

A normal intrauterine gestational sac is embedded below the mid-line endometrial stripe. The hormonal changes associated with a pregnancy results in an endometrial fluid collection (pseudo-sac) in 8% of ectopic pregnancies (Hill, 1990) (Figure 2). A low-level echo pattern may be observed in a pseudogestational sac, particularly in a patient with a high B-hCG level (Thorsen, 1990).

To view an enlargement, click on the image.

Figure 2. A debris-filled pseudogestational sac associated with an ectopic gestation.

The presence of an embryo with cardiac activity outside of the uterus is diagnostic of an ectopic pregnancy (Figure 3). In the past this presentation of an ectopic pregnancy occurred between 8% -26% of the time (Timor-Tritsch, 1989; Atri, 1992). Today an "echogenic ring" (Figure 4) has been reported more commonly; occurring in 40% to 70% of ectopic pregnancies (Atri 1992; Fleischer, 1990). Because of there approximation, it is sometimes difficult to distinguish between an ectopic "echogenic ring" adjacent to an ovary and a corpus luteum. The transvaginal transducer can be used to determine if the "echogenic ring" moves with or is independent of, the ovary.

To view an enlargement, click on the image.

Figure 3. An ectopic pregnancy with a heart rate of 115 beats/minute.

 

To view an enlargement, click on the image.

Figure 4. The characteristic echogenic ring of an ectopic pregnancy (arrows). The patient's B-hCG was 2100 mIU/ml.

Once an ectopic pregnancy has ruptured, a complex adnexal mass of mixed echogenicity (Figure 5) may be imaged. Particulate cul-de-sac fluid indicates associated intraperitoneal hemorrhage (Nyberg, 1991).

Because of the surrounding myometrium, cornual ectopics can grow to a large size before becoming symptomatic. Since a cornual pregnancy is not located within the endometrial cavity, transvaginal sonography will reveal an "interstitial line" that extends from the uterine cavity to the cornual gestational sac (Figure 6) (Frates, 1995).

To view an enlargement, click on the image.

Figure 5. An ectopic pregnancy presenting as a complex right adnexal mass (u = uterus)

To view an enlargement, click on the image.

Figure 6. A left cornual pregnancy at 11 weeks' gestation (arrow = endometrial cavity).

In order to diagnose a cervical pregnancy, the embryo/fetus must not be within the uterine cavity and the placenta must be attached to the cervix (Figure 7). The differential diagnosis would include an imminent miscarriage. The presence of cardiac activity in a cervically located gestational sac would confirm the diagnosis. When cardiac activity is not present, a follow-up scan in 24 hours would exclude a diagnosis of an imminent miscarriage. Cervical ectopics occur more frequently after invitro fertilization (Parente 1983; Ginsburg, 1994).

To view an enlargement, click on the image.

Figure 7. A cervical ectopic pregnancy 2 cm from the internal cervical os. A yolk sac (arrow) is visualized within the gestational sac.

Ovarian pregnancies result from either ovum fertilization within the ovary (primary) or the implantation of a tubal abortion on an ovary (secondary). The sonographic appearance of an ovarian pregnancy can vary from an "echogenic ring" fixed to the ovary to a complex adnexal mass that involves the ovary. It may, therefore, be difficult to distinguish a hemorrhagic ovarian cyst from an ovarian pregnancy (Malinger, 1988). Since the fallopian tube is not affected, an ovarian pregnancy is not a risk factor for a repeat ectopic pregnancy.

An abdominal pregnancy occurs when a tubal abortion implants on a peritoneal cavity and continues to grow. While anhydramnios is common, it is not an invariable finding with abdominal pregnancies. Additional sonographic signs include a failure to visualize the uterine wall around a pregnancy; an abnormal fetal lie; and an empty uterus with an adjacent fetus. A pregnancy in one horn of a bicornuate or didelphysis uterus may mimic an abdominal pregnancy (Ombelet, 1988; Stanley 1986).

Color Doppler

Vascular flow around an ectopic pregnancy is directly related to the amount of viable trophobastic tissue present. In the classic case there is a "ring of fire" surrounding the ectopic (Figure 8). A corpus luteum may have a similar sonographic appearance. There is more flow surrounding an established ectopic pregnancy. However, in these cases the "echogenic ring" would be most apparent on standard two-dimensional sonography. In 1 of 65 cases color Doppler identified an ectopic pregnancy that was not identified with gray scale (Pellerito, 1992). While color Doppler has been a useful adjunct, it has not changed the diagnostic accuracy achieved with the combination of B-hCG levels and transvaginal sonography (Tekay, 1992; Bourne, 1991).

 

Figure 8. The "ring of fire" (power Doppler) associated with an ectopic pregnancy.

To view an enlargement, click on the image.

Management

The traditional management for ectopic pregnancies has been surgical, i.e. salpingectomy or linear salpingostomy. With the latter approach, residual chorionic villi may remain. The prevalence of a persistent ectopic pregnancy is 2%-5% with linear salpingostomy at laparotomy in contrast to 3% - 20% at laparoscopy (Seifer, 1993). Prophylactic methotrexate within 24 hours of salpingostomy significantly reduces the incidence of persistent ectopic pregnancy (Graczykowski, 1997).

Medical management of ectopic pregnancies consists of the systemic administration of methotrexate (50 mg/m2 of body surface area, IM). A falling B-hCG level of > 15% between days 4 and 7 after treatment is considered successful therapy; B-hCG levels are then followed weekly until they are not detectable. When the B-hCG level fails to fall 15% , either initially or when the subsequent weekly follow-up levels are obtained, a repeat dose of methotrexate is given. Successful treatment of ectopic pregnancies with methotrexate has been reported in 85.7% to 94.2% of selected cases (Brumsted, 1996). All of the reports have not been this successful. In a systematic review of single-dose intramuscular methotrexate for ectopic pregnancy, Parker et al (1998) reported a pooled success rate of 71%. Serious complications, including 1 maternal death, have occurred after methotrexate therapy for ectopic pregnancy. When methotrexate is successful, post treatment hysterosalpingograms have demonstrated tubal patency on the side of the ectopic in 82.3% of patients (Stoval, 1993).

 

References

1. Abramov Y, Nadjar M, Shushan A, Prus D, Anteby SO. Doppler findings in chronic ectopic pregnancy: case report. Ultrasound Obstet Gynecol 1997;9:344-346.

2. Ackerman R, Deutsch S, Krumholz B. Levels of human chorionic gonadotropin in unruptured and ruptured ectopic pregnancy. Obstet Gynecol 1982;60:13-14.

3. Atri M, deStempel J, Bret P. Accuracy of transvaginal ultrasonography for the detection of hematosalpinx in ectopic pregnancy. J Clin Ultrasound 1992;20:255-61.

4. Bourne TH. Transvaginal color Doppler in gynecology. Ultrasound Obstet Gynecol 1991;1:359-73.

5. Breen JL. A 21 year survey of 654 ectopic pregnancies. Am J Obstet Gynecol 1970;106:1004-19.

6. Brumsted JB. Managing ectopic pregnancy non-surgically. Cont Ob Gyn 1996;41:43-56.

7. Daya S. Human chorionic gonadotropin increase in normal pregnancy. Am J Obstet Gynecol 1987;156:286-90.

8. Filly RA. Ectopic pregnancy: the role of sonography. Radiology 1987;162:661-668.

9. Fleischer AC, Pennell RG, McKee MS, Worrell JA, Keefe B, Herbert CM, Hill GA, Cartwright PS, Kept DM. Ectopic pregnancy: features at transvaginal sonography. Radiology 1990;174:375-8.

10. Frates MC, Laing FC. Sonographic evaluation of ectopic pregnancy: an update. AJR 1995;165:251-9.

11. Ginsburg ES, Frates MC, Rein MS, Fox JH, Hornstein MD, Friedman AJ. Early diagnosis and treatment of cervical pregnancy in an in-vitro fertilization program. Fert Steril 1994;61:966-969.

12. Graczykowski JW, Mishell DR Jr. Methotrexate prophylaxsis of persistent ectopic pregnancy after conservative treatment by salpingostomy. Obstet Gynecol 1997;89:118-122.

13. Hay DL, DeCrespigny L, McKenna M. Monitoring early pregnancy with transvaginal ultraosund and choriogonadotropin levels. Aust NZ J Obstet Gynecol 1989;29:165-67.

14. Hill LM, Kislak S, Martin JG. Transvaginal sonographic detection of the pseudo-gestational sac associated with ectopic pregnancy. Obstet Gynecol 1990;75:986-88.

15. Kadar N, Bohrer M, Kemmann E, Shelden R. The discriminatory human chorionic gonadotropin zone for endovaginal sonography: a prospective, randomized study. Fertil Steril 1994;61:1016-20.

16. Kim DS, Chung SR, Park MI, Kim YP. Comparative review of diagnostic accuracy in tubal pregnancy: A 14-year study of 1040 cases. Obstet Gynecol 1987;70:547-54.

17. Malinger G, Achiron R, Treschan O, Zakut H. Ovarian pregnancy - ultrasonographic diagnosis. Acta Obstet Gynecol Scand 1988;67:561-563.

18. Nazari A, Askari HA, Check JH, O'Shauhnessy A. Embryo transfer technique as a cause of ectopic pregnancy in in-vitro fertilization. Fertil Steril 1993;60:919-21.

19. NCHS: Advanced Report of Final Mortality Statistics 1992 (Report No. 43, suppl). Hyattsville, MD, US Dept of Health and Human Services, Public Health Service, CDC, 1994.

20. Nyberg DA, Hughes MP, Mack LA, Wang KY. Extra-uterine findings of ectopic pregnancy at transvaginal ultrasound: importance of echogenic fluid. Radiol 1991;178:823-6.

21. Ombelet W, Vandermerwe JV, Van Assche FA. Advanced extra-uterine pregnancy: description of 38 cases with literature survey. Obstet Gynecol Surv 1988;43:386-397.

22. Parente JT, Ou C-S, Levy J, Legatt E. Cervical pregnancy analysis: a review and report of five cases. Obstet Gynecol 1983;62:79-82.

23. Parker J, Bisits A, Proietto AM. A systematic review of single-dose intramuscular methotrexate for the treatment of ectopic pregnancy. Aust NZJ Obstet Gynecol 1998;38:145-150.

24. Pellerito JS, Taylor KJ, Quedens-Case C, Hammers LW, Scoutt LM, Ramos IM, Meyer W. Ectopic pregnancy: Evaluation with endovaginal color flow imaging. Radiology 1992;183:407-11.

25. Seifer DB, Gutman JN, Grant WD, Kamps CA, DeCherney AH. Comparison of persistent ectopic pregnancy after laparoscopic salpingostomy versus salpingostomy at laparotomy for ectopic pregnancy. Obstet Gynecol 1993;81:378-382.

26. Senterman M, Jiboth R, Tulandi T. Histopathologic study of ampullary and isthmic tubal ectopic pregnancy. Am J Obstet Gynecol 1988;159:939-41.

27. Shapiro BS, Escobar M, Makuch R, Lavy G, DeCherney AH. A model-based prediction for transvaginal ultrasonographic identification of early intrauterine pregnancy. Am J Obstet Gynecol 1992;166:1495-500.

28. Stabile I, Gradzinskas JG. Ectopic pregnancy: a review of incidence, etiology, and diagnostic aspects. Obstet Gynecol Surv 1990;45:335-47.

29. Stanley JH, Horger EO III, Fagan CJ, Andriole JG, Fleischer AC. Sonographic findings in abdominal pregnancy. AJR 1986;147:1043-1046.

30. Stovall TG, Ling FW. Single-dose methotrexate: an expanded clinical trial. Am J Obstet Gynecol 1993;168:1759-65.

31. Tekay A, Jouppila P. Color doppler flow as an indicator of trophoblastic activity in tubal pregnancies detected by transvaginal ultrasound. Obstet Gynecol 1992;80:995-9.

32. Thorsen MK, Lawson TL, Aiman EJ, Miller DP, McAsey ME, Erickson SJ, Quiroz F, Perret RS. Diagnosis of ectopic pregnancy: endovaginal versus transabdominal sonography. AJR 1990;155:307-10.

33. Timor-Tritsch IA, Yeh MN, Peisner DB, Lesser KB, Slavik BA. The use of transvaginal ultrasonography in the diagnosis of ectopic pregnancy. Am J Obstet Gynecol 1989;161:159-61.

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