Ectopic Pregnancy

Ectopic pregnancy | Radiology Reference Article |

Ectopic pregnancy refers to the implantation of a fertilised ovum outside of the uterine cavity. On this page: Epidemiology Clinical presentation Pathology Radiographic features Complications Treatment and prognosis Differential diagnosis Related Articles References Cases and Figures Imaging Differential Diagnosis Epidemiology

The overall incidence has increased over the last few decades and is currently thought to affect 1-2% of pregnancies. There is an increased incidence associated with in-vitro fertilisation (IVF) pregnancies.Clinical presentation

The classic presentation is with abdominal pain and bleeding. In practice, the symptoms are not necessarily severe - often there may be only mild pelvic pain and PV spotting in a patient in early pregnancy (5-9 weeks of amenorrhoea5). Nonetheless, monitoring of haemodynamic status is crucial, as haemorrhage can be life threatening.PathologyLocations

In the vast majority of cases, the ectopic implantation site is within a Fallopian tube. tubal ectopic: 93-97% ampullary ectopic: most common ~70% of tubal ectopics and ~65% of all ectopics isthmal ectopic: ~12% of tubal ectopics and ~11% of all ectopics fimbrial ectopic: ~11% of tubal ectopics and ~10% of all ectopics interstitial ectopic/cornual ectopic: 3-4%; also essentially a type of tubal ectopic ovarian ectopic: ovarian pregnancy; 0.5-1% cervical ectopic: cervical pregnancy; rare 1% scar ectopic: site of previous Caesarian section scar; rare abdominal ectopic: rare; ~1.4% Risk factors in vitro fertilization (IVF) prior ectopic pregnancy tubal injury or surgery pelvic inflammatory disease salpingitis isthmica nodosa endometrial injury or congenital anomalies use of intrauterine contraceptive devices 5 Markers

Serum beta HCG levels tend to increase at a slower rate. Whereas a normal doubling rate in early pregnancy is approximately 48 hours, an increase of 50% or less in 48 hours is strongly suggestive of a non-viable (either intra- or extra-uterine) pregnancy 10. Rarely the urinary and/or serum b-HCG will be negative despite an ectopic pregnancy 12.

Serum progesterone levels are generally lower in a non-viable (including ectopic) pregnancy 6; a progesterone of 5 ng/ml or less is strongly associated with pregnancy failure, whereas in a viable pregnancy, progesterone is usually 20 ng/ml or more 5. Clearly, there is a significant grey zone. Furthermore, serum progesterone levels may take days to process. Progesterone is therefore not included in standard protocols for managing suspected ectopic pregnancy.Radiographic features

It is useful to know a quantitative beta HCG prior to scanning as this will guide what you expect to see. At levels 2000 IU, a normal early pregnancy may not be visible.Ultrasound

The ultrasound exam should be performed both transabdominally and transvaginally. The transabdominal component provides a wider overview of the abdomen, whereas a transvaginal scan is important for diagnostic sensitivity.

Positive sonographic findings include: uterus empty uterine cavity or no evidence of intrauterine pregnancy pseudogestational sac or decidual cyst: may be seen in 10-20% of ectopic pregnanciescurrent evidence suggests that one should not initiate treatment for an ectopic pregnancy in a haemodynamically stable woman on the basis of a single hCG value 10 decidual cast thick echogenic endometrium tube and ovary simple adnexal cyst: 10% chance of an ectopic complex extra-adnexal cyst/mass: 95% chance of a tubal ectopic (if no IUP)an intra-adnexal cyst/mass is more likely to be a corpus luteum solid hyperechoic mass is possible, but non-specific tubal ring sign 95% chance of a tubal ectopic if seen described in 49% of ectopics and in 68% of unruptured ectopics ring of fire sign: can be seen on colour Doppler in a tubal ectopic, but can also be seen in a corpus luteum absence of colour Doppler flow does not exclude an ectopic live extrauterine pregnancy (i.e. extra-uterine fetal cardiac activity): 100% specific, but only seen in a minority of cases peritoneal cavity free pelvic fluid or haemoperitoneum in the pouch of Douglasthe presence of free intraperitoneal fluid in the context of a positive beta HCG and empty uterus is ~70% specific for an ectopic pregnancy 4 ~63% sensitive for ectopic pregnancy 4 not specific for ruptured ectopic (seen in 37% of intact tubal ectopics) live pregnancy: 100% specific, but only seen in a minority of cases

In patients receiving in vitro fertilisation (IVF), it is important not to be completely reassured by the presence of a live intrauterine pregnancy 8, as there is a possibility of a coexisting ectopic pregnancy in ~1:500 (i.e. heterotopic pregnancy). In patients not receiving IVF, the risk of heterotopic pregnancy is minuscule (1:30,000).Complications

Complications somewhat depend on the type of ectopic. General complications for a typical (tubal) ectopic pregnancy include: tubal rupture: 15-20%Treatment and prognosis

Management depends on the location of the ectopic pregnancy and the patient's haemodynamic status. In general, the options are: surgical: (in the case of tubal ectopics with open or laparoscopic salpingectomy or salpingotomy) medical methotrexate (a folate antagonist) either administered systemically or by direct ultrasound guided injection or potassium chloride (direct injection only obviously) relative contraindications to methotrexate include 11: rupture mass 3.5 cm fetal cardiac activity bHCG 6000-15,000 mIU/mL the gestational mass can paradoxically increase in size following methotrexate on subsequent scanning and does not necessarily imply failure of methotrexate therapy 3 conservative or expectant management is being recognised as an option for those ectopics where rupture has not occurred (i.e. no haemoperitoneum) and fetal demise has already taken place Differential diagnosis

The differential diagnosis of abdominal pain in a pregnant patient is broad. An ectopic pregnancy must be excluded with ultrasound. Other common diagnoses in this setting include: ruptured corpus luteum exophytic corpus luteum of pregnancy intrauterine pregnancy incidental adnexal mass appendicitis (negative beta-hCG)

The scenario of clinically suspected ectopic pregnancy that is not confirmed on ultrasound, is referred to as a pregnancy of unknown location, with the alternative possibilities being of a very early pregnancy or a completed miscarriage. Related articles First trimester of pregnancy first trimester ultrasound findings in early pregnancy gestational sacmean sac diameter (MSD) yolk sac fetal polecrown rump length (CRL) confirming intrauterine gestation double decidual sac sign intradecidual sign double bleb sign pregnancy of unknown location (PUL) first trimester vaginal bleeding ectopic pregnancy ​pseudogestational sac decidual cast tubal ectopic ampullary isthmal fimbrial atypical ectopic pregnancies interstitial ectopic eccentric gestational sac interstitial line sign ovarian ectopic cervical ectopic scar ectopic abdominal ectopic live ectopic pregnancy heterotopic pregnancy tubal rupture failed early pregnancy pregnancy of uncertain viability (PUV) miscarriage threatened miscarriageirregular gestational sac missed miscarriage inevitable miscarriage incomplete miscarriage complete miscarriage anembryonic pregnancyanembryonic pregnancy in the exam yolk sac abnormalities irregular yolk sac calcified yolk sac echogenic yolk sac​​ small yolk sac large yolk sac gestational trophoblastic disease subchorionic haemorrhage demise of a twin implantation bleeding aneuploidy testing antenatal screening nuchal translucency Ultrasound - obstetric ultrasound (introduction) obstetric ultrasound first trimester and early pregnancy gestational sac double decidual sac sign intradecidual sac sign mean sac diameter empty gestational sac pseudogestational sac yolk sac embryo/fetus crown rump length (CRL) fetal heart rate fetal tachycardia fetal bradycardia fetal bradyarrhythmia(s) physiologic gut herniation embryonic rhombencephalon amnion chorion Beta-hCG levels ectopic pregnancy tubal ectopic interstitial or cornual ectopic cervical ectopic ovarian ectopic abdominal ectopic heterotopic pregnancy Cesarean scar ectopic multiple gestations monochorionic monoamniotic twin pregnancy monochorionic diamniotic twin pregnancy dichorionic diamniotic twin pregnancy signs T sign twin peak sign subchorionic hematoma failed early pregnancy second trimester​ fetal biometry basic biometry biparietal diameter (BPD) head circumference (HC) abdominal circumference (AC) femur length (FL) amniotic fluid volume amniotic fluid index maximal vertical pocket method two diameter pocket method polyhydramnios oligohydramnios (mnemonic)oligohydramnios sequence fetal morphology assessment fetal echocardiography views four chamber view (fetal) LVOT view (fetal) RVOT view (fetal) nonvisualisation of the fetal stomach soft markers nuchal fold thickness ventriculomegaly absent nasal bonehypoplastic nasal bone choroid plexus cysts enlarged cisterna magna shortened fetal long bones shortened femur shortened humerus echogenic intracardiac focus (EIF) echogenic fetal bowel aberrant right sublavian artery fetal pyelectasis / fetal renal pelvic dilatation single umbilical artery sandal gap toes amnioreduction umbilical artery Doppler assessment single umbilical artery ​absent umbilical arterial end diastolic flow reversal of umbilical arterial end diastolic flow fetal middle cerebral arterial Doppler assessment fetal MCA pulsatility index (PI) fetal MCA peak systolic velocity (PSV) fetal MCA systolic/diastolic (S/D) ratio nuchal translucency chorionic villus sampling (CVS) and amniocentesis placenta low lying placenta placenta previa placenta accreta placenta increta placenta percreta placental abruption circumvallate placenta marginal cord insertion velamentous cord insertion vasa previa succenturiate placenta uteroplacental blood flow assessment placental tumours other gestational trophoblastic disease retained products of conception References 1. Weissleder R, Wittenberg J, Harisinghani MG. Primer of diagnostic imaging. Mosby Inc. (2007) ISBN:0323040683. Read it at Google Books - Find it at Amazon 2. Chudleigh P, Thilaganathan B, Chudleigh T. Obstetric ultrasound, how, why and when. Churchill Livingstone. (2004) ISBN:0443054711. Read it at Google Books - Find it at Amazon 3. Levine D. Ectopic pregnancy. Radiology. 2007;245 (2): 385-97. doi:10.1148/radiol.2452061031 - Pubmed citation 4. Kaakaji Y, Nghiem HV, Nodell C et-al. Sonography of obstetric and gynecologic emergencies: Part I, Obstetric emergencies. AJR Am J Roentgenol. 2000;174 (3): 641-9. AJR Am J Roentgenol (full text) - Pubmed citation 5. Lin EP, Bhatt S, Dogra VS. Diagnostic clues to ectopic pregnancy. Radiographics. 2008;28 (6): 1661-71. doi:10.1148/rg.286085506 - Pubmed citation 6. Valley VT, Mateer JR, Aiman EJ et-al. Serum progesterone and endovaginal sonography by emergency physicians in the evaluation of ectopic pregnancy. Acad Emerg Med. 1998;5 (4): 309-13. Acad Emerg Med (link) - Pubmed citation 7. Chandrasekhar C. Ectopic pregnancy: a pictorial review. Clin Imaging. 32 (6): 468-73. doi:10.1016/j.clinimag.2008.02.027 - Pubmed citation 8. Talbot K, Simpson R, Price N et-al. Heterotopic pregnancy. J Obstet Gynaecol. 2011;31 (1): 7-12. doi:10.3109/01443615.2010.522749 - Pubmed citation 9. Government of Western Australia: Suspected ectopic pregnancy Diagnostic imaging pathway 9. Doubilet PM, Benson CB. Further evidence against the reliability of the human chorionic gonadotropin discriminatory level. J Ultrasound Med. 2012;30 (12): 1637-42. Pubmed citation 10. Lipscomb GH, Stovall TG, and Ling FW. Nonsurgical Treatment of Ectopic Pregnancy. N Engl J Med 2000; 343:1325-1329 11. Bachman EA, Barnhart K. Medical management of ectopic pregnancy: a comparison of regimens. Clin Obstet Gynecol. 2012;55 (2): 440-7. doi:10.1097/GRF.0b013e3182510a73 - Free text at pubmed - Pubmed citation 12. Daniilidis A, Pantelis A, Makris V et-al. A unique case of ruptured ectopic pregnancy in a patient with negative pregnancy test - a case report and brief review of the literature. Hippokratia. 2015;18 (3): 282-4. Free text at pubmed - Pubmed citation 13. Dibble EH, Lourenco AP. Imaging Unusual Pregnancy Implantations: Rare Ectopic Pregnancies and More. AJR Am J Roentgenol. 2016; 1-13. doi:10.2214/AJR.15.15290 - Pubmed citation Edit Article Share ArticleView Revision History URL of Article Article Information rID: 1258 Systems: Obstetrics, Gynaecology Section: Pathology Tags: core condition, ultrasound, abr certifying ultrasound Synonyms or Alternate Spellings: Ectopic pregnancies Extrauterine gestation Extra-uterine gestation Ectopic Cases and FiguresFigure 1: location of ectopicsFigure 1: location of ectopicsDrag here to reorder.Case 2 Case 2 Drag here to reorder.Case 3: live adnexal ectopicCase 3: live adnexal ectopicDrag here to reorder.Case 4: with a hyperechoic tubal ring Case 4: with a hyperechoic tubal ring Drag here to reorder.Case 5: live ovarian ectopicCase 5: live ovarian ectopicDrag here to reorder.Case 6: ring of fire sign (hypervascular ring)Case 6: ring of fire sign (hypervascular ring)Drag here to reorder.Case 7: tubal ectopicCase 7: tubal ectopicDrag here to reorder. Case 8 Case 8Drag here to reorder.Case 9Case 9Drag here to reorder. Case 10 Case 10Drag here to reorder.Imaging Differential DiagnosisCorpus luteum rupture with haemoperitoneumCorpus luteum rupture with haemoperitoneumDrag here to reorder.

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