Case 4.

25
HISTORY: A 22-year-old female presented with severe right lower quadrant pain, nausea, and vomiting

FIGURE 4.25.1 FIGURE 4.25.2

FIGURE 4.25.3

FINDINGS: Transvaginal scan, sagittal image
through the uterus (Fig. 4.25.1) shows normal endo-
metrial stripe without any intrauterine gestational
sac. There is significant amount of free fluid noted
posterior to the uterus. Figure  4.25.2 through the
right adnexa shows a large anechoic cystic mass
(O), which represents right ovary with corpus luteal
cyst. Anterior to that, there is an echogenic ring-like
structure (short arrows) that represents an extrauter-
ine gestational sac. A small yolk sac (long arrow) is
also present within the gestation sac. Figure 4.25.3
is a color Doppler US image through the right ad-
nexal region showing increased vascularity around
the gestational sac.
DIAGNOSIS: Right ectopic pregnancy
DISCUSSION: The incidence of ectopic pregnancy
has increased in recent years and is seen in 1%
to 2% of all pregnancies in United States (44–46). It
most commonly occurs in fallopian tubes (97%) but
can occur in cervix, ovary, cornua of the uterus or
even intra-abdominally. Among the tubal pregnan-
cies, ampulla is the most common site of implanta-
tion. If the patient’s beta-hCG is more than 1,500
to 2,000 mIU/mL and an intrauterine pregnancy is
not seen on a transvaginal scan, an ectopic preg-
nancy should be suspected (New9). Patients usually
present with lower abdominal pain. The risk fac-
tors include previous tubal surgery, previous ectopic
pregnancy, infertility treatment, and intrauterine
contraceptive device. On ultrasound, tubal preg-
nancy usually presents as a complex adnexal mass,

4 / ULTRASOUND 217

(c) 2015 Wolters Kluwer. All Rights Reserved.

 Case 4.25  (Continued)
which may show increased peripheral vascularity
frequently termed as ring of fire appearance. Pres-
ence of complex free fluid and a complex adnexal
mass suggests ruptured ectopic pregnancy in the ap-
propriate setting. Uterine endometrium may show
thickening owing to decidual reaction but without
a gestational sac. Occurrence of concomitant in-
trauterine and ectopic pregnancy is extremely rare
(1:30,000). Ovaries may show cystic changes from
corpus luteum formation and increased peripheral
vascularity, which in many cases may be mistaken
for an ectopic pregnancy.
218 AUNT MINNIE’S ATLAS AND IMAGING-SPECIFIC DIAGNOSIS
(c) 2015 Wolters Kluwer. All Rights Reserved.
Aunt Minnie’s Pearls
Inability to demonstrate an intrauterine gestational sac
with transvaginal scan in a patient with beta-hCG lev-
els of >2,000 mIU/mL should always raise suspicion for
an ectopic pregnancy.
Endometrial (decidual) cysts may be seen even with
ectopic pregnancy (pseudosac) and should not be
mistaken for a true sac. Demonstration of a yolk sac
within an intrauterine gestational sac more accurately
confirms an intrauterine pregnancy.