ECTOPIC PREGNANCY

Introduction

Ectopic pregnancy accounts for 1.4% of all

pregnancies and for approximately 15% of
maternal deaths.
An increase in the prevalence of risk factors has
led to a parallel increase in the incidence of
ectopic pregnancy.
The case-fatality rate, however, has declined
from 3.5 in 1000 in 1970 to less than 1 in 1000,
probably because of improved diagnostic
accuracy in the early stages of ectopic
pregnancy and resultant earlier intervention.

Factors Associated With an Increased

Incidence of Ectopic Pregnancy Past history
of:

Salpingitis or pelvic inflammatory disease

Tubal surgery
Ectopic pregnancy
Intrauterine contraceptive device
Advanced maternal age
Infertility
Ovulation Induction
In vitro fertilization

Sonographic Diagnosis

Regardless of clinical presentation, the primary goal

of early first trimester sonographic diagnosis should
be to identify the location of the gestational sac.
Because of the low incidence of heterotopic
pregnancy, sonographic demonstration of an
intrauterine pregnancy reduces the likelihood of
ectopic pregnancy to an almost insignificant level.
Heterotopic pregnancy, however, should be
suspected in the appropriate clinical setting,
especially in high-risk groups.
Evaluation of the adnexa should be routine in all
patients,
including
those
with
documented
intrauterine pregnancies.

Sonographic Diagnosis

Heterotopic Pregnancy

Sonographic Diagnosis

The demonstration of a live embryo in the

adnexa is diagnostic of ectopic pregnancy.
In early intrauterine pregnancy, incomplete
miscarriage, or ectopic pregnancy, one
cannot always identify the gestational sac.
In the absence of specific sonographic
findings,
the
probability
of
ectopic
pregnancy
can
be
predicted
by
identification of nonspecific sonographic
features and by correlation with the
discriminatory level of the serum -hCG.

Sonographic Diagnosis

The intradecidual sign can be used to

demonstrate the presence of an intrauterine
pregnancy before visualization of the yolk sac or
embryo.
In patients with ectopic pregnancies, the decidua
may slough, resulting in a fluid collection within
the endometrial canal that is referred to as a
decidual cast or pseudogestational sac
A pseudogestational sac is a fluid collection
within the endometrial canal surrounded by a
single decidual layer, as opposed to a sac within
the decidua abutting the endometrial canal
(intradecidual sign) or the two concentric rings of
the double-decidual sign

Sonographic Diagnosis

Decidual cast. (A) Sagittal and (B) coronal sonograms of the uterus. The
"pseudogestational sac" is composed of fluid (arrowhead) and debris (c)
within the endometrium, surrounded by a single layer of decidua.

Sonographic Diagnosis

Intradecidual sign.

Endovaginal sonogram in the sagittal plane(A) and coronal

plane (B) in a patient at 4.5 weeks menstrual age. The 3 mm gestational sac (electronic
calipers) is demonstrated within the decidua abutting and slightly displacing the echogenic
endometrial canal (arrows).

Sonographic Diagnosis

Comparison of the ultrasound features of an intrauterine pregnancy and a

pseudogestational sac.
The intrauterine pregnancy appears as a spherical/oval image, in an eccentric position in
the endometrium, with regular profiles, anechoic content, and a double hyperechoic
external ring.
On the contrary, the pseudosac has jagged margins, inhomogeneous content and irregular
morphology that changes over the time of the exam or between two successive scans.

Decidual cyst

Decidual cyst in a patient with ectopic pregnancy. A 3 mm cyst

(arrow) is identified within the decidua. This cyst is not an
intradecidual gestational sac in that it is peripherally located
within the decidua and does not abut the endometrial canal.

Live Embryo in the Adnexa

The sonographic demonstration of a live

embryo in the adnexa is specific for the
diagnosis of ectopic pregnancy.
A live extrauterine fetus has been
detected with EVS in 17% to 28% of
patients with ectopic pregnancies
compared with approximately 10% with
TAS.

Live Embryo in the Adnexa

Live ectopic pregnancy. A 7 mm embryo (calipers) and yolk sac (arrow)

are visualized within a well-defined trophoblastic ring (arrowheads).
The sac is situated in the posterior cul-de-sac, adjacent to the uterus (u).
Embryonic cardiac activity was identified at sonography.

Live Embryo in the Adnexa

Live Embryo in the Adnexa

NONSPECIFIC FINDINGS

Adnexal Mass

An adnexal mass can be found in

conditions other than ectopic pregnancy
and is therefore not diagnostic.
The presence of an adnexal mass in
patients with a positive -hCG who have
no
sonographic
evidence
of
an
intrauterine pregnancy, however, has a
positive predictive value of 70% to 75%
for ectopic pregnancy

Adnexal Mass

Tubal Ring

A tubal ring is an echogenic adnexal ring

separate from the ovary created by the
trophoblast of the ectopic pregnancy
surrounding the gestational sac.
In the series of Nyberg and colleagues
the positive predictive value of a tubal
ring for ectopic pregnancy was 100%.

Tubal Ring

Ectopic pregnancy: tubal ring. An extrauterine trophoblastic ring (arrowheads) is visualized

adjacent to the uterus (u).

Fluid (ff) and blood clot are present in the posterior cul-de-sac. The uterus is retroverted.

Tubal Ring

Free Fluid

The presence of free fluid is a nonspecific

finding that suggests the presence of an
ectopic pregnancy in the appropriate clinical
setting
The amount of fluid and the echogenicity of
the fluid are important clues in predicting the
presence of an ectopic pregnancy.
A large amount of fluid and increased
echogenicity of the fluid are both more
indicative of an ectopic pregnancy.
The presence of a large amount of free fluid or
of echogenic free fluid increases the positive
predictive value from 63% to 86%.

Free Fluid

Ectopic pregnancy: free fluid. Echogenic fluid(ff) is

present in the adnexa adjacent to an adnexal cyst(c) in a
patient with a ruptured ectopic pregnancy.

Free Fluid

Ectopic pregnancy: gray scale.

Coronol sonogram through the right adnexa shows a fallopian tube (tube)
filled with echogenic fluid (blood) and a trophoblastic ring (arrow) Echo-free
fluid (ff) surrounds the tube

Free Fluid

Although the presence of a large amount

of free fluid suggests tubal rupture, free
fluid is not a specific finding because the
tube may be intact in the presence of a
large hemoperitoneum.
In patients with suspected ectopic
pregnancy, the combination of an adnexal
mass and echogenic free fluid is
associated with a 97% positive predictive
value for ectopic pregnancy

Free Fluid+ Adnexal Mass

Normal Sonogram

Patients with ectopic pregnancy may have a

completely
normal
pelvic
ultrasound
examination.
In the series of Nyberg and associates, 34% of
patients with ectopic pregnancy had no
evidence of either an adnexal mass or free fluid
Pregnancy of unknown location (RCOG Guideline) :
No signs of either intra- or extrauterine pregnancy or
retained products of conception in a woman with a
positive pregnancy test.

Endovaginal Color Flow

Doppler

EVCFD diagnosis of ectopic pregnancy is

based on the identification of adnexal
peritrophoblastic flow defined as highvelocity, low-resistance flow separate
from the ovary
Studies
demonstrate
that
EVCFD
increases the diagnostic sensitivity for
diagnosis
of
ectopic
pregnancy
compared with EVS alone

Endovaginal Color Flow

Doppler

Endovaginal color flow Doppler and pulsed

Doppler demonstrate peritrophoblasic flow
showing high velocity and low resistance.

Endovaginal Color Flow

Doppler

Endovaginal Color Flow

Doppler

Endovaginal Color Flow

Doppler

Ectopic Pregnancy: Extrauterine Findings

Sonographic Findings

Sensitivity
(%)

Specificity
(%)

Positive
Predictive
Value (%)

Negative
Predictive
value (%)

Adnexal mass

21

93

70

58

Free fluid

63

69

63

69

Moderate-to-large
amount of free fluid

29

96

86

62

Echogenic fluid, no mass

15

98

85

58

Adnexal mass, no fluid

22

94

75

57

Echogenic fluid plus

adnexal mass

42

99

97

67

Diagnostic Table for Patients With Suspected

Ectopic Pregnancy and Positive Pregnancy
Test
B-HCG
(First
International
Reference

Sonographic
Findings

Preparation)

(uterine and adnexa)

(1st IRP)
(mIU/ml)

Intrauterine pregnancy
with
normal adnexa

Intrauterine pregnancy

Intrauterine pregnancy
with
adnexal mass or free
fluid
No intrauterine
pregnancy
with no adnexal
abnormality
No intrauterine
pregnancy
with no adnexal
abnormality

Diagnosis

Possible heteropic pregnancy;

clinical correlation required
>1700

Probable ectopic pregnancy; possible

incomplete miscarriage or
abnormal
intrauterine pregnancy

<1700

Likelihood of ectopic pregnancy

depending on clinical finding.
Follow-up

MOLAR PREGNANCY

Types of Gestational
Trophoblastic Neoplasia [GTD]

A wide spectrum of entities characterized by

abnormal proliferation of pregnancy-related
trophoblasts with variable malignant potential:
1. Non-invasive hydatidiform mole [complete
or partial],
2. Invasive mole,
3. Choriocarcinoma,
4. Placental site trophoblastic tumor [PSST]
and
5. Epithelioid trophoblastic tumor [a newer
entity].

Etio-pathogenesis

Molar gestations are increased in older and very young

females of reproductive age and in those with a history of
prior molar pregnancy.
Advanced paternal age may be a risk factor for a complete
molar pregnancy

A complete molar pregnancy occurs when a sperm fertilizes an

empty ovum, resulting in the development of only placental parts.
A complete mole is completely paternal in origin, with a karyotype of
usually 46 XX.
A partial mole results when two sperms fertilize a single ovum and
results in development of certain or all fetal parts.
A partial mole predominantly has a triploid karyotype of 69XXX or 69
XXY or 69 XYY; however, a diploid karyotype may also exist.

Clinical Presentation

Patients with a complete molar pregnancy

usually present with the classical symptoms
of vaginal bleeding, hyperemesis, passage of
grape like vesicles per vagina and a uterus
larger than dates [although some may
present with a smaller than dates uterus].
With a partial molar pregnancy, patients are
usually asymptomatic or may present with
symptoms of a missed or incomplete
miscarriage

Imaging: Complete Mole

The diagnosis of molar pregnancy can nearly always be made

by ultrasound, because the chorionic villi of a typical complete
mole proliferate with vacuolar swelling and produce a
characteristic vesicular sonographic pattern.
When the diagnosis is made at a later stage of gestation, the
classical snowstorm pattern of the uterus was described; however
this is not commonly seen now.
The majority of first trimester complete moles demonstrated a
typical sonographic appearance of a complex and echogenic
intrauterine mass containing many small cystic spaces {which
correspond to the hydropic villi on gross pathology}.
One may see a large, central fluid collection that mimics an
anembryonic gestation or miscarriage.
Occasionally, there is merely a central mass of variable
echogenicity, presumably because the villiare too small to be seen
with sonography at that time.

Imaging: Complete Mole

The classical bunch-of-grapes appearance or snow-storm

appearance in the uterine cavity is noted. This is the typical
appearance of a gestational trophoblastic disease.

Imaging: Complete Mole

Transverse sonogram of the uterus demonstrates the

heterogeneous mass within the endometrial cavity. The
visualized anterior and posterior myometrium appear to be
normal and uninvolved.

Imaging: Complete Mole

Molar pregnancy with large cystic spaces

Imaging: Complete Mole

Molar pregnancy starting expulsion

Imaging: Complete Mole

Studies have shown color Doppler to be useful in the

evaluation and follow up of gestational trophoblastic
tumors.
Angiogenesis is an integral part of any tumor
development and color Doppler usually reveals
increased vascularity in the mole, followed by a
decrease with treatment.
Low resistance blood vessels with low pulsatility
and resistance indices have been noted in
malignant
and
aggressive
gestational
trophoblastic tumors.
These may also be useful in predicting the response to
treatment
in
addition
to
diagnosis.

Imaging: Complete Mole

Color Doppler scan in a patient with a molar gestation

The hyperechoic mass in the uterus demonstrates areas of increased
vascularity.

Imaging: Complete Mole

Spectral waveform analysis in a case of gestational trophoblastic

neoplasm
The spectral waveform within the cystic mass in the uterus reveals a
mixed arterial and venous waveform, with low resistance arterial flow.

Imaging: Complete Mole

Imaging: Complete Mole

Molar pregnancy: EVCFD showing vascular myometrium

with no flow in the molar tissue indicating molar
degeneration

Imaging: Complete Mole

Ovarian enlargement with bilateral theca

lutein cysts is a common association.

InvasiveGTD

InvasiveGTDincluding choriocarcinomas
however show increased intratumoral blood
flow, and focal areas of increased flow in the
myometrium as well, if there is local invasion.
Presence of extrauterine gestational disease
confirms the aggressive nature of the GTD.
In borderline cases, the final diagnosis of
invasion versus non-invasion is confirmed only
by histopathology and hence all the evacuated
moles need to undergo a complete pathological
workup.

InvasiveGTD

Partial Mole

Partial moles are often indistinguishable from

complete moles on ultrasound.
However, demonstration of fetal parts favors the
diagnosis of a partial mole.
Naumoff, et al described the following appearances:
Enlarged and thickened placenta relative to the size
of the uterus.
Cystic spaces within the placenta.
An alive or dead, well formed but growth retarded
fetus.
An empty gestational sac [anembryonic appearance]
or a sac that contains ill-defined fetal echoes.

Partial Mole

An enlarged uterus with multiple cystic areas within endometrium/placenta is noted. A rounded
11 mm structure thought to be the yolk sac is identified [on the right side].
This is abnormal as the normal yolk sac diameter should be < 6 mm at 10 weeks of gestation.
This was a non-invasive partial molar pregnancy, with hydropic changes in an enlarged
placenta.
Differential Diagnosis: Hydropic placental degeneration, typically associated with an abnormal
or failing first trimester pregnancy, may appear similar to a partial molar pregnancy on
ultrasound.

Management

Studies have concluded that it is not always

possible to make a diagnosis of early molar
pregnancy by ultrasonography and therefore,
histological examination of the aborted or
evacuated specimens remains important and DNA
analysis should be carried out for the final
diagnosis, if histology is inconclusive.
A complete mole has about a 2% chance of
recurrence, while a partial mole has about a 0.5%
chance.
Patients are often counseled to avoid pregnancy
for at least one year to minimize the risk of
missing persistent trophoblastic neoplasia.

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