Diagnostic Imaging Pathways - Ectopic Pregnancy (Suspected)
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This pathway provides guidance on the imaging of female patients presenting with suspected ectopic pregnancy.
Date reviewed: October 2013
Date of next review: 2017/2018
Published: November 2013
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1a |  |
Ectopic Pregnancy Images 1a and b (Transvaginal Ultrasound): Views demonstrating an adnexal mass containing an embryo (Image 1a) and an empty uterus (Image 1b). |
| 1b |  |
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| 2a |  |
Ectopic Pregnancy
Image 2a and 2b (HE, x20). Resection of fallopian tube with an ectopic tubal pregnancy. The histological section shows ulceration of the tubal epithelium, haemorrhage and chorionic villi (arrows) which confirm the presence of products of conception. |
| 2b |  |
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Teaching Points
Teaching Points
- Transvaginal and abdominal US combined with the measurement of serum β-hCG are the investigations of choice for suspected ectopic pregnancy
- In a small proportion of cases the TVUS may be non-diagnostic. Follow up of these patients is dependant on the value of the quantitative β-hCG -
- A β-hCG > 1500 IU should proceed to laparoscopy
- A β-hCG < 1500 IU should be repeated in 48hrs if the patient is clinically stable, expecting a rise of > 66%
- A normal US does not exclude an ectopic pregnancy
hcg
Serum Human Chorionic Gonadotrophin (ß-hCG) Levels
- Levels of 1000-1500iu/l should be associated with the presence of an intrauterine gestation on transvaginal US (6000-6500 iu/l for transabdominal), although in multiple pregnancy this level may be higher 8
- Serum ß-hCG levels double approximately every 48 hours in 85% of normal intrauterine pregnancies of between 4 and 6 weeks' gestation 20
- 80% of ectopic pregnancies are associated with a rise in ß-hCG of less than 66% 19,20
us
Transabdominal +/- Transvaginal Ultrasonography
- Pelvic ultrasonography (transabdominal US +/- transvaginal US) combined with measurement of serum ß-hCG levels, is an effective screening strategy for diagnosing ectopic pregnancy 3-6
- Allows identification of an intrauterine pregnancy, which is the single most important finding for the exclusion of ectopic gestation as the presence of both intra- and extra-uterine pregnancy, is very rare 1,3-6
- Compared to transabdominal ultrasonography, transvaginal ultrasonography is more sensitive and has a lower discriminatory zone (the range of serum ß-hCG concentrations above which gestational sac can be visualised consistently). This allows earlier diagnoses of intrauterine or ectopic pregnancies 7-11
- Sensitivity for transvaginal ultrasonography ranges from 69 to 96% and specificity from 84 to 99% 1,3,9,12
- When used in conjunction with serum ß-hCG levels, transvaginal ultrasound has comparable sensitivity and specificity for ectopic pregnancy to laparoscopy 13
- Presence of an adnexal mass and/or free pelvic fluid is strong predictor of an ectopic pregnancy 10,14-17
- Findings suggestive of ectopic pregnancy include 13
- Fluid in the pouch of Douglas, an adnexal mass and an empty uterus
- An adnexal mass, empty uterus or pseudogestational sac and a positive ß-hCG
- Direct demonstration of ectopic fetus and fetal heart
- Normal US does not exclude the diagnosis of ectopic pregnancy 3,14,15
- Patients with indeterminate ultrasonography findings require further evaluation with quantitative ß-hCG levels +/- follow-up US or laparoscopy as about 15-20% of these patients will have a final diagnosis of ectopic pregnancy 18,19
References
References
Date of literature search: July 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Kaplan BC, Dart RG, Moskos M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996;28:10-17. (Level II evidence) View the reference
- Abbott JT, Emmans LS, Lowenstein SR. Ectopic pregnancy: ten common pitfalls in diagnosis. Am J Emerg Med. 1990;8:515-22. (Level IV evidence)
- Braffman BH, Coleman BG, Ramchandani P, et al. Emergency department screening for ectopic pregnancy: a prospective US study. Radiology. 1994;190:797-802. (Level II evidence) View the reference
- Barnhart K, Mennuti MT, Benjamin I, et al. Prompt diagnosis of ectopic pregnancy in an emergency department setting. Obstet Gynecol. 1994;84:1010-5. (Level II evidence)
- Gracia CR, Barnhart KT. Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstet Gynecol. 2001;97:464-70. (Level II evidence)
- Wong TW, Lau CC, Yeung A, et al. Efficacy of transabdominal ultrasound examination in the diagnosis of early pregnancy complications in an emergency department. J Accid Emerg Med. 1998;15:155-8. (Level II evidence) View the reference
- Jain KA, Hamper UM, Sanders RC. Comparison of transvaginal and transabdominal sonography in the detection of early pregnancy and its complications. AJR Am J Roentgenol. 1988;151:1139-43. (Level III evidence)
- Nyberg DA, Mack LA, Laing FC, et al. Early pregnancy complications: endovaginal sonographic findings correlated with human chorionic gonadotropin levels. Radiology. 1988;167:619-22. (Level III evidence)
- Nyberg DA, Mack LA, Jeffery RB Jr, et al. Endovaginal sonographic evaluation of ectopic pregnancy: a prospective study. AJR Am J Roentgenol. 1987;149:1181-6. (Level III evidence)
- Cacciatore B, Stenman UH, Ylostalo P. Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hCG level of 1000 IU/l [IRP]. Br J Obstet Gynaecol. 1990;97:904-8. (Level II evidence) View the reference
- Cacciatore B, Stenman UH, Ylostalo P, et al. Comparison of abdominal and vaginal sonography in suspected ectopic pregnancy. Obstet Gynecol. 1989;73:770-4. (Level III evidence)
- Timor-Tritch IA, Yeh MN, Peisner DB, et al. The use of transvaginal ultrasonography in the diagnosis of ectopic pregnancy. Am J Obst Gynecol. 1989;161:157-61. (Level III evidence)
- Sadek AL, Schiotz HA. Transvaginal sonography in the management of ectopic pregnancy. Acta Obstet Gynecol Scand. 1995;74:293-6. (Level II evidence)
- Brown DL, Doubilet PM. Transvaginal sonography for diagnosing ectopic pregnancy: positivity criteria and performance characteristics. J Ultrasound Med 1994;13:259-66. (Level II evidence) View the reference
- Russell SA, Filly RA, Damato N. Sonographic diagnosis of ectopic pregnancy with endovaginal probes: what really has changed? J Ultrasound Med. 1993;3:145-51. (Level III evidence)
- Nyberg DA, Hughes MP, Mack LA, et al. Extrauterine findings of ectopic pregnancy at transvaginal US: importance of echogenic fluid. Radiology. 1991;178:823-6. (Level II evidence) View the reference
- Cacciatore B. Can the status of tubal pregnancy be predicted with transvaginal sonography? A prospective comparison of sonographic, surgical and serum hCG findings. Radiology. 1990;177:481-4. (Level II evidence) View the reference
- Dart RG, Burke G, Dart L. Subclassification of indeterminate pelvic ultrasonography: prospective evaluation of the risk of ectopic pregnancy. Ann Emer Med. 2002;39:382-8. (Level II evidence) View the reference
- Dart RG, Mitterando J, Dart LM. Rate of change of serial ß-human chorionic gonadotropin values as a predictor of ectopic pregnancy in patients with indeterminate transvaginal ultrasound findings. Ann Emerg Med. 1999;34:703-10. (Level II evidence) View the reference
- Symonds IM. Ectopic pregnancy: modern management. Current Obstetrics & Gynaecology. 1998;8:27-31. (Review article) View the reference
Further Reading
- Dart RG. Role of pelvic ultrasonography in evaluation of symptomatic first-trimester pregnancy. Ann Emerg Med. 1999;33:310-20. (Review article)
- Frates MC, Laing FC. Sonographic evaluation of ectopic pregnancy: an update. AJR Am J Roentgenol. 1995;165:251-9. (Review article)
- Durston WE, Carl ML, Guerra W, et al. Ultrasound availability in the evaluation of ectopic pregnancy in the ED: comparison of quality and cost-effectiveness with different approaches. Am J Emerg Med. 2000;18:408-17. (Level III evidence)
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Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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