Ectopic Pregnancy

Safiye Gurel, MD
KEYWORDS
 Ectopic  Pregnancy  Ultrasonography

19 per 1000 pregnancies between 1976 and

1993), United Kingdom (11,000 cases per year),
and United States (from 0.5% to 1% to 2% in the
past 30 years).2,11,12 This remarkable increase in
the prevalence of EP during the past 2 decades
might be a result of several factors such as more
sensitive ultrasound (US) examinations using
advanced technology, more infertility treatment, increased incidence of PID and endometriosis, and
widespread use of laparascopy.5 Parallel to the increase in the prevalence of EP, a steady decrease
in its morbidity and mortality is observed mostly
because of earlier and prompt diagnosis with
advanced technology of transvaginal US (TVUS).

CLINICAL PRESENTATION
The clinical finding of EP has a wide spectrum ranging between a completely asymptomatic status and
peritoneal irritation resulting from rupture and
consequent bleeding into the peritoneal cavity
and hypovolemic shock.13 The classic clinical triad
of pain, abnormal vaginal bleeding, palpable
adnexal mass is present in only 45% of patients
with EP and this triad has a positive predictive value
of only 14%.14 Today, the ability to diagnose and
evaluate pregnancy at very early gestational ages
has altered the traditional presenting symptoms of
EP. Up to 9% of patients report no pain, and 36%
of them lack adnexal mass.1,11,13 In spite of absence of pathognomonic symptoms and physical
findings, a history of delayed or irregular menstrual
period, prior history of assisted reproductive surgery, patient age, smoking, use of contraceptive
methods, or prior tubal surgery can provide useful
hints for suggesting EP in the differential diagnosis.

DIAGNOSIS
The mainstay parameters to use confidently in
diagnosing an EP, after quite much discussion

Department of Radiology, Izzet Baysal University School of Medicine, Golkoy, 14280, Bolu, Turkey
E-mail address: [email protected]
Ultrasound Clin 3 (2008) 331343
doi:10.1016/j.cult.2008.07.003
1556-858X/08/$ see front matter 2008 Elsevier Inc. All rights reserved.

ultrasound.theclinics.com

Ectopic pregnancy (EP) is any pregnancy occurring outside the endometrial cavity of uterus
and was first described by the Arab physician
El-Zahrawi (Albucasis) in the tenth century who is
acknowledged as the chief surgeon of the middle
ages and up to the Renaissance.1 EP can be studied in several subsets in terms of localization of
implantation as extrauterine (tubal, ovarian,
abdominal) and intrauterine (cornual, interstitial,
cervical), presence of accompanying normal intrauterine pregnancy (heterotopic pregnancy), and
clinical presentation as acute or chronic EP.
EP is one of the major causes of maternal-fetal
morbidity and mortality and loss of pregnancy. It
remains the leading cause of maternal death in
the first trimester, the second leading cause of
maternal mortality overall, and has an associated
mortality that is 4 times greater than that of
childbirth and 38 times greater than that of a legal
induced abortion.2,3 All causes of EP are associated with abnormalities of tubal structure or transport. It is much higher in the population treated
with assisted reproductive techniques, with a prior
history of EP, tubal surgery, tubal obstruction
resulting from pelvic inflammatory disease (PID)
or endometriosis, and use of intrauterine contraceptive device.4,5 Cigarette smoking is another etiologic factor, in direct proportion to the total dose,
possibly as a result of impaired tubal function.6,7
Other risk factors such as vaginal douching, early
onset of sexual activity, and multiple partners
probably increase the risk of EP indirectly by
increasing the risk of infection.8 Contraceptive
use is known to decrease the total incidence of
EP. On the other hand, when a contraception
methodmostly with intrauterine devices, progestin-based contraceptives, and tubal ligation
failure occurs, the risk of EP is relatively higher
than among women not using contraception.9,10
Recent studies show that the incidence of EP is
increasing worldwide, particularly in industrialized
countries such as Northern Europe (from 11 to

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Gurel
and debate, is a combination of TVUS findings and
serial serum b-hCG levels.1518
b-hCG, used in most laboratories today,
becomes positive at approximately 23 menstrual
days, in other words 9 days after conception,
which is before a sac can be seen with TVUS.19
In normally developing intrauterine pregnancies,
serum levels of b-hCG approximately double in
value every 48 hours during the first 10 weeks after
the last menstrual period. The serum level of
b-hCG peaks at approximately 10 menstrual
weeks, and then begins to decline. During the first
10 weeks, a 66% rise over 2 days is generally considered acceptable evidence of a viable intrauterine pregnancy. However, rates of increase over
48 hours as high as 228% and as low as 53%
have been documented in viable pregnancies.16
In ectopic pregnancies, values may plateau or
increase at a slower than normal rate. In one recent study, almost 30% of women with ectopic
pregnancies had patterns of b-hCG change that
mimicked either intrauterine pregnancy or complete miscarriage.20 Thus, serial b-hCG is most
useful when combined with TVUS. At a b-hCG
level of 1000 mIU/mL (Second International Standard, IS) or 2000 mIU/mL (International Reference
Preparation, IRP), an intrauterine pregnancy
should be clearly visible if present, and this serum
b-hCG level is defined as the discriminatory
zone.2123 In case of b-hCG level lower than the
discriminatory zone and absence of an intrauterine
pregnancy, an ectopic pregnancy, a miscarriage,
or a very early intrauterine pregnancy should be
considered. Decreasing b-hCG values before
10 weeks gestation usually indicate pregnancy
loss, but do not identify the site of the pregnancy.
Women with ruptured or nonruptured ectopic
pregnancies have been reported to display
a wide range of b-hCG values; therefore, women
who are symptomatic require further evaluation
regardless of b-hCG level.2426 A negative
b-hCG value does not reliably rule out EP, as
chronic ectopic pregnancy is reported to be present with its low titers or a negative b-hCG value.27,28
TVUS, defined as the ultimate diagnostic tool,
has brought a revolution in the early diagnosis of
EP.29 Sensitivity, specificity, and positive and negative predictive values of TVUS in diagnosing EP
are found to be over 90% in different studies while
diagnostic reliability of transabdominal sonography has been shown to be 70%.29,30 However,
both transabdominal and transvaginal scanning
play a complementary role in diagnosis of EP.
Transabdominal views are important to screen
for hemoperitoneum and to visualize ectopic pregnancies beyond the range of the transvaginal
probe.31,32 Transvaginal scanning is important for

detailed visualization of endometrial contents and

evaluation of adnexa. If the patient has an empty
bladder, it is easy and reasonable to begin with
a transvaginal scan; however, if the adnexa are
beyond the field of view of the endovaginal probe
and not well evaluated, a transabdominal scan
with a full bladder is necessary. Another important
point while examining with US is to scan above
and below the ovaries and between the uterus
and ovaries, as most ectopic pregnancies are
located within the tubes. Although very rare,
abdominal pregnancy should be sought with US
as a whole abdominal examination in the presence
of positive serum b-hCG values and absence of
intrauterine pregnancy.
Gestational sacs grow at a rate of 0.8 mm/day;
therefore, a follow-up sonography in 2 to 3 days
will demonstrate growth in normal pregnancy.
Ectopic pregnancies do grow as in normal pregnancies, may hemorrhage, and become (5% to
18%) more apparent on follow-up US. If an exact
diagnosis is not established at the time of initial
scanning, and if the patient is stable, follow-up
sonography, accompanied with or without serum
b-hcG level is necessary.15,33

SONOGRAPHIC DIAGNOSIS OF ECTOPIC

PREGNANCY
Endometrial Findings
Several endometrial patterns and cut-off values for
endometrial thicknesses have been studied in the
prediction of EP;3437 however, no specific and
sensitive endometrial pattern or thickness has
been determined. In EP, the endometrial cavity
can exhibit various appearances such as trilaminar, homogeneously hyperechoic, heterogeneously hyperechoic, containing decidual cyst or
pseudogestational sac, and thickness such as
normal, thickened or thin. However, EP can be associated with thinner endometrium compared with
normal intrauterine pregnancy and first trimester
loss possibly in correlation with serum progesterone and b-hCG levels.34,38
Decidual cyst is a small fluid collection without
an echogenic rim, which might represent an early
breakdown of the decidua. They are typically
located at the junction of the endometrium and
myometrium (Fig. 1).39 It is neither specific nor
sensitive for EP as it can be seen in intrauterine
pregnancy and in nonpregnant patients as
well.4,40 Multiplicity of decidual cyst, although not
a truly distinguishing feature, and absence of an
echogenic rim might help in differentiating it from
an intradecidual sign.
Pseudosac or pseudogestational sac or pseudosac is a fluid collection within the endometrial

Ectopic Pregnancy
Adnexal Findings
Tubal pregnancy is the most common location of
EP, constituting 99% of extraovarian EP, with
75% in the ampullary portion, 10% in the isthmic
portion, 5% in the fimbrial end, 2% to 4% in the
interstitial end.1,43 The combination of positive
b-hCG, absence of intrauterine pregnancy and
presence, of an adnexal mass other than a simple
intraovarian cyst should be regarded as an EP until
proven otherwise. Sonographic adnexal findings
of EP can appear in four different ways as given
below in decreasing order of specificity:
Fig.1. Decidual cyst. An anechoic fluid collection without a perceptible echogenic wall (arrow) is seen
eccentrically within the endometrial cavity on sagittal
transvaginal image. (From Gurel S, Sarikaya B, Gurel
K, et al. Role of sonography in the diagnosis of ectopic
pregnancy. J Clin Ultrasoun 2007;35(9):50916; with
permission. Fig. 1 is used.)

cavity (Fig. 2). It represents blood and debris in the

endometrial cavity, which can be seen in both intrauterine and ectopic pregnancy. It is found to
be present in 20% of EP.41 It might be seen as
a simple or complex and at times moving fluid. It
is centrally located within the endometrial cavity
and surrounded by only one echogenic layer corresponding to the endometrial decidual reaction.
Central localization of pseudogestational sac
helps in differentiation from decidual cyst, while
central localization and one echogenic rim helps
in differentiation from double decidual sac sign
seen in early intrauterine pregnancy.42

Fig. 2. Pseudogestational sac. A cystic area with

a weekly echogenic rim, different from the surrounding two prominent echogenic rims double decidual
sac sign, located centrally within the endometrial cavity
is demonstrated on sagittal transvaginal image. (From
Gurel S, Sarikaya B, Gurel K, et al. Role of sonography
in the diagnosis of ectopic pregnancy. J Clin Ultrasoun
2007;35(9):50916; with permission. Fig. 2 is used.)

(1) An extrauterine live embryo with positive heart

motion
(2) An extrauterine gestational sac containing
a yolk sac with or without an embryo
(3) A tubal ring without an embryo or yolk sac
(4) A complex or solid adnexal mass separate
from the ovary
The pathognomonic finding of EP, a live embryo
with positive heart motion, is present in only 8% to
26% of ectopic pregnancies on TVUS (Fig. 3A, B).32
The second most specific sign an extrauterine
gestational sac containing a yolk sac with or
without an embryo carries the risk of being
confused with a hemorrhagic cyst containing
debris mimicking a yolk sac or embryo (Fig. 4).44
The tubal ring is an oval, round, or, if ruptured,
irregular mass with hyperechoic rim of trophoblastic tissue and has a specificity of 40% to 68% for
EP (Fig. 5). A complex or solid adnexal mass separate from the ovary is slightly less specific but
more common than a tubal ring.4551
Adnexal findings, other than a live embryo, need
to be differentiated from a hemorrhagic corpus
luteum cyst arising from the ovary. A sonographic
clue for this differentiation is echogenicity of the
wall of the corpus luteum, which is more hypoechoic when compared to the wall of the tubal
ring and endometrium (Fig. 6AC).52,53 Follow-up
sonographic examinations help to detect the
changes in a hemorrhagic corpus luteum as the
blood products within it evolve. When it is unclear
if the mass is ovarian or extraovarian, a maneuver
performed while scanning with gentle pressure on
the endovaginal probe and anterior abdominal wall
can be used to demonstrate that a corpus luteum
moves with the ovary, while tubal EP moves separately from the ovary.

Pelvic Fluid
In normal pregnancies usually a small amount of
free fluid, accepted as physiological, is seen in
the pelvis. In both intrauterine and ectopic

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Gurel

Fig. 3. Tubal ectopic pregnancy. A tubal ring (echogenic trophoblastic tissue) (arrow) containing a yolk sac (angled
arrow) is seen on transabdominal axial image. (A) Fetal pole (cursor) is also present and a live embryo is identified
on M-Mode scanning (B).

pregnancies, free fluid accumulates in the culde-sac, which is the most dependent location in
the pelvis. In EP, free pelvic fluid is seen either because of a response to the distention of the fallopian tube or bleeding from the damaged tube
or the EP itself.54 It can have a simple (anechoic)
or complex appearance with floating echoes, or
a layering appearance. Complex fluid suggests
hemoperitoneum and, sometimes, even blood
clot can be seen, surrounding the uterus giving
its contours an ill-defined appearance. Complex
pelvic fluid when present in a patient with a positive
b-hcG level has a positive predictive value of 86%
to 93% in the diagnosis of EP and may be the only
endovaginal sonographic finding (Fig. 7).44,55,56

Fig. 4. A tubal ectopic pregnancy with a well-formed

gestational sac containing a nonliving embryo.

It should be kept in mind that a moderate

amount of echogenic fluid might be present owing
to retrograde passage of blood in an intrauterine
pregnancy when the patient is bleeding or a hemorrhagic corpus luteum cyst ruptures. Although
quantification of pelvic fluid is not necessary, it is
important to scan up by the hepatorenal space
(Morrisons pouch) to assess for the degree of
hemoperitoneum. In general, when pelvic complex
fluid is seen extending beyond the cul-de-sac,
EP should be considered in the differential
diagnosis.57,58

Fig. 5. Tubal ring. A homogeneously hyperechoic ringlike structure, representing trophoblastic tissue, (short
arrows) with a central cystic component is illustrated
on a transvaginal coronal image in a case of ampullary
EP. The tubal ring is adjacent to the ovary (long arrow)
and accompanying periovarian free fluid (F) with lowlevel echoes is present.

Ectopic Pregnancy

Fig. 6. Echogenicity of the wall of corpus luteum (A) is seen as more hypoechoic compared to the wall of the tubal
ring (B) and endometrium (C) on coronal and sagittal transvaginal images respectively.

Doppler Findings
The process of implantation shows local hemodynamic changes characterized as high-velocity and
low-impedance flow, whether it occurs within or
other than the endometrial cavity. Regarding the
asymmetry between two adnexa, the increased
blood flow around the conceptus of a tubal EP is
defined as ring of fire.59,60 The limitation for
this finding is that the blood flow pattern of corpus
luteum, luteal flow, may have a similar appearance and to avoid an overestimation, it should be
remembered that corpus luteum cysts are much
more common than EP (Fig. 8A, D). Peripheral
hypervascularity is a nonspecific finding and may

also be seen surrounding a normal maturing follicle

or corpus luteal cyst or hemorrhagic cyst. As
a result of all studies and reports up to now, there
is no pathognomonic or specific Doppler finding
for EP because of the overlap with a corpus luteum
cyst, at least in resistive indices.61 The only discriminating feature between these two entities is
the location. A corpus luteum cyst is always
located in the ovary, whereas an EP is 90% unilateral to the corpus luteum.53 Recently, a finding
called the leash sign, a combination of grayscale and Doppler sonographic findings was
reported by Ramanan and Gajaraj.62 This sign
mostly depends on the abnormal implantation

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Gurel

Fig. 7. Free fluid. A ruptured tubal ectopic pregnancy presenting with massiveperiovarian (A), cul-de-sac, and
pelvic (B)echogenic (hemorrhagic) free fluid.

and tubal trophoblast invasion causing marked

blood flow changes in the adjacent supplying
vessels.63,64 The sign has 3 parts: (1) gray-scale
identification of an adnexal abnormality (eg, a
swollen tube or a ring-like structure suggestive of

an EP); (2) a linear artery supplying the tube at

one point; (3) a low-resistance placental type of
flow on spectral Doppler interrogation of the above
artery. With fulfillment of the above criteria, a sensitivity of 100% and a specificity of 98% have been

Fig. 8. Ring of fire. Doppler findings of a corpus luteum cyst and a tubal EP. On power Doppler imaging corpus
luteum cyst is encircled with a rim of color (A) and displaying a low-resistance (resistive index: 0.41) high blood
flow pattern (B). On color Doppler imaging, tubal EP demonstrates an intense color rim (C) with a low resistance
spectral pattern (D) similar to corpus luteum cyst. (From Gurel S, Sarikaya B, Gurel K, et al. Role of sonography in
the diagnosis of ectopic pregnancy. J Clin Ultrasoun 2007;35(9):50916; with permission. Fig. 9A is used.)

Ectopic Pregnancy
reported in the diagnosis of an early EP in a limited
number of cases. However, an overlap was shown
to be present in an ovary with a mature cystic
teratoma, therefore, this sign still needs to be
verified both with larger series and various ovarian
pathologies.
Color Doppler is most helpful when an EP is not
seen, but highly suspected. At that time, Doppler
imaging can be used to find a mass representing
an EP.

RARE TYPES OF ECTOPIC PREGNANCY

Ovarian
Ovarian pregnancy is very rare, constituting 3% of
all ectopic pregnancies.65 It has an estimated
frequency ranging from 1 in 2100 to 1 in 7000 pregnancies and there is a high frequency of rupture
and hemorrhage if the diagnosis is delayed.66,67
The exact diagnosis is by demonstration of
a yolk sac or embryo either on the surface or within
the parenchyma of the ovary (Fig. 9). On TVUS,
ovarian EP is usually seen as a well-defined echogenic ring which is indistinguishable from a corpus
luteum cyst and the diagnosis is usually confirmed
histopathologically.67,68 Therefore, a complex cyst
is the least specific finding for the diagnosis of an
ovarian EP, as corpus luteum cyst is much more

Fig. 9. Ovarian ectopic pregnancy. A true ovarian

pregnancy located eccentrically within the ovarian parenchyma is demonstrated on transvaginal axial image. The gestational sac (long arrow) without a fetal
pole or yolk sac is confirmed histopathologically.
(From Gurel S, Sarikaya B, Gurel K, et al. Role of
sonography in the diagnosis of ectopic pregnancy.
J Clin Ultrasoun 2007;35(9):50916; with permission.
Fig. 11 is used.)

common than an ovarian EP, which is less than

1% of all EP.

Abdominal
Abdominal pregnancy is implantation of blastocyst
anywhere within the peritoneum or retroperitoneum. It is very rare, with a varying reported
incidence between 1 in 3372 and 1 in 7931 pregnancies.69 Reported sites for abdominal
pregnancy are pouch of Douglas, posterior uterine
wall, uterine fundus, liver, spleen, omentum, diaphragm, and retroperitoneum.6971 Symptoms
might be quite intriguing when compared with
classical tubal pregnancy. The most common
symptom is severe abdominal pain in which delay
in menstruation or vaginal bleeding can be absent.
In the presence of a negative TVUS, a positive
serum b-hCG, and symptomatology, sonographic
examination should be directed to encompass the
whole abdomen, in populations with or without risk
factors for EP (Fig. 10).

Interstitial
Interstitial pregnancy constitutes 2% to 4% of all
EP. It occurs in the interstitial (intramyometrial)
portion of the fallopian tube. Interstitial EP, as
a term, is sometimes used interchangeably with
cornual EP. However, it would be more

Fig. 10. Abdominal pregnancy. A 40-year-old woman

presented with irregular and minimal amount of
vaginal bleeding and weight gain. An intra-abdominal extrauterine, live 14 weeks gestation fetus
overlooked with transvaginal sonography, is detected
on transabdominal sonography. (From Gurel S,
Sarikaya B, Gurel K, et al. Role of sonography in the
diagnosis of ectopic pregnancy. J Clin Ultrasoun
2007;35(9):50916; with permission. Fig. 4 is used.)

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Gurel
appropriate to use cornual pregnancy for an intrauterine pregnancy implanted in one horn of a septated or bicornuate uterus. In these patients,
pregnancy can continue for a longer period of
time and present with myometrial rupture usually
at the end of first trimester or in the beginning of
the second trimester. Ruptured myometrium leads
to life-threatening hemorrhage. Maternal mortality
is in the range of 2.0% to 2.5%, which is approximately twice that of other tubal pregnancies.72,73
An eccentrically located gestational sac within
the uterine wall (40% sensitivity and 62% specificity) that is surrounded by a thin myometrium (40%
sensitivity and 74% specificity) can be seen on US.
The surrounding myometrium can be either thin
(<5 mm) or absent laterally.48,74 Another finding,
the interstitial line sign(80% sensitivity and
99% specificity) is described as an echogenic
line reflecting the two opposing layers of endometrium seen, not surrounding but just, adjacent to
the gestational sac, owing to an interposing
myometrium between the gestational sac and interstitial line.75 Braxton-Hicks contractions,
cornual pregnancy, and uterine fibroids might
cause misdiagnosis of interstitial EP. Follow-up
TVUS is helpful in detecting the transient nature
of Braxton-Hicks contractions, whereas threedimensional US is reported to help in demonstrating uterine anomalies or fibroids with an eccentric
gestational sac.7679

Cervical
Cervical EP constitutes less than 1% of all EP.80
Implantation occurs within the cervical mucosa,
below the level of the internal os. It presents as
painless bleeding in the first trimester. Preoperative diagnosis of cervical EP is important because,
owing to the lack of cervical contractile tissue,
therapeutic dilatation and curettage (D/C)
frequently leads to excessive bleeding, ultimately

requiring hysterectomy. The differential diagnosis

consists of spontaneous abortion. The most
reliable sonographic finding of cervical EP is
identification of a gestational sac with peritrophoblastic flow or a live embryo within the cervix.
Follow-up scanning allows for differentiation as
well, because in cases of ectopic pregnancy, the
sac does not change in position, whereas in spontaneous abortion the sac shape and position
changes.19 Some secondary sonographic findings, which are not entirely reliable but can be
helpful in the differential diagnosis of cervical EP,
are summarized in Table 1.81

Uterine Scar
A uterine scar pregnancy is a gestation separated
from the endometrial cavity and completely surrounded by the myometrium and the fibrous tissue
of the scar. The suggested mechanism is the
entrance of the blastocyst into the myometrium
through a microscopic dehiscent tract. This tract
can develop from trauma from previous surgeries
such as D/C, myomectomy, metroplasty and Caesarean section (C-section). They are most common in the site of a previous C-section scar.82,83
Vial and colleagues84 suggested two different degrees of implantation. One is implantation of the
amniotic sac on a scar with a progression of the
pregnancy toward the cervico-isthmic space and
uterine cavity; the other is a deeper implantation
in a C-section scar defect. These typically result
in rupture and bleeding during the first trimester.
Although C-section scar EP is known to be the
rarest form of EP, its true incidence is not known
yet, and it is expected to be higher than the
reported cases in the current literature because
of the increasing rate of C-section deliveries all
over the world. The women with placental pathology, ectopic pregnancy, multiple C-section

Table 1
Ancillary sonographic findings of cervical EP and spontaneous abortion
Cervical EP

Spontaneous Abortion

No evidence of intrauterine pregnancy

Minimal uterine enlargement
Closed internal os
Eccentrically located gestational sac
within the endocervical canal
Hourglass-shaped uterus with a ballooned
cervical canal (because of the resistance
in the external os)

Residual placental tissue or fluid in the endometrial cavity

Uterine enlargement beyond the nongravid uterus state
Open internal os
Centrally located gestational sac within the endocervical
canal

Abbreviation: EP, ectopic pregnancy.

Ectopic Pregnancy
surgeries, and Caesarean breech delivery are at
higher risk for C-section scar pregnancy.85
In C-section scar EP, the gestational sac can be
seen in the lower part of the uterine cavity or at the
level of the uterine isthmus. The differential diagnosis is spontaneous abortion in progress in the
former and cervico-isthmic pregnancy in the latter
form.
TVUS combined with color flow Doppler (CFD) is
a reliable tool for early diagnosis of C-section scar
EP.8688 Sonographic imaging criteria are as
follows:
(1) Empty uterine cavity and cervical canal;
(2) A gestational sac in the anterior uterine wall at
the isthmus (presumed site of the previous
lower segment C-section scar);
(3) Absence of healthy myometrium between the
bladder sac, allowing differentiation between
from cervico-isthmic implantation
(4) A negative sliding organs sign, which is
described as the inability to displace the gestational sac from its position at the level of the
internal os with gentle pressure applied by
the endovaginal probe
(5) Evidence of functional throphoblastic circulation on Doppler examination, defined by the
presence of an area of increased peritrophoblastic
vascularity
on
color
Doppler
examination
In the cervical phase of a proceeding spontaneous abortion, an avascular gestational sac, reflecting that the sac has been detached from its
implantation site, is seen in the cervical canal and
easily displaced while applying pressure with transvaginal probe (positive sliding organ sign).88,89

Heterotopic
Heterotopic pregnancy is defined as the simultaneous presence of an intrauterine and ectopic
gestation. Spontaneous heterotopic pregnancy is
rare and occurs in from 1 in 10,000 to 1 in 50,000
pregnancies,90 but its incidence increases with
age and multiparity. On the other hand, the incidence is as high as 1% in women undergoing
assisted reproductive techniques. Particularly in
this population, visualization of an intrauterine
pregnancy is not reliable and adequate to rule
out EP in a symptomatic patient and a careful
search should be performed to look for an ectopic
pregnancy.91

Chronic
Chronic ectopic pregnancy is an independent
entity apart from acutely ruptured ectopic pregnancy. There is still no agreement about the

definition of this condition and its etiology is unknown. The incidence of chronic ectopic pregnancy varies from 6.5% to 84.0% of ectopic
pregnancies, which might be a result of lack of
consensus about its definition.27,92 In most cases,
it is assumed that it is a result of tubal abortion or
ruptured EP in which the hemodynamic insult was
subclinical and self-limited.
It may present with a long period of amenorrhea,
abdominal pain, and a low or negative titer of
b-hCG.92,93 Chronic ectopic pregnancy is usually
diagnosed intraoperatively or histopathologically
because of the paucity of clinical and laboratory
findings. Operative findings consist of an adnexal
mass with a significant amount of adhesions
incorporating uterus, bowel, or the contralateral
adnexa. Histopathologically, it presents a delayed
involutional process, because of intraluminal retention of extensive blood clot with inflammation
and necrotic hyalinized or degenerated ghost chorionic villi.94,95 There is not much data concerning
the abdominal or transvaginal sonographic findings of chronic EP. Reported transabdominal US
findings are
(1) An extrauterine complex mass occupying the
adnexa uni- or bilaterally and cul-de-sac with
a considerably varying ratio of cystic-solid
components. Variations in the echo patterns
might represent hematoceles consisting of liquid blood, fresh clot, organized hematoma and
adhesions96
(2) Fluid in the cul-de-sac97
(3) Normal in 9% of chronic EP96

TVUS findings are similar to transabdominal US

findings including an extrauterine complex mass
occupying one or both adnexa or cul-de-sac accompanied with an empty uterus and simple or
particulate fluid in the cul-de-sac/pelvis.27
Doppler findings are quite sparse in the literature
demonstrating no blood flow within or in the
periphery of the complex mass or extensive
vascularization, aberrant vessels, arteriovenous
shunting without an internal blood flow.27,95
The sonographic pattern of chronic EP is similar
to pelvic inflammatory disease, endometrioma,
leiomyoma, complex ovarian cyst and ovarian neoplasm and although definitive diagnosis is mostly
operative and histopathological, a combination of
absence of intrauterine gestation, low titers or absence of serum b-hcG, and an extrauterine mass
can be helpful in the diagnosis of chronic EP. On
the other hand, in the absence of b-hCG, differential diagnosis consists of a wide spectrum of
adnexal and other pelvic pathologies.

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Gurel
Persistent
Persistent EP can be defined as the presence of
residual trophoblastic tissue after surgical management of tubal pregnancy. It is commonly seen
following conservative management with salpingostomy or fimbrial expression.98,99 Women with
a small ectopic pregnancy, less than 8 mm in
diameter, detected by preoperative US are at
high risk of developing or remaining residual trophoblastic tissue. It should be suspected in all patients with elevated or plateauing serum b-hCG
levels 1 week after management of an ectopic
pregnancy. Its management is based on symptomatology and follow-up serum b-hCG levels.100
In conclusion, when combined with serum
b-hCG level, ultrasonography is the only and
most effective radiologic modality in diagnosis of
EP. Although transvaginal approach has brought
high-resolution imaging of uterus and adnexa,
complementary use of transabdominal ultrasonography should be performed whenever possible. Three-dimensional imaging US, which is
quite new in routine practice, compared to threedimensional imaging in CT and MR imaging, is
continuing to evolve and it might bring new facilities in overcoming some limitations of todays
sonographic display formats.

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review. Curr Surg 2000;57(5):48492.
2. Centers for Disease Control. Current trends in
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