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EVALUATION OF ECTOPIC GESTATION

 Commonest clinical presentation of ectopic pregnancy occurs at a mean of 7 weeks

after the last normal menstrual period, with a range of 5 to 8 weeks

Clinical Presentation
Three basic clinical presentations-
 Early
 Mid
 Late

Early Presentation
Early symptoms are either absent or subtle.
1.Overdue periods by 1-2 weeks with bleeding PV usually mild.
2.Pain
3.Tenderness

1.Vaginal bleeding:Usually mild.

 Ectopic pregnancy ---falling levels of progesterone from the corpus luteum on the
ovary cause withdrawal bleeding.
 Can be indistinguishable from an early miscarriage or the 'implantation bleed' of a
normal early pregnancy
 Endometrium is usually thick due to decidual reaction

2. Pain ---May be present or absent.

 Pain may be confused with a strong stomach pain, it may also feel like a strong cramp
 Pain while urinating
 Pain and discomfort, usually mild. A corpus luteum in the ovary in a normal
pregnancy may give very similar symptoms. .
 Pain while having a bowel movement

3. Tenderness--
 On TVS , forniceal tenderness is commonly present when the probe is pressed against
the area of location of the sac.

Mid presentation
 Commonly with 2-4 weeks overdue periods
 Pain may be variable.
 At times it may be very severe with fainting attacks & the patient may even come in
shock. However the pain may be similarly confused with stomach pain or pain due to
urinary infection.
 Bleeding may be continuing for a number of days & as such the endometrium may be
thick or thin.
 Thinning of endometrium may be when a lot of endometrium has been shed due to
bleeding.

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Late (Chronic)
 Lower abdominal pain commonly present but usually not very severe & in some it
may be even absent.
 At times there may be a referred pain eg: when the ectopic mass is pressing on the
ureter it may cause ureteric colic with hydronephrosis.
 Shoulder pain may be present in both mid & late ectopics and is due to free blood
tracking of the abdominal cavity.
 Clinically patients of chronic ectopic usually do not have fever ,however mild fever
may be seen in some cases.
 H/O complete ammenorrhoea is usually less common and more comonly h/o irregular
bleeding since 2-5 months is seen.
 Endometrium is usually not thickened.

Sonographic presentation in ectopic-Early cases

 In very early cases a small sac is seen outside the uterine cavity with or without fetal
node or yolk sac.
 The margins of the sac are thick with echogenicity equal to or more than that of
endometrium.
 Endometrium is thick and uterine cavity is empty.
 <10% cases have a pseudosac.
 Fluid is usually mild with internal echoes

Ectopic sac-Thick echogenic ring(arrow)

TVS-Ectopic sac(arrow) & thick endometrium(E). TVS-Ectopic sac (arrow head) with yolk
U-Uterus sac(arrow)

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TVS-Hemorrhagic fluid(F) with thick endometrium(arrow

Pseudosac v/s true sac

 Pseudo sac is fluid collection in the uterine cavity which may be anechoic or have
internal echoes of blood or decidual cast.
 It is tubular unlike a true sac which is more rounded or oval.
 Pseudosac commonly occupies a larger portion of uterne cavity unlike a true sac.
 At times, when the true sac is abnormal and is in the process of abortion it may also
become tubular.
 If yolk sac or fetal node are seen within the sac it confirms the diagnosis of intra-
uterine true sac.
 However in the absence of yolk sac or fetal node presence of “double decidual ring
sign” is useful in differentiaition.

TVS-Pseudo sac(arrows) M-chronic ectopic mass

Double Ring
While presence of double ring is diagnostic of IUP ,absence does not rule out IUP since in
later cases it may be obliterated.

Mid cases
 When presenting with features of shock, hemorrhagic peritoneal fluid having internal
echoes is usually moderate to marked.
 A gestational sac is commonly lying within the fluid and may sometimes be difficult
to visualize.

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TVS showing ectopic sac.e-endometrium TVS showing ectopic sac.Fl-fluid

TVS showing marked hemorrhagic fluid collection in pelvic peritoneal cavity (BL)

Late cases
 Masses are usually big having oval appearance, commonly lying close to midline &
ileopsoas muscle.
 Major part of the mass is comprised of blood clots in varying stages giving a
hetrogenous texture to the mass with only a small area occupied by the sac.
 Sac may or may not be located within the mass.

Chronic ectopic mass (arrowheads). Chronic ectopic mass (M) with

U-Uterus pseudosac(arrows)

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Fluid in the peritoneal cavity

 It is present in almost all types of ectopic.
 Early ectopics may have fluid localized only in the pelvic cavity and may be mild
while in later stages, it may be seen in various locations of upper abdomen like
Morrison's pouch and perihepatic space.

Mild fluid--Differentiation from other causes

Even a normal intra-uterine pregnancy in very early stage may have mild fluid in the
pelvic peritoneal cavity.This fluid however does not have the internal echoes which are
usually seen in cases of ectopic.Internal echoes are better visualized on TVS.
Additionally ,other features may help in differentiation:
--Visualization of ectopic sac
--If intra-uterine pregnancy sac is seen then the fluid is rarely due to ectopic (since
heterotrophic pregnancy is rare)
---The most common misdiagnosis assigned to early ectopic pregnancy is PID.
--The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare
to find pregnancy with an active Pelvic Inflammatory Disease (PID).

D/D
Ruptured Corpus Luteum Cysts
 Here the pain may or may not be associated with overdue periods.
 When periods are not overdue, the confusion with ectopic does not arise. If doubts
still exist, UPT may be done which will be negative.
 With overdue periods and positive UPT hemorrhagic corpus luteum cyst will be
associated with an IUP.
 In very early IUP when sac is not seen and only thick endometrium is present, a
follow up scan may be done after 3-4 days to see for presence of sac
 .Although fluid may be seen in both, in ectopic internal echoes are almost always seen
while in ruptured corpus luteum cyst the fluid may or may not have internal echoes.
 In ectopic a sac may be seen lying outside the ovary while ruptured corpus luteum
will be seen as irregular area within the ovary.
 In case, when ectopic sac is lying within the tube but close to the ovary and confusion
occurs with an eccentrically located CL cyst ,following may be helpful:
 1.Sliding sign—which will show sac to move away from ovary.
 2.Claw sign—A C-shaped area of ovarian tissue may be seen around an eccentric CL
cyst while in ectopic sac no such area will be seen

Other D/D-
 Appendicitis
 Other gastrointestinal disorder
 Problems of the urinary system
 Pelvic Inflammatory disease
 Other gynaecologic problems

Institute Of Ultrasound Training, New Delhi, India