Ultrasound with Ectopics | HaleQad Ultrasound Training Solution

 

Ultrasound in Ectopic Pregnancy: A Complete Diagnostic Guide

Ectopic pregnancy is a critical obstetric condition where the fertilized ovum implants outside the uterine cavity. It accounts for 1-2% of all pregnancies and remains one of the leading causes of first-trimester maternal mortality. Early diagnosis is essential to prevent life-threatening complications. Ultrasound imaging, especially transvaginal sonography (TVS), plays a central role in timely detection, diagnosis, and management.

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🔍 What is an Ectopic Pregnancy?

An ectopic pregnancy occurs when a fertilized egg implants outside the endometrial lining of the uterus. The fallopian tube is the most common site (around 95%), but other rare implantation sites include:

• Interstitial (cornual) region

• Ovary

• Cervix

• Abdominal cavity

• Cesarean section scar

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🧾 Clinical Symptoms of Ectopic Pregnancy

Patients may present with:

• Missed period (amenorrhea)

• Lower abdominal or pelvic pain

• Abnormal vaginal bleeding or spotting

• Shoulder tip pain (suggests diaphragmatic irritation from intra-abdominal bleeding)

• Dizziness or syncope (in ruptured ectopics due to internal bleeding)

⚠️ Note: Some cases may be asymptomatic, or mimic normal pregnancy or miscarriage.

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🧪 Correlation with Serum β-hCG

• In a normal intrauterine pregnancy, a gestational sac should be seen on TVS when β-hCG > 1500-2000 mIU/mL (discriminatory zone).

• If β-hCG is above this range and no intrauterine sac is visible, ectopic pregnancy must be suspected.

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🖥️ Role of Ultrasound in Ectopic Pregnancy

🔹 Transvaginal Ultrasound (TVS)

• Gold standard for early diagnosis

• Provides high-resolution images of uterus, adnexa, and pelvic structures

• Can detect early ectopic gestations and signs of rupture

🔹 Transabdominal Ultrasound (TAS)

• Useful when TVS is not possible or in advanced gestation

• Helps visualize free fluid in upper abdomen (e.g., Morrison’s pouch)

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📸 Ultrasound Findings in Ectopic Pregnancy

1. Empty Uterus

• No gestational sac in the uterine cavity despite elevated β-hCG

• May occasionally see pseudogestational sac (central fluid collection without double decidual sign)

2. Adnexal Mass

• Most common and reliable sign

• Types:

  • Tubal ring: Hyperechoic ring with echolucent center in adnexa

  • Non-specific complex mass

  • Live extrauterine embryo: Confirmatory of ectopic pregnancy

3. Free Fluid

• Anechoic or echogenic fluid in:

  • Pouch of Douglas (cul-de-sac)

  • Morrison’s pouch

• Suggests ruptured ectopic with hemoperitoneum

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📍 Ultrasound Appearance Based on Ectopic Location

Type	Ultrasound Features
Tubal	Adnexal mass with/without yolk sac or fetal pole; often with ring of fire
Interstitial	Gestational sac in upper uterine corner; surrounded by thin myometrium
Cervical	Sac in cervical canal; absence of sliding sign
Ovarian	Gestational sac within ovary, with ovarian cortex surrounding
Scar Ectopic	Sac located in previous cesarean scar; may show deep implantation in anterior myometrium

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❓ Differential Diagnoses on Ultrasound

• Early intrauterine pregnancy

• Incomplete miscarriage

• Corpus luteum or hemorrhagic cyst

• Pseudogestational sac

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⚙️ Management Strategies Based on Ultrasound

Findings	Recommended Management
No IUP with β-hCG > 2000	Repeat β-hCG + follow-up scan or diagnostic laparoscopy
Adnexal mass without rupture	Methotrexate (if stable and criteria met)
Viable ectopic with heartbeat	Surgical intervention (laparoscopy preferred)
Free fluid + unstable vitals	Emergency surgical exploration
Pregnancy of unknown location (PUL)	Serial β-hCG and repeat ultrasound

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🧠 Key Points for Sonographers and Clinicians

• Always correlate β-hCG values with ultrasound findings.

• In women of reproductive age with pain and bleeding, always rule out ectopic.

• Use TVS as first-line, especially in early gestation.

• Recognizing atypical ectopic sites like scar or abdominal is vital.

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