J Clin liltrasound 18:274-279, May 1990

Criteria for Transvaginal Sonographic

Diagnosis of Ectopic Pregnancy
Shraga Rottem, MD, DSc, Israel Thaler, MD, Jacob Levron, MD,
Bezalel A. Peretz, MD, Joseph Itskovitz, MD, DSc,
and Joseph M. Brandes, MD

Abstract: Transvaginal ultrasonography was performed in 1150 patients suspected

of having an ectopic gestation. The criteria for transvaginal sonographic diagnosis of
ectopic pregnancy were established by targeted scanning of the pelvic organs and
spaces. Sonographic assessment of tubal pregnancy and its differential diagnosis were
based on six criteria: (1)the presence or absence of gestational structures within the
fallopian tube, (2) the presence or absence of amorphous material in a dilated fallo-
pian tube, f3) the presence or absence of indirect signs of ectopic pregnancy within the
pelvis, ( 4 ) the echogenicity of a suspected finding relative to the ovary, ( 5 ) the pres-
ence or absence of flow (of lacunar origin) within the suspected sonographic finding,
and 16) the relationship of a suspected sonographic sign to an intentionally displaced
ovary. The latter 3 criteria help differentiate between tubal gestation and a corpus
luteum. We believe these diagnostic criteria should be applied when performing
transvaginal sonographic scanning of patients suspected of having an ectopic gesta-
tion. Indexing words: Ectopic pregnancy, diagnosis of * Transvaginal sonographic
criteria

Despite impressive advances in the technology of
ultrasound imaging achieved by many manufac-
turers, the traditional abdominal probes offer
limited and in many instances delayed informa-
tion on ectopic pregnancy. When scanning pa-
tients suspected of having an extrauterine gesta-
tion, ultrasonography can contribute to a final
diagnosis mainly by “ruling in” an intrauterine
pregnancy. Under certain conditions, e.g., gesta-
tion less than 5 weeks to 6 weeks or vaginal
bleeding, the sonographic examination may not
provide any useful information on the uterine
content. Under other circumstances, such as in
patients with an ectopic pregnancy, the decidual
reaction, possibly trapping some blood, may dem-
onstrate a small ring-like structure- the
pseudo-gestational sac-and erroneously indi-
cate an ongoing intrauterine gestation.
The direct diagnosis of ectopic pregnancy
From the Department of Obstetrics and Gynecology, Ram-
barn Medical Center, and Faculty of Medicine, Technion-Is-
rael Institute of Technology, Haifa, Israel. For reprints con-
tact S. Rottem, MD, DSc, Department of Obstetrics and Gy-
necology, Rambam Medical Center, Haifa, Israel 31096.
274
based on sonographical findings is possible only
when fetal echoes or heart motion are detected
outside the uterine cavity (5% to 10% of the
cases). Of the remaining cases indirect signs
such as an adnexal ring or mass, free fluid in the
cul-de-sac, and an empty uterus will suggest an
ectopic implantation, especially if the p human
chorionic gonadotropin (P-hCG) level is greater
than 6000 mIUimL. Although the combined use
of ultrasonography together with determination
of P-hCG level were reported to improve diagnos-
tic accuracy, this would be applicable only in
17% of the patients, based on this discriminatory
zone. In a recent study’ the distribution of men-
strual ages at the time of surgery in 1985 was
observed t o be similar to that in 1975. This casts
doubt on the often-cited opinion of earlier diag-
nosis that was attributed to the introduction of
these procedures. The vaginal probes, now
widely available, are undoubtedly changing the
scene in gynecological practice in general and in
the workup of the ectopic pregnancy in particu-
lar.2
High-frequency transvaginal probes (e.g., 6.5
MHz to 7.5 MHz) with their better resolution
0 1990 by John Wiley & Sons, Inc.
CCC 0091-2751190104274-06 $04.00
 DIAGNOSIS OF ECTOPIC PREGNANCY 275

generate higher quality images than the tradi- ent characteristic pattern^.^ The first depends on
tional 3.5-5 MHz abdominal probes. The im- the capability of TVS to recognize gestational
proved images obtained involve all the target or- structures within the fallopian tube using the
gans and spaces which are scanned in the same criteria as in an intrauterine pregnancy.
workup of ectopic pregnancy.3 A systematic ap- Therefore one may rely upon the detection of
proach to the diagnosis and treatment of ectopic structures such as gestational sac, yolk sac, and
pregnancy based on the use of the transvaginal embryo within the fallopian tube when making
probe is presented after three years experience the diagnosis (Figures 1-3). According to our ex-
with 1150 patients suspected of having this pa- perience, in nearly 50% of the diagnosed tubal
thology. pregnancies one or more embryonic or extraem-
bryonic structures could be detected by the high-
frequency transvaginal probe. Moreover, fetal
TARGETORGANSANDSPACES
heartbeats were observed in nearly 23% of the
diagnosed tubal pregnancies. The second pattern
The Uterus is based on the recognition of a fallopian tube
The detection of an intrauterine gestational sac containing a n amorphous content. At surgery
can be achieved by the high-frequency transvag- this content was found t o be composed of blood,
inal probes as early as 16 days to 19 days after blood clots, and gestational material. This pat-
conception. The serum P-hCG level at this time tern was observed in nearly 40%) of the diag-
was found in our institution to range from 385 nosed tubal pregnancies. In about 10% of the di-
mIU/mL to 700 mIU/mL (First International agnosed tubal pregnancies, the diagnosis was
Reference). However, the detection of any given based on indirect signs such as an empty uterus,
early pregnancy structure may differ tempo- a positive serum p-hCG test, and detection of
rarily under the following conditions: blood andlor blood clots i n the cul de sac (the
1. Pronounced anteversion of the uterus. third pattern).
2. The presence of myomas, which may delay the
detection of the gestational sac by a week.
3. The gestational sacs of a multiple pregnancy Scanning the Cul-de-sac
may be detected sequentially a t one or two When a gestational sac is not detected within the
days intervals, while obvious deviation of the uterine cavity and the scan of the adnexae offers
serum p-hCG levels should also be considered no additional information, one should proceed to
in such cases. the examination of the cul-de-sac. Even small
The occurrence of a combined intrauterine and
extrauterine pregnancy is an extremely rare
event in the general population (1:30,000), but
this risk increases in the in vitro fertilization
programs where transfer of more than one em-
bryo is p e r f ~ r r n e d .Therefore
~.~ a thorough exam-
ination of the adnexa has to be undertaken in
this population, despite the presence of an in-
trauterine sac. When using abdominal probes,
one may find it difficult to differentiate a pseudo-
gestational sac from a true gestational sac. Us-
ing transvaginal sonography (TVS) these echoes
were found to originate from local blood clots or
from a central sonolucent area outlined by a
thick endometrium. If an intrauterine gestation
cannot be identified, one should proceed to scan
the fallopian tubes.

The Fallopian Tubes

The fallopian tube may be identified if outlined
by fluid or if its lumen contains a fluid phase
(e.g., a gestational sac).' The recognition of tubal
pregnancy by TVS can be based on three differ-
FIGURE 1. Cross-section of the Fallopian tube containing a 5 mm
gestational sac at 5 weeks from the first day of the last menstrual
period (LMP). (U, uterus; 0, ovary.)

VOL. 18, NO. 4, MAY 1990

276
amounts of free blood or blood clots are readily
detected by the high-frequency transvaginal
probe. Blood clots appear as bizzarre-shaped
floating structures that move about as the posi-
tion of the probe or the patient changes (Figure 4).
Nontubal Ectopic Pregnancy
Detection of an ectopic pregnancy in other sites
than the fallopian tube is a challenge for sonog-
raphers even when using the transvaginal probe.
Cornual pregnancy may not be directly recog-
nized because there is no unique discernable ab-
normal feature and/or clotted blood in the cul-de-
sac. This is especially the case in a ruptured cor-
nual pregnancy. The sonographic diagnosis of
cervical pregnancy is facilitated by the proximity
of the probe to the area of interest. The implan-
tation of the chorionic vesicle within the cervical
canal should be strongly suspected when a gesta-
tional sac is detected in this site (Figure 5a),
without involvement of the corpus uteri, which
only exhibits the appropriate decidual reaction
(Figure 5b).
While the available literature does not yet de-
scribe the TVS diagnosis of ovarian pregnancy,
this pathology is potentially diagnosable. The
ovary can be readily seen and if any of the gesta-
tional structures are detected within its paren-
chyma the diagnosis would be established.
FIGURE 2. Cross-section of the Fallopian tube containing a 5 m m gestational sac and a yolk sac of 5 m m at 5
weeks and 3 days from the first day of the LMP.The ovary ( 0 )is also shown. Note the more echogenic
appearance of the tubal wall compared t o the ovarian parenchima.
ROTTEM ET AL.
An abdominal and intraligamentous preg-
nancy may not be detected at all using a high-
frequency transvaginal probe due to the short fo-
cal length of this device (see the section on limi-
tations).
DIFFERENTIAL DIAGNOSIS
Corpus Luteum
Images of many pelvic structures may mimic an
ectopic pregnancy but if there is one structure
that can be misdiagnosed as a tubal gestation,
the corpus luteum of pregnancy is the one! The
corpus luteum may exhibit “many faces” such as
a ring-like structure with or without internal
echoes, similar to the fallopian tube containing
the gestational sac or blood clot. Three useful
features differentiate a corpus luteum from a tu-
bal gestation.
The first is that the ovarian parenchyma is less
echogenic than the tubal gestation (see Figure 2).
In vitro comparison of fallopian tubes containing
a gestational sac with normal ovaries showed
that the more echogenic image of the fallopian
tube is due to the presence of the placental mate-
rial.
The second observation is that tubal gestations
with a demonstrable yolk sac and an embryo
show a peculiar flow within the lacunar
JOURNAL OF CLINICAL ULTRASOUND
 DIAGNOSIS OF EC'rOPIC PREGNANCY
FIGURE 3. Cross-section of the Fallopian tube showing the gesta-
tional sac and a 1.1 c m embryo at 7 weeks and 3 days from the first
day of the LMP. The cephalic pole (arrow), the upper limb buds and
the embryonal trunk can be seen.
structures of the ectopic implanted placenta. This
flow is readily demonstrable by increasing the
frame rate and by disabling filters (such as
frame average). In this case transvaginal sonog-
raphy will display the trophoblastic circulation
as a tubal lacunar flow that will not appear if the
probe is directed toward a corpus luteum.
T h e third means o f differentiation is that by
pushing the questionable finding manually or
with the probe while maintaining the angle, the
entire ovary with its bulging corpus luteum is
displayed. I n case of a n ectopic gestation the ring-
like structure of the tubal pregnancy will slide be-
side the ovary while being distinctly separated
f r o m it. When in doubt, one should apply the cri-
terion dealing with the different echogenicity
between the tubal placenta and the ovarian pa-
renchyma.
Graafian Follicle
This structure has a wall thinner than that of
the tubal ring and it is typically found within
the ovary, adjacent to similar structures of dif-
ferent size (i.e., other follicles).
The Small Bowel
A cross section of a loop of the small bowel may
mimic a tubal ring and fecal material may
VOL. 18, NO. 4, M A Y 1990
277
FIGURE 4. A blood clot (C) and free blood in the cul-de-sac. (U,
uterus.)
mimic a tubal gestational content. However,
close observation usually reveals peristalsis of
the small bowel.
Other Tuba1 Pathology
A cross section of a hydro- or pyosalpinx may
also mimic the tubal ring. However, the pus usu-
ally forms two distinct echogenic levels while the
inflammed endosalpinx typically protrudes into
the tubal lumen.
Nabothian Cyst
The novice sonographer may interpret a cervical
gland as an ectopic gestational sac. This struc-
ture is usually centrally located, far from the ad-
nexa, and it is better visualized when the vagi-
nal probe is withdrawn 2 cm t o 3 cm.
LIMITATIONS
A prudent approach to the management of ec-
topic pregnancy should take into consideration a
number of limitations of TVS in the workup of
this condition. The main limitation is the risk of
obtaining a false positive diagnosis due to misin-
terpretation of one of the variants of the corpus
luteum. A false negative diagnosis may be made
in the case of an ectopic gestation that is located
outside the true pelvis or in the event of very
small tubal gestation.
Nearly a third of the false negatives in our se-
278
FIGURE 5. (A1 Cross-section of the cervix showing a gestational sac (arrows) still implanted in the cervical channel. Note the prominent param-
etria. (6) Longitudinal scan of the corpus uteri showing an empty endometrial cavity and decidual reaction (arrows). Fractional D & C and histo-
pathological examination confirmed the diagnosis of cervical pregnancy
ries were tubal pregnancies located outside the
true pelvis while the remaining cases were small
ampular pregnancies that were smaller than
than 1 cm. One of these small tubal pregnancies
was missed both by TVS and at laparotomy be-
cause both procedures were performed at a very
early menstrual age. The tubal gestation contin-
ued its natural course and the patient was
treated with intrasmucular methotrexate in or-
der to avoid a second surgical intervention. Two
weeks after the first laparotomy the patient had
a second laparotomy due t o rupture of the tube
and an intraperitoneal bleeding. One should also
be careful in evaluating the amount of the intra-
abdominal bleeding by TVS. The Douglas pouch
is only one of the spaces into which the free blood
may go, and the presence of a moderate amount
of free blood in this compartment may be associ-
ated with the presence of a much larger quantity
of blood (up to sixfold) in other locations.
When massive bleeding and clotting occurs,
the vaginal probe will detect the free blood and
part of the clots, but accurate assessment of the
blood loss is impossible.
THE ROUTINE DIAGNOSTIC WORKUP
Based on our three years’ experience, TVS can be
incorporated into the routine diagnostic workup
of patients suspected of having an ectopic gesta-
tion. There is no need for special patient prepa-
ration. As expected, many patients will demon-
ROTTEM ET AL.
strate an intrauterine gestation, while in others
no sign of either intrauterine or extrauterine
pregnancy may be present. In about 13% of the
patients suspected of having a tubal gestation,
TVS will diagnose one of the three types of ec-
topic pregnancy. In the diagnostic process, one
should consider the timing of the examination,
the serum level of P-hCG and the natural dy-
namics of an early gestation.
When confronted with a low level of p-hCG
and no positive findings on TVS, it is imperative
to perform a subsequent scan. If TVS is per-
formed too early one could miss a normal intrau-
terine gestation. On the other hand, low levels of
P-hCG may herald an abnormal condition such
as an early ectopic gestation, where an abnormal
hormonal pattern may further complicate the
situation. Most of our false negative cases had a
very low P-hCG level. Patients with high levels
of P-hCG and no evidence of an intra- or extrau-
terine gestation at the TVS examination may
not need an additional sonographical evaluation.
Most of these cases will eventually be diagnosed
as having- a complete or incomplete intrauterine
abortion by clinical, biochemical or histological
follow-up.
TVS-AIDED THERAPY
Transvaginal sonographically aided therapy of
tubal pregnancy was recently suggested by vari-
ous authors. Instillation of methotrexate into the
JOURNAL OF CLINICAL ULTRASOUND
 DIAGNOSIS OF ECTOPIC PREGNANCY
tubal gestation is one example.8 In this method,
the antimitotic potential of this agent is ex-
ploited t o hamper the growth of the ectopic ges-
tation. Other authors describe the injection of
KCl into the tubal sac.' A simple aspiration of
the gestational sac can also be attempted. All
these procedures should be followed by serial de-
termination of p-hCG levels," by repeated sono-
grams, and by clinical evaluation. Bleeding or
rupture of the ectopic gestation may occur fol-
lowing these procedures, therefore careful obser-
vation is needed.
CONCLUSIONS
The availability of quantitative P-hCG and the
latest sophistication of ultrasound technology
have made possible the noninvasive early diag-
nosis of ectopic pregnancy. The major goal is
early intervention, prior to substantial tubal
damage. Because high-frequency TVS enables
recognition of this disease at its early stages, cli-
nicians should rely on this method with higher
confidence compared to its transabdominal coun-
terpart. Today, in many departments, TVS has
become a first-line diagnostic test for any patient
who is suspected or having an ectopic pregnancy.
10. Adoni A, Mildwidsky A, Hurvitz A, et al: Declin-
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