ª Springer Science+Business Media New York 2017 Abdom Radiol (2017) 42:1524–1542
Abdominal Published online: 31 January 2017
Radiology
Pitfalls and tips in the diagnosis of ectopic
pregnancy
E. Mausner Geffen , C. Slywotzky, G. Bennett
Department of Radiology, NYU Langone Medical Center, 550 1st Avenue, New York, NY 10016, USA
Abstract
Women of reproductive age with pelvic pain, vaginal
bleeding, and a positive pregnancy test often require
evaluation with pelvic ultrasound. In these situations, the
primary role of pelvic ultrasound is to differentiate an
ectopic pregnancy from either a normal or abnormal
intrauterine pregnancy. While an accurately performed
and interpreted pelvic ultrasound results in rapid diag-
nosis and management, numerous diagnostic pitfalls can
lead to negative outcomes. Therefore, familiarity with
the appropriate laboratory tests, sonographic technique,
and imaging features of ectopic pregnancy is essential for
all radiologists. We present a review of ectopic pregnancy
cases from our institution with attention to common
pitfalls and troubleshooting tips for physicians who
perform and interpret pelvic ultrasounds. We also pre-
sent recently published literature to aid in the manage-
ment of first trimester pregnancy.
Key words: Ectopic pregnancy—Pregnancy of unknown
location—Human chorionic gonadotropin (HCG)
Ectopic pregnancy is an increasingly common occur-
rence reported in approximately 1.5–2.0% of all preg-
nancies [1]. Since ruptured ectopic pregnancy accounts
for 6% of pregnancy-related deaths and is the leading
cause of first trimester maternal death, early perfor-
mance and accurate interpretation of pelvic ultrasonog-
raphy are essential [1, 2]. In this review, we demonstrate
the various types of ectopic pregnancies and the associ-
ated ultrasound findings, common diagnostic imaging
pitfalls, and indications for further imaging with 3D
ultrasound or dedicated MRI of the pelvis (Fig. 1).
Correspondence to: E. Mausner Geffen; email: evm221@nyumc.org
DOI: 10.1007/s00261-016-1020-4
General principles
Obtaining a history
When screening patients for possible ectopic pregnancy,
it is important to document a complete history and
physical examination, including the patient’s last men-
strual period (LMP). Particular attention should be paid
to risk factors associated with ectopic pregnancy such as
pelvic inflammatory disease, endometriosis, smoking,
presence of an intrauterine contraceptive device, use of
assisted reproductive techniques (ART), and a history of
prior ectopic pregnancy [2]. In addition to past medical
and reproductive history, a thorough surgical history
including prior tubal surgery, dilatation and curettage
(D&C), and Cesarean sections should be addressed [2].
However, it should be remembered that approximately
fifty percent of ectopic pregnancies occur in patients
without any clear risk factors [1].
Tip Patients may be unaware of pertinent details or
may not be forthcoming with sensitive information, and
therefore clinical suspicion for ectopic pregnancy should
not be dismissed in the absence of historical data.
Nonspecific lower abdominal/pelvic pain
The evaluation of a female patient with abdominal or
pelvic pain often begins with a broad differential. We
urge clinicians to consider, and evaluate the possibility
of, ectopic pregnancy in all women of reproductive age.
This includes women with a known history of gyneco-
logic pathology as well as teenage girls who present with
right lower quadrant pain in whom alternative diagnoses
such as appendicitis are favored. Because of the potential
danger of a delayed diagnosis and rupture of an ectopic
pregnancy, a urine pregnancy test (qualitative beta-hu-
man chorionic gonadotropin test) should be obtained
prior to cross-sectional imaging with MRI or CAT scan.
In cases with a positive beta-human chorionic gonado-
tropin (beta-HCG), a pelvic ultrasound should always be
the initial test of choice. Thus, early beta-HCG testing
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 1. Diagram summarizing the possible locations where ectopic pregnancies may occur.
helps guide physicians to the best imaging test, and can
potentially avoid inappropriate imaging (Figs. 2, 3).
Tip In women with right lower quadrant pain and a
positive beta-HCG, the first imaging test performed
should be a pelvic ultrasound to rule out ectopic preg-
nancy even in cases where appendicitis was the original
leading diagnosis. A graded compression ultrasound of
the right lower quadrant can be performed simultane-
ously with a pelvic ultrasound to look for appendicitis.
Beta-HCG values—what do they mean?
When interpreting a quantitative beta-HCG value, it is
essential to know the reference range and laboratory
preparation used at a given institution. In general,
transvaginal ultrasound is capable of detecting an
intrauterine pregnancy (IUP) when the quantitative beta-
HCG level is greater than 2000 mIU/mL (discriminatory
zone, Third International Standard); however, physi-
cians should be aware that three different reference
ranges exist [3]. The three standards, referred to as the
First, Second, and Third International Standard (IS),
1525
respectively, may cause confusion if they are compared
to one another. Additionally, the discriminatory zone
will vary based on the beta-HCG assay used [3]. While
much of the older literature on the discriminatory zone
was written using the Second IS, most hospitals are
currently using the Third IS. The conversion between the
two systems is as follows: Second IS 91.8 = Third IS.
Of note, the Third IS was originally referred to as the
First International Reference Preparation (IRP) and
these two terms may be used interchangeably.
Tip Always make sure that the beta-HCG discrimi-
natory zone reference range being used is correct for your
laboratory preparation as values can vary across insti-
tutions.
Qualitative vs. quantitative beta-HCG
and trending the beta-HCG level
A commonly encountered problem in the clinical setting
occurs when only the qualitative beta-HCG (i.e., the
urine pregnancy test) is positive, but there is no quanti-
tative beta-HCG blood test available at the time of
1526 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
ultrasound interpretation. In this situation, an indeter-
minate ultrasound showing that there is no ectopic
pregnancy or IUP visualized is of unclear significance.
Fig. 2. Teenage female presented to ED with abdominal
pain and a CT scan was performed to evaluate for appen-
dicitis. Beta-HCG found to be positive only after the CT scan
was performed. Axial CT with oral contrast demonstrates
heterogeneous complex fluid collection and hemorrhage in
the pelvis with a left adnexal mass (arrow). At surgery, this
was found to represent a ruptured ectopic pregnancy. Normal
appendix (not shown).
Fig. 3. 34-year-old female with known uterine fibroids was
referred to MRI for lower abdominal pain and continuous
uterine bleeding for one month. MRI was intended for surgical
planning prior to myomectomy. Axial T2 TSE image demon-
strated a right adnexal mass (white arrow) separate from the
With only a qualitative result, it is unknown whether the
beta-HCG value is above the discriminatory zone and in
a range where an IUP could reliably be identified [4].
When this occurs, radiologists should request a quanti-
tative beta-HCG blood test; if the quantitative beta-
HCG value is below the discriminatory zone, close fol-
low-up with serial beta-HCGs and ultrasounds is re-
quired to determine pregnancy viability.
A second common problem is seen when patients
present emergently with a single isolated beta-HCG va-
lue. The difficulty in this scenario is that an indetermi-
nate ultrasound in a patient with a single beta-HCG
value above the discriminatory zone (in one series as high
as 4336 mIU/mL Third IS) does not preclude an IUP [5].
As such, a similar conservative management strategy
with serial beta-HCGs and ultrasounds should be em-
ployed in a stable patient with a desired pregnancy, as
per the recommendations of the Society of Radiologists
in Ultrasound (SRU). [6].
A common misconception is that ectopic pregnancies
are only visible when the beta-HCG level is above the
discriminatory zone of 2000 mIU/mL. This is dangerous
as either high or low beta-HCGs can be seen at the time
of diagnosis of an ectopic pregnancy (Fig. 4). In fact,
more than 50% of patients with a visible ectopic preg-
nancy on ultrasound have a beta-HCG less than
2000 mIU/mL [7].
Tip Though a pelvic ultrasound is unlikely to
demonstrate an IUP if the beta-HCG is below the dis-
criminatory zone, a low beta-HCG should not deter
ovary (black arrow) (A). Post-contrast T1 GRE images (con-
trast was given as the patient was not known to be pregnant)
demonstrated peripheral enhancement in the adnexal mass
(B). Surgical pathology revealed a right adnexal ectopic
pregnancy.
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 4. 41-year-old female with a beta-HCG of 1330 mIU/mL
who presented with vaginal bleeding. Transvaginal ultrasound
showed a heterogeneous left adnexal mass (calipers) with
associated hemoperitoneum, which was suspicious for a
ruptured tubal ectopic pregnancy. This diagnosis was con-
firmed at surgery.
performance of a pelvic ultrasound if there is a concern
for an ectopic pregnancy. Ectopic pregnancies are often
visible when the beta-HCG is well below the discrimi-
natory zone.
Tip Not all ectopic pregnancies require immediate
medical or surgical management. Watchful waiting may
be the best course of action for a stable patient with a low
beta-HCG level (£200 mIU/mL) that is down trending
[8].
Sonographic technique
Approach
Choosing the scanning approach is the first step in a
properly performed pelvic ultrasound examination. We
have found that it is a common mistake for practitioners
to rely solely on transvaginal ultrasound (TVUS) in the
diagnosis of an ectopic pregnancy. In one case at our
institution, a woman presented with vaginal spotting,
right-sided abdominal pain, and a beta-HCG of
153 mIU/mL. On transvaginal ultrasound, no IUP or
ectopic pregnancy was seen. Note was also made that the
right adnexa was not well visualized at TVUS. Upon
further imaging with a transabdominal approach, a tubal
ring was visualized in the right adnexa and confirmed to
be an ectopic pregnancy (Fig. 5). The patient received
immediate treatment as opposed to a watchful surveil-
lance approach for a pregnancy for unknown location.
A different problem arises when the gestational sac is
first identified by TVUS. In this setting, the coned-down
field of view provided by TVUS may exclude portions of
1527
the surrounding anatomy and lead to misinterpretation
of the location of the gestational sac. In one such case at
our institution, a patient presented for initial TVUS,
which documented an apparent IUP and seemingly
normal circumferential endometrial tissue. However, on
further transabdominal imaging, the sac was noted to be
anteroinferiorly displaced within a thinned-out Cesarean
section scar (Fig. 6). The patient was diagnosed with a
scar ectopic implantation. In light of this, we believe that
both transabdominal and transvaginal ultrasound should
be routinely performed on all patients in whom ectopic
pregnancy is suspected [9]. We recommend first per-
forming a transabdominal ultrasound for a global view
of the abdomen and pelvis. This should include imaging
of both Morrison’s pouch and the paracolic gutters to
evaluate for hemorrhage. It is helpful if the bladder is
moderately distended to allow for an optimal acoustic
window; however, scanning should not be delayed until
the bladder is full. Indeed, a scan without a distended
bladder may still yield valuable information. Subsequent
scanning with a transvaginal ultrasound should then be
performed (after the patient has voided) for higher res-
olution images.
Tip Both transabdominal and transvaginal ultra-
sound should be routinely performed on all patients in
whom ectopic pregnancy is suspected.
The transducer
Prior to beginning the pelvic ultrasound, the appropriate
transducer must be selected. Images with a curvilinear
abdominal probe (1–6 MHz) should be obtained for
transabdominal scanning first, with the patient’s bladder
distended to allow optimal visualization. Then, the pa-
tient is asked to void, and transvaginal images are ob-
tained. Transvaginal ultrasound should be performed
with a high-frequency transducer (7.5–10 MHz) in order
to obtain high-resolution images and allow for better
visualization of early pregnancy structures. Using a low-
frequency transvaginal transducer may cause the inter-
preting physician to miss key imaging findings.
A comprehensive scan
When scanning the female pelvis, is it important to en-
sure visualization of the entire uterus from the cervix to
the cornua as well as the adnexa. Obtaining images only
in the plane of the endometrial cavity is insufficient to
confidently exclude an ectopic pregnancy. It is our
practice to routinely include cine clips of the entire uterus
and adnexa as part of a complete pelvic ultrasound.
These clips are also useful through areas of clinical
concern, especially for radiologists reading remotely. In
addition to scanning the entire pelvis, it is important to
consider the abdomen as a site for a possible ectopic
pregnancy [10]. This is particularly important when the
1528 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 5. Female patient presenting with vaginal spotting,
right-sided abdominal pain, and a beta-HCG of 153 mIU/mL.
On transvaginal ultrasound, no IUP or ectopic pregnancy was
seen (A). The right adnexa was incompletely visualized by
patient can localize pain to a specific quadrant within the
abdomen. In one case, a patient presented with a positive
beta-HCG and left upper quadrant abdominal pain.
Initial transabdominal and transvaginal sonography
failed to show an IUP or ectopic pregnancy. Further
dedicated ultrasound images of the left upper quadrant
over the area of maximal tenderness documented a
splenic ectopic pregnancy (Fig. 7).
Tip In order to achieve the best diagnostic accuracy, it
should be standard practice to ask the patient to localize
her discomfort and dedicated images should be obtained
in this region.
No imaging findings (a normal pelvic
ultrasound)
Pregnancy of unknown location
This scenario occurs when there is no IUP demonstrated,
no definite evidence for recent pregnancy loss, and no
TVUS (B). Upon further transabdominal imaging, a tubal ring
(arrow) was visualized in the right adnexa adjacent to the right
ovary (star) and confirmed to be a tubal ectopic pregnancy
(C).
evidence of an ectopic pregnancy. In such instances, the
patient needs a follow-up beta-HCG blood level and
pelvic ultrasound to monitor for an occult ectopic
pregnancy. Detailed guidelines for follow-up of these
cases are addressed in the Society of Radiologists in
Ultrasound (SRU) recommendations (Fig. 8) [6].
Indirect imaging findings
Intrauterine fluid
The examination of a patient with pelvic pain and a
positive beta-HCG always begins by evaluating for the
presence of an IUP [11–15]. The earliest documented
sonographic finding of an IUP is the intradecidual sign
(IDS) first seen at 4.5 weeks after the patient’s LMP [3].
The IDS is a round, eccentrically located, anechoic fluid
collection surrounded by an echogenic ring within the
decidua of the endometrium [12]. The double sac sign
(DSS) is another indicator of an IUP and first appears
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 6. 34-year-old female presented for routine evaluation
of a desired pregnancy. Initial transvaginal ultrasound
demonstrated a gestational sac with apparent normal
intrauterine location (A). Subsequent transabdominal images
showed that the sac was actually in the lower uterine segment
consistent with a Cesarean section niche ectopic pregnancy.
around 5 weeks. The DSS appears as two echogenic rings
around an anechoic round fluid collection. The etiology
of these echogenic rings is controversial. One common
theory suggests that they represent two layers of decid-
ua—the inner decidua capsularis and the outer decidua
vera [12]. Soon after the double decidual reaction begins,
the yolk sac develops within the gestational sac
(5.5 weeks) [3]. The presence of a yolk sac within the
endometrial cavity is 100% specific for the diagnosis of
an IUP [3].
While the IDS or DSS strongly suggests the presence
of an IUP, the absence of these signs does not exclude the
possibility of an IUP [12]. In addition, differentiating
1529
Additionally, a thin endometrium was noted which is atypical
for an IUP (B). Three week follow-up transvaginal ultrasound
demonstrated the gestational sac in direct contact with the
bladder without overlying myometrium (C). The pregnancy
was carried to term, and hysterectomy was performed at the
time of delivery.
IDS and DSS from the intrauterine fluid of an ectopic
pregnancy (pseudogestational sac) can be quite difficult
(Fig. 9). Though it raises concern for an ectopic preg-
nancy, a nonspecific centrally located intrauterine fluid
collection without an IUP remains an equivocal finding.
In fact, nonspecific intrauterine fluid is seen in approxi-
mately 0.2% of normal intrauterine pregnancies. Based
on the greater prevalence of IUPs compared to ectopic
pregnancies, the finding of nonspecific intrauterine fluid
is statistically more likely to represent an IUP rather than
a pseudogestational sac [15].
Tip The possibility of an early IUP should always be
suggested in cases of nonspecific intrauterine fluid col-
1530 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 7. Female patient presented with left upper quadrant
pain. No IUP or pelvic ectopic identified (not shown). Addi-
tional ultrasound images in the left upper quadrant in the area
of concern demonstrated a gestational sac in the spleen
Fig. 8. 29-year-old G3P1011 female at 5 weeks and 5 days
by LMP presented with left-sided pelvic pain for 1 week. The
initial transvaginal ultrasound demonstrated a thickened en-
dometrium without an intrauterine gestational sac (A). The
bilateral adnexa were normal. The patient was diagnosed with
lections [13, 15]. Conservative management (rather than
upfront methotrexate) with close follow-up should be
offered to all patients who are stable and desire a preg-
nancy.
Tip In cases where intrauterine fluid is not well de-
fined on standard two-dimensional ultrasound, three-
dimensional ultrasound can be utilized to more clearly
depict the IDS and increase interpreter confidence
regarding the presence of an IUP (Fig. 10).
(SPL) (A). Left kidney (LT KID) for anatomic reference. Fol-
low-up axial contrast-enhanced CT confirmed the splenic
gestational sac (B). Case courtesy of Ushma Patel, MD,
University of Medicine and Dentistry of New Jersey.
a pregnancy of unknown location, and follow-up ultrasound
was recommended. Repeat pelvic ultrasound performed
10 days later showed a left adnexal mass consistent with a
tubal ectopic pregnancy (arrow) (B). Star denotes left ovary in
(B).
Extrauterine fluid
In addition to assessing the uterus for fluid collections,
evaluation for extrauterine fluid, particularly in the cul-
de-sac, is a key component of the pelvic ultrasound [2].
Hemoperitoneum may be seen in the setting of an ectopic
pregnancy, though this finding is also seen with hemor-
rhagic corpus luteum cysts, endometriomas, and spon-
taneous abortions. Hemoperitoneum may present as
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 9. 40-year-old G5P2022 female presented with right
lower quadrant pain and spotting for 2 days. Beta-HCG on
admission was 687 mIU/mL. Transabdominal ultrasound
demonstrated hypoechoic fluid centrally within the endome-
trial canal concerning for a pseudogestational sac (arrow) (A).
There was no intrauterine yolk sac or embryo. The patient
Fig. 10. Example of two-dimensional sonogram (A) with
accompanying three-dimensional volume rendered imaging
(B). 3D ultrasound nicely demonstrates a fluid collection with
focal clot with a heterogeneous collection in the pelvis
(Fig. 11). This collection may obscure vital structures
and confound diagnosis of an ectopic pregnancy. When
hemoperitoneum is present in the pelvis, the upper ab-
domen should be scanned to assess the extent of bleeding
[2]. The key places in the abdomen to evaluate include
the paracolic gutters and Morrison’s pouch. The pres-
ence of complex echogenic fluid in these regions indicates
a large peritoneal bleed (greater than 500 cc) and raises
concern for a tubal rupture; however, this finding has a
1531
was found to have a tubal ectopic pregnancy. In contrast, a
reproductive age patient with an early IUP demonstrating the
intradecidual sign (IDS). Here, there is an eccentrically lo-
cated fluid collection separate from the endometrial cavity and
within the decidua of the endometrium (B).
surrounding echogenic rim eccentrically located within the
endometrium, consistent with the intradecidual sign (arrow).
low sensitivity, specificity, and positive predictive value
[16]. If a patient with hemoperitoneum becomes hemo-
dynamically unstable, emergent surgical intervention is
typically warranted regardless of the cause (Fig. 12; Ta-
ble 1). The ultrasound should be quickly terminated and
the referring clinician must be notified.
Tip Extrauterine hemoperitoneum may be seen in a
patient with an ectopic pregnancy; however, the differ-
ential diagnosis is broad. Additionally, the upper abdo-
1532 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 11. Reproductive age female with positive qualitative
beta-HCG presented with abdominal pain and vaginal
bleeding. Transvaginal ultrasound in the sagittal plane
demonstrated echogenic clot and debris (arrrow) surrounding
the uterus (star) concerning for a ruptured ectopic pregnancy
with hemoperitoneum. No intrauterine pregnancy identified.
men should be evaluated to gauge the extent of possible
bleeding and help direct patient management.
Direct imaging findings
Tubal pregnancy
The most common location of an ectopic pregnancy is in
the fallopian tube, most frequently in the ampullary
portion of the tube. Ultrasound findings in tubal preg-
nancy include a live extrauterine pregnancy, tubal ring,
heterogeneous adnexal mass, hematosalpinx, and a ring
of fire on color Doppler (Fig. 13). Diagnostic confidence
increases significantly if a yolk sac or cardiac activity can
be demonstrated within the adnexal mass. The ring of
fire seen on color Doppler is a measure of the hyper-
vascularity of the ectopic gestational sac. This sign is
useful for locating a potential ectopic pregnancy, par-
ticularly if the adnexa is obscured by surrounding he-
matoma [14] (Fig. 14). The tubal ring sign is defined by
the presence of a round hypoechoic adnexal collection
with a well-defined hyperechoic rim [17]. This represents
a gestational sac (hypoechoic center) with surrounding
trophoblast (hyperechoic rim) and is present in up to
71% of tubal ectopic pregnancies (Fig. 15A). Tubal
pregnancies can be confused with ovarian findings such
as corpus luteum cysts and ovarian follicles due to the
similarity of the greyscale and color Doppler appear-
ances. In all cases, it is important to demonstrate that the
tubal ring is extraovarian—moving separately from the
ovary during real-time examination. The use of gentle
pressure with the transvaginal probe may help to move
the tubal ectopic pregnancy away from the ovary and
confirm the diagnosis. This finding is known as the
sliding organ sign [18].
Tip The peripheral trophoblast of the tubal ring is
often more echogenic than the ovarian stroma whereas
the corpus luteum is more hypoechoic, which can also
help differentiate the two [17] (Fig. 15).
Interstitial and cornual pregnancies
An interstitial pregnancy refers to an ectopic pregnancy
located in the portion of the fallopian tube that passes
through the uterine wall. Interstitial pregnancies are rare,
making up 2–4% of cases [19]. In addition to being rare,
they are difficult to diagnose and easily confused with
intrauterine pregnancies. As a result, they tend to be
diagnosed late and are associated with an increased risk
of rupture. On ultrasound, an interstitial pregnancy is
seen as an eccentric gestational sac (greater than 1 cm
from the lateral wall of the uterine cavity) surrounded by
an asymmetric thin myometrial mantle [20]. A sono-
graphic marker of an interstitial pregnancy is the inter-
stitial line sign (ILS), defined as an echogenic line
extending from the gestational sac into the cornua of the
uterus (Fig. 16A, B). When present, the ILS is highly
sensitive and specific for interstitial pregnancy [21]. The
term cornual pregnancy is frequently used inappropri-
ately and interchangeably with interstitial pregnancy.
Unlike interstitial pregnancies, cornual pregnancies are
intrauterine and occur when a gestational sac implants in
one horn of a bicornuate or septate uterus (Fig. 15C, D)
[19].
Tip On routine two-dimensional ultrasound, a cor-
nual pregnancy and interstitial pregnancy may be indis-
tinguishable if the uterine anatomy is indeterminate.
Therefore, it is our recommendation that when ultra-
sound findings are equivocal, all interstitial and cornual
pregnancies should be further evaluated with three-di-
mensional ultrasound or pelvic MRI (Fig. 16B, D). Ad-
vanced imaging allows for characterization of variant
uterine anatomy and clarification of the location of the
gestational sac.
Cervical pregnancy
A cervical pregnancy occurs when a blastocyst implants
in the endocervical canal. Cervical implantation is seen in
less than 1% of all ectopic pregnancies. This type of ec-
topic pregnancy most frequently occurs in patients who
have undergone prior D&C or those using ART [2, 14].
A cervical ectopic may result in a figure of eight (hour-
glass) uterine shape formed by a distended cervical canal
at one end and the uterine fundus at the other (Fig. 17).
The presence of cardiac activity within a cervical gesta-
tional sac provides a definitive diagnosis of cervical
pregnancy [22]. For this reason, cardiac motion should
be documented whenever possible (Fig. 18). Addition-
ally, color Doppler imaging of the gestational sac doc-
umenting prominent peritrophoblastic vascularity should
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 12. 30-year-old G5P3013 female presented with pelvic
pain and vaginal bleeding. Beta-HCG was 5596 mIU/mL.
Transabdominal midline longitudinal and transverse ultrasound
through the pelvis showed an empty uterus surrounded by
be obtained, and can help distinguish a spontaneous
abortion from a live ectopic pregnancy. In cases of sus-
pected cervical ectopic pregnancy, the internal and
external cervical os should be routinely imaged. If either
os are open, this favors an abortion in progress over a
cervical ectopic pregnancy.
Tip A common pitfall occurs when attempting to
differentiate a cervical ectopic pregnancy from the
1533
echogenic soft tissue and complex free fluid (A, B). Transab-
dominal images of the upper abdomen showed large volume
echogenic fluid consistent with massive hemoperitoneum (C).
The patient was taken emergently to the operating room.
products of an ongoing spontaneous abortion. In both
cases, a gestational sac can be seen within the cervical
canal. One key difference is that a cervical ectopic
pregnancy will have a round shape and remain adherent
to the cervix during the ultrasound (Fig. 18A, B).
Alternatively, an abortion in progress may show an
irregular-shaped sac extending from the uterine cavity
into the cervix with an open internal and/or external os.
1534 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 13. 34-year-old G3P2002 female at 7 weeks by LMP
presented with lower abdominal pain. Pelvic ultrasound through
the uterus showed an irregularly thickened endometrium and
Table 1. Ultrasound findings and contraindications to medical man-
agement of ectopic pregnancy
Hemoperitoneum in patient who is hemodynamically unstable
Embryo with cardiac activity (relative contraindication)
Gestational sac ‡3.5 cm (relative contraindication)
Adapted from ACOG Practice Bulletin No. 94
An abortion in progress may also change shape and
location during the ultrasound (Fig. 18C, D). If the
distinction between residual products of conception and
cervical ectopic cannot be made, short-term follow-up
can be performed to assess for interval change. If a cer-
vical ectopic pregnancy is favored, dilatation and curet-
tage (D&C) should be avoided in order to prevent life-
threatening hemorrhage.
complex fluid in the endometrial cavity. No intrauterine gesta-
tion was identified (A). A live tubal ectopic pregnancy was
identified in the region of the right adnexa (B, C).
Scar pregnancy
A scar pregnancy refers to implantation within the uterus
at the site of a prior Cesarean section incision. This type
of ectopic pregnancy has become increasingly common
with rising rates of Cesarean sections (roughly 1/3 of all
deliveries in the US are by Cesarean section) [23]. It is
also a particularly dangerous type of ectopic pregnancy
because of the high risk for uterine rupture [24]. Addi-
tionally, recent literature suggests that some morbidly
adherent placentas originate from scar pregnancies, fur-
thering the importance of early diagnosis and manage-
ment [25]. Scar pregnancies are outside of the
endometrial cavity and are only surrounded by a thin rim
of myometrium and fibrous tissue. On ultrasound, the
gestational sac is typically found at the anterior lower
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
uterine segment along the enlarged scar. To confidently
diagnose a scar pregnancy at sonography, several criteria
should be met: both the endometrial cavity and cervical
canal should be empty; a gestational sac should be seen
within the anterior lower uterine segment; and a thin
Fig. 14. Reproductive age female patient presented with
vaginal bleeding, pain, and a positive beta-HCG. At pelvic
ultrasound, the patient was found to have a large right ad-
nexal hematoma obscuring visualization of anatomic detail.
Further transabdominal imaging of the right adnexa with
power Doppler demonstrated the ring of fire appearance of a
tubal ectopic within the large pelvic hematoma.
Fig. 15. 27-year-old G4P2012 female presented with pain
and spotting for 2 days. Beta-HCG on admission was
20,375 mIU/mL. Transvaginal ultrasound of the right adnexa
demonstrated a round echogenic paraovarian mass consis-
tent with a tubal ring (white arrow) (A). The tubal ring is
1535
band of myometrial tissue should remain between the
bladder and the sac [24] (Fig. 19). Another clue is that
the gestational sac may be triangular in shape as it
conforms to the shape of the preexisting Cesarean scar
niche (Fig. 20). It is important to remember that D&C is
contraindicated in scar pregnancies due to an increased
risk of uterine perforation.
Tip In cases of suspected scar pregnancy, three-di-
mensional ultrasound can be used to reconstruct the
pelvic anatomy and increase diagnostic accuracy.
Intra-abdominal pregnancy
In an intra-abdominal ectopic pregnancy, implantation
occurs within the peritoneal cavity. This type of ectopic is
extremely rare (less than 1% of cases) and typically oc-
curs after the rupture of a tubal ectopic with resultant
implantation in the peritoneal cavity. Intra-abdominal
ectopic pregnancies are most commonly found on the
broad ligament and in the pouch of Douglas [26]. Other
sites include the liver, spleen, omentum, lesser sac, and
bowel (Fig. 7). Diagnosis of an intra-abdominal preg-
nancy requires the absence of an intrauterine sac, tubal
dilatation, or adnexal mass. In rare cases, visualization of
a gestational sac surrounded by loops of bowel can help
improve diagnostic accuracy. Intra-abdominal pregnan-
cies can grow significantly before becoming symptomatic
[10]. When finally brought to the attention of a clinician,
distorted anatomy can make the diagnosis difficult.
hyperechoic relative to the ovary (star). Additional transvagi-
nal ultrasound images demonstrated an ovarian corpus lu-
teum cyst (black arrow), which is hypoechoic relative to the
surrounding ovarian stroma (star) (B).
1536 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 16. 22-year-old G2P0010 female presented with vagi-
nal bleeding and abdominal cramping. Beta-HCG on admis-
sion was 6860 mIU/mL. Two-dimensional transvaginal
ultrasound demonstrated an eccentrically located ectopic
gestational sac. The differential diagnosis for this finding in-
cluded a cornual pregnancy and an interstitial ectopic preg-
nancy (A). Follow-up imaging with three-dimensional
transvaginal ultrasound was performed to exclude a con-
genital uterine duplication. The interstitial line sign was also
Tip If there is concern for an intra-abdominal preg-
nancy, an MRI of the abdomen and pelvis is the imaging
modality of choice (Fig. 21).
Heterotopic pregnancy
Heterotopic pregnancy is an unusual situation in which
extrauterine (ectopic) and intrauterine gestations occur
identified and confirmed the presence of the left interstitial
ectopic pregnancy (B). For comparison, transvaginal pelvic
ultrasound performed in a 27-year-old G1P0 with beta-HCG of
2300 mIU/mL again shows an eccentrically located ectopic
gestational sac. In this case, there was an incomplete uterine
septum, and the diagnosis of cornual pregnancy was favored
(C). Coronal Haste pelvic MRI was performed to confirm the
presence of an incomplete uterine septum with a gestational
sac in the left cornua (D).
concurrently. Heterotopic pregnancies account for 1–3%
of all ectopic pregnancies but are more common in wo-
men using assisted reproductive technology [27]
(Fig. 22). While a history of in vitro fertilization should
prompt particular attention to the possibility of multiple
intra- and extrauterine pregnancies, heterotopic preg-
nancies also occur spontaneously in women without risk
factors (Fig. 23). Therefore, a thorough pelvic ultra-
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 17. 33-year-old female presented with vaginal bleeding
and a positive qualitative beta-HCG. Transabdominal and
transvaginal pelvic ultrasound showed a gestational sac in the
Fig. 18. 26-year-old G6P0050 female presented with vagi-
nal bleeding and a beta-HCG of 12,814 mIU/mL. Transvagi-
nal pelvic ultrasound demonstrated a gestational sac at the
internal cervical os (arrow) (A). M-mode ultrasound through
the embryo demonstrated a heart rate of 65 bpm, which is
diagnostic of a live cervical ectopic pregnancy (B). In contrast,
1537
cervix. The intrauterine fluid and cervical gestational sac
create a figure of eight appearance (A, B).
a 25-year-old G1P0 at 7 2/7 weeks presented with a gesta-
tional sac in the cervix (arrow) on initial prevoid transvaginal
ultrasound (C). Follow-up postvoid transvaginal ultrasound
image obtained 15 min later showed hematocolpos and ab-
sence of the endocervical sac (arrow). This is diagnostic of a
spontaneous abortion.
1538 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 19. Reproductive age female with history of prior Ce-
sarean section presented with pelvic pain, bleeding, and a
positive qualitative beta-HCG. Transvaginal ultrasound iden-
Fig. 20. 32-year-old female with a history of a prior Cesar-
ean section presented with pelvic pain. Sagittal T2 TSE MRI
of the pelvis demonstrated a triangular fluid-filled Cesarean
scar niche (arrow). This niche serves as a potential reservoir
for ectopic pregnancy implantation.
sound should always include an assessment of the adnexa
even when an IUP is initially identified.
Tip It is important to remember that the presence of
an IUP never obviates the need to examine the adnexa.
Tip A common pitfall in the diagnosis of a hetero-
topic pregnancy lies in the failure to correlate the
quantitative beta-HCG with the intrauterine ultrasound
findings. Physicians should be aware of the approximate
values for serum beta-HCG at various gestational ages.
For example, a peak beta-HCG level of greater than
100,000 mIU/mL is expected at a gestational age of
8–11 weeks. If the beta-HCG value is higher than that
expected for the gestational age of an IUP documented
tified a gestational sac in the anterior lower uterine segment
consistent with a Cesarean scar ectopic pregnancy. Both the
uterine cavity and cervical canal were empty.
by ultrasound, the presence of a molar or heterotopic
pregnancy must be reevaluated. Likewise, if the beta-
HCG remains persistently elevated after elective termi-
nation of pregnancy or spontaneous abortion, the
physician should have a high index of suspicion for
heterotopic pregnancy (Table 2).
Ovarian pregnancy
An ovarian ectopic pregnancy refers to a pregnancy that
remains within the ovary itself and is the least common
type of ectopic pregnancy (Fig. 24). Sonographically, an
ovarian ectopic pregnancy appears as a gestational sac
surrounded by ovarian tissue in a patient with normal
fallopian tubes [28]. Based on the extremely low inci-
dence of ovarian ectopic pregnancies, a thorough search
for an alternative site of ectopic pregnancy should be
performed. Even when an ovarian abnormality is visible,
likelihood would favor an alternate ovarian process such
as a corpus luteum cyst, which can be an incidental
finding in the setting of an ectopic pregnancy.
Tip The absence of the sliding organ sign between the
ectopic pregnancy and the ovary should heighten con-
cern for an intra-ovarian ectopic pregnancy. To test for
the sliding organ sign, gentle pressure should be applied
with the tip of the transvaginal probe in the direction of
the ovary in question; failure to separate the gestational
sac from the ovary can be viewed as evidence that the
gestational sac is within the ovary.
Multimodal approach—pelvic MRI and three-
dimensional ultrasound
As mentioned within this review, both three-dimensional
ultrasound and noncontrast pelvic MRI can be used as
safe and effective problem-solving tools in the evaluation
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 21. Reproductive age female presented for pelvic MRI
for further evaluation of ectopic pregnancy. Sagittal T2 pelvic
MRI showed an advanced extrauterine gestation (arrow)
displacing the empty uterus (star) (A). This was consistent
with an abdominal ectopic pregnancy. Case courtesy of
Fig. 22. Reproductive age female with known first trimester
pregnancy presented with pelvic pain. Initial transvaginal
ultrasound images demonstrated a live intrauterine pregnancy
(A). Additional transabdominal ultrasound images through the
cul-de-sac demonstrated two extrauterine yolk sacs (YS1 and
of ectopic pregnancy. This is particularly useful when the
pelvic anatomy is distorted or an ectopic pregnancy is
suspected in an atypical location. MRI is most com-
monly used when there is a question of an intra-ab-
dominal ectopic pregnancy or when a uterine anomaly
1539
Alampady Shanbhogue, MD, New York University Langone
Medical Center. This is in contrast to a cornual pregnancy
(arrow), which is surrounded by endometrial tissue and con-
tained within one horn of a septate uterus (B).
YS2) and two embryos (1, 2) surrounded by hypoechoic fluid
(B). This was diagnostic of a heterotopic abdominal preg-
nancy with a single intrauterine pregnancy and two abdominal
ectopic gestations in the rectouterine pouch.
makes it difficult to decipher between an IUP and an
ectopic pregnancy (Fig. 21) [10, 29]. Three-dimensional
ultrasound offers the advantage over MRI of being easily
accessible and rapidly performed. Three-dimensional
ultrasound is especially helpful for the evaluation of
1540 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy

Fig. 23. 29-year-old female at 9 2/7 weeks with no prior risk the region of the right adnexa showed a second tubal gesta-
factors presented with right lower quadrant pain and vaginal tion (C). These findings were consistent with a heterotopic
bleeding. Midline transabdominal and transvaginal ultrasound pregnancy.
revealed a live IUP (A, B). Further transabdominal images in

interstitial ectopic pregnancies (Figure 16), cervical ectopically located pregnancy from a failed (avascular)
pregnancies, and scar pregnancies [30, 31]. Additionally, aborting IUP [32]. Given the complexity of ectopic
three-dimensional ultrasound with power Doppler is pregnancy cases, radiologists should recommend and
being increasingly used to differentiate a live but perform advanced imaging when possible.
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy 1541

Table 2. Beta-HCG levels and common pelvic ultrasound differentials

Beta-HCG level (mIU/mL) Considerations

0–6000+ May be an early intrauterine pregnancy without gestational sac seen or could be in ectopic location.
>100,000 If no IUP, consider molar pregnancy or abdominal ectopic
Persistently elevated following termination Consider heterotopic pregnancy or retained products of conception
or spontaneous abortion

Fig. 24. 29-year-old G1P0 at 9 0/7 by dates presented with mass was also noted (arrow) (B, C). The mass was insepa-
pelvic pain and vaginal bleeding. Greyscale transvaginal rable from the ovary (star) despite attempts to elicit the sliding
ultrasound demonstrated a normal uterus without an organ sign. The findings were suspicious for an ovarian ec-
intrauterine gestational sac (A). A large vascular left adnexal topic pregnancy and were confirmed by surgical pathology.

Conclusion be comfortable obtaining a focused history, reviewing

It is our hope that the cases we have presented and the
tips we have provided in this article will enable physi-
cians at all levels of training to more readily and accu-
rately diagnose an ectopic pregnancy. It is of paramount
importance that radiologists continue to improve their
diagnostic skills in this area in order to prevent damage
to a potentially normal early IUP. Radiologists should
laboratory tests, and performing a transabdominal and
transvaginal ultrasound. Improved understanding of the
spectrum of imaging findings associated with ectopic
pregnancies, the common diagnostic pitfalls, and the
limitations of two-dimensional sonography will ensure
that reproductive age women with pelvic pain receive
appropriate and timely management.
1542 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Compliance with ethical standards
Funding No funding was received for this study.
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent Statement of informed consent was not applicable
since the manuscript does not contain any patient data.
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