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ABDOMINAL EMERGENCIES 1661

Diagnostic Clues to
Ectopic Pregnancy1
Edward P. Lin, MD • Shweta Bhatt, MD • Vikram S. Dogra, MD

Ectopic pregnancy accounts for approximately 2% of all pregnancies

TEACHING
POINTS
and is the most common cause of pregnancy-related mortality in the
See last page first trimester. Initial evaluation consists of hormonal assays and pelvic
ultrasonography (US). A history of pelvic pain along with an abnormal
β human chorionic gonadotropin level should trigger an evaluation for
an ectopic pregnancy. The fallopian tube is the most common loca-
tion for an ectopic pregnancy. An adnexal mass that is separate from
the ovary and the tubal ring sign are the most common findings of a
tubal pregnancy. Other types of ectopic pregnancy include interstitial,
cornual, ovarian, cervical, scar, intraabdominal, and heterotopic preg-
nancy. Interstitial pregnancy occurs when the gestational sac implants
in the myometrial segment of the fallopian tube. Cornual pregnancy
refers to the implantation of a blastocyst within the cornua of a bicor-
nuate or septate uterus. An ovarian pregnancy occurs when an ovum is
fertilized and is retained within the ovary. Cervical pregnancy results
from an implantation within the endocervical canal. In a scar pregnan-
cy, implantation takes place within the scar of a prior cesarean section.
In an intraabdominal pregnancy, implantation occurs within the intra-
peritoneal cavity. Heterotopic pregnancy occurs when an intrauterine
and an extrauterine pregnancy occur simultaneously. A spectrum of
intra- and extrauterine findings may be seen on US images. Although
many of the US findings are nonspecific by themselves, when several
of them are seen, the specificity of US in depicting an ectopic preg-
nancy substantially improves.
©
RSNA, 2008 • radiographics.rsnajnls.org

Abbreviation: hCG = human chorionic gonadotropin

RadioGraphics 2008; 28:1661–1671 • Published online 10.1148/rg.286085506 • Content Codes:

1
From the Department of Imaging Sciences, University of Rochester School of Medicine, 601 Elmwood Ave, Box 648, Rochester, NY 14642. Re-
ceived January 30, 2008; revision requested March 14 and received March 31; accepted April 14. All authors have no financial relationships to dis-
close. Address correspondence to V.S.D. (e-mail: Vikram_Dogra@URMC.Rochester.edu).
©
RSNA, 2008
 1662 October Special Issue 2008
Introduction
Ectopic pregnancy occurs when a blastocyst ab-
normally implants outside the endometrium of
the uterus. The incidence of ectopic pregnancy
has increased from 0.37% of pregnancies in 1948
to approximately 2% of pregnancies in 1992 (1).
Although mortality decreased by nearly 90%
from 1979 to 1992, ectopic pregnancy remains
Teaching the leading cause of death during the first trimes-
Point ter of pregnancy, with a 9%–14% mortality rate
(1,2). The main risk factors for ectopic pregnancy
include a history of ectopic pregnancy, tubal sur-
gery, and pelvic inflammatory disease. Other risk
factors are summarized in Table 1.
Early diagnosis and treatment of ectopic
pregnancy are essential in reducing maternal
mortality and preserving future fertility. Most
patients who have an ectopic pregnancy present
with a 5–9-week history of amenorrhea, mild pel-
vic pain, and vaginal spotting. These symptoms
should trigger an evaluation for an ectopic preg-
nancy (3,4). Up to 50% of patients who have an
ectopic pregnancy are asymptomatic. Therefore,
some authors have advocated routine documen-
tation of intrauterine pregnancies for all patients
in their first trimester. Other clinicians limit first
trimester ultrasonography (US) to high-risk and
symptomatic patients.
As an ectopic pregnancy enlarges, its risk for
rupture increases. The severity of pelvic pain
does not necessarily correlate with the size of an
ectopic pregnancy, and pain may even decrease
or disappear following tubal rupture (4). Hypovo-
lemic shock and shoulder pain secondary to dia-
phragmatic irritation are indirect signs of a rup-
tured ectopic pregnancy. Any clinical suspicion
for a ruptured ectopic pregnancy in a patient in
an unstable condition warrants emergent surgical
intervention (4).
The initial evaluation of patients suspected
to have an ectopic pregnancy entails a quantita-
tive measurement of serum human chorionic
gonadotropin (hCG), with or without evaluation
of progesterone levels, and transvaginal US. The
hormonal assays, findings seen on US images,
and diagnostic criteria that can improve specific-
ity in diagnosing ectopic pregnancies are briefly
discussed in this article.
Laboratory Evaluation
Human chorionic gonadotropin is a glycoprotein
hormone that contains both an alpha and a beta
subunit. β-hCG levels begin to ascend in a cur-
RG ■ Volume 28 • Number 6
Table 1
Risk Factors of Ectopic Pregnancy
Prior ectopic pregnancy
History of pelvic inflammatory disease
History of gynecologic surgery
Infertility
Use of intrauterine device
History of placenta previa
Use of in vitro fertilization
Congenital uterine anomalies
History of smoking
Endometriosis
Exposure to diethylstilbestrol
vilinear fashion early in pregnancy and continue
until they reach a plateau at approximately 9–11
weeks (3). The plateau lasts for only a few days,
and thereafter β-hCG levels begin to decline at
20 weeks. The average doubling time of β-hCG
in a normal, viable intrauterine pregnancy is ap-
proximately 48 hours (range, 1.2–2.2 days) (4–7).
Because of the various impurities and con-
taminants that are found when determining hCG
levels, standardized methods for measuring hCG
levels have been established by the International
Federation of Clinical Chemistry and the World
Health Organization (8). The third International
Standard (IS), or the first International Refer-
ence Preparation, is the most widely used stan-
dard and is the first IS to account for the alpha
and beta subunits of hCG (8). The hCG level at
which US can demonstrate an intrauterine ges-
tational sac differs from one IS to another; the
clinician should be aware of the IS used at his or
her institution. Many earlier studies that inves-
tigated ectopic pregnancies were based on the
second IS. The second IS can be converted to the
International Reference Preparation by multiply-
ing by a factor of 1.8. From here on, this article
will refer to the third IS when discussing β-hCG
levels.
In ectopic pregnancies, serum hCG levels of-
ten rise at a much slower rate. If β-hCG levels in-
crease by less than 50% during a 48-hour period,
there is almost always a nonviable pregnancy
associated, be it intra- or extrauterine (3). Eighty-
five percent of viable intrauterine pregnancies
reflect an increase in β-hCG levels of 66% or
more during a 48-hour period (7). However, up
to 21% of ectopic pregnancies demonstrate a
β-hCG doubling time identical to that of intra-
uterine pregnancies (9). Arriving at a β-hCG pla-
teau early in the pregnancy is highly suggestive of
an ectopic pregnancy.
RG ■ Volume 28 • Number 6
Figure 1. Diagram of the various locations of an ectopic pregnancy.
A normal serum progesterone level in viable
pregnancies is typically more than 25 ng/mL.
Ninety-nine percent of nonviable pregnancies
have a progesterone level of less than 5 ng/mL
(10,11). The combination of a low serum pro-
gesterone level and an abnormal rise in serum
β-hCG is nearly diagnostic of a nonviable preg-
nancy. However, progesterone levels often take
several days to process. If a laboratory is unable
to report a value within 24 hours, the test has
limited use. Because of the delay in measuring
progesterone levels, clinical management often
relies on measuring β-hCG levels and on the pa-
tient’s clinical picture.
US Evaluation
When a patient presents with symptoms that
suggest an ectopic pregnancy or when hormonal
assays indicate an abnormal pregnancy, pelvic US
should be performed to determine the location
of an intra- or extrauterine pregnancy. Transvagi-
nal US is the preferred method of evaluation.
Transvaginal US should be able to demonstrate
a gestational sac when β-hCG levels are greater
than 2000 mIU/mL, which is the discriminatory
level of β-hCG (12). However, some institutions
may use a higher threshold. Transabdominal US
can demonstrate an intrauterine pregnancy when
β-hCG levels reach 6500 mIU/mL (4).
The goal of first-trimester screening is to
document the presence of an intrauterine preg-
nancy, be it normal or abnormal. US is very
sensitive and specific in differentiating between
normal and abnormal pregnancies in the first
trimester (13). In normal pregnancies, transvagi-
nal US can demonstrate an intradecidual sign
approximately 4.5 weeks after the last menstrual
period (12). The intradecidual sign is a small
collection of fluid that is eccentrically located
Lin et al 1663
within the endometrium and is surrounded by
a hyperechoic ring. At approximately 5 weeks,
the double decidual sac sign can be visualized.
The double decidual sac sign consists of two
concentric hyperechoic rings that surround an
anechoic gestational sac in a normal intrauterine
pregnancy (13). The secondary yolk sac may be
identified at transvaginal US at approximately 5.5
weeks, when the gestational sac reaches 10 mm
(14,15). Embryonic cardiac activity should also
be visualized at transvaginal US at approximately
5–6 weeks, when the gestational sac measures
more than 18 mm or when the embryonic pole
measures 5 mm or more (16).
When neither an intrauterine pregnancy nor
specific findings of an ectopic pregnancy can be
documented in a patient with a subthreshold
β-hCG level, the patient should be closely moni-
tored with serial US examinations, and β-hCG
levels should be continually tested until either an
ectopic or an intrauterine pregnancy is identified
(17).
When an abnormal pregnancy is suspected be-
cause of hormonal assays, a spectrum of abnor-
malities can be detected at pelvic US (16). The Teaching
absence of an intrauterine gestational sac should Point
trigger a detailed search for an ectopic pregnancy.
In addition, up to 35% of ectopic pregnan-
cies may not display any adnexal abnormalities Teaching
(12,14). Possible locations of ectopic pregnancy Point
are illustrated in Figure 1.
US Findings by Location
Tubal Pregnancy
Ninety-five percent of ectopic pregnancies are Teaching
tubal; they occur mostly in the ampulla (70%) Point
1664 October Special Issue 2008 RG ■ Volume 28 • Number 6

Figure 2. Transvaginal gray-

scale US image obtained with
M-mode scanning demon-
strates a left tubal ring with a
yolk sac and a live embryo (ar-
rowhead), which is suggested
by the presence of cardiac
activity. A live tubal pregnancy
was confirmed at surgery.

Figure 3. Transvaginal gray-scale US image of the

right adnexa reveals an extraovarian adnexal mass with
a hyperechoic tubal ring (arrow). A tubal pregnancy
was confirmed at surgery. OV = right ovary.

Figure 4. Tubal ring sign. Transvaginal US image of

the left adnexa reveals an extraovarian gestational sac
with a yolk sac (arrow). The yolk sac is surrounded by
a thick echogenic ring (arrowhead).
Figure 5. Ring of fire sign. Transvaginal color Dop-
pler US images of a tubal pregnancy show peripheral
hypervascularity surrounding the extrauterine gesta-
tional sac (a) and a hemorrhagic ovarian cyst (b), a
finding that is a mimic of the ring of fire sign.
RG ■ Volume 28 • Number 6 Lin et al 1665

Figure 6. Pseudo–gestational sac.

Transvaginal gray-scale US image ob-
tained along the longitudinal axis shows
an intrauterine pseudo–gestational sac
(arrow); there is no yolk sac or fetal
pole. Free fluid is seen in the cul-de-sac
(*). The patient also had a tubal ectopic
pregnancy, which is shown in Figure 4.

Figure 7. Diagrams show a pseudo–gestational sac in an ectopic pregnancy (a) and a double
decidual sac sign in a normal intrauterine pregnancy (b).

or isthmus (12%) and are less common in the
fimbria (11.1%) (18,19). An adnexal mass that
is separate from the ovary is the most common
finding of a tubal pregnancy and is seen on US
images in up to 89%–100% of patients (20,21).
An adnexal mass is more specific for an ectopic
pregnancy when it contains a yolk sac or a living
embryo (Fig 2) or when it moves independently
from the ovary (Fig 3) (22). However, an extra-
uterine mass may not be detected at transvaginal
US in 15%–35% of patients with an ectopic preg-
nancy (12).
The tubal ring sign is the second most com-
mon sign of a tubal pregnancy. The tubal ring
sign describes a hyperechoic ring surrounding
an extrauterine gestational sac (Fig 4). A related
finding is the “ring of fire” sign, which is recog-
nized by peripheral hypervascularity of the hy-
perechoic ring. The term ring of fire was used by
Pellerito et al (23) to describe the high-velocity,
low-impedance flow surrounding an ectopic ad-
nexal pregnancy. Peripheral hypervascularity is
a nonspecific finding of the ring of fire sign and
may also be seen surrounding a normal matur-
ing follicle or a corpus luteal cyst (Fig 5) (24).
Therefore, the ring of fire sign should not be used
to describe the corpus luteum. Determining the
location of this type of flow, whether it is within
the ovary or outside the ovary, is most important
to distinguish between an ectopic pregnancy and
a corpus luteum. However, the ring of fire sign is
most helpful when no definite ectopic pregnancy
is seen on gray-scale images. Color Doppler im-
ages of the adnexa may demonstrate the ring-
of-fire flow in an otherwise nondescript adnexal
lesion and thereby may improve confidence in the
diagnosis of ectopic pregnancy.
Intrauterine findings of an ectopic pregnancy
include a “normal endometrium,” a pseudo–
gestational sac, a trilaminar endometrium, and a
thin-walled decidual cyst. A pseudo–gestational
sac represents a thick decidual reaction surround-
ing intrauterine fluid (Fig 6). Ten percent of
patients with an ectopic pregnancy demonstrate
a pseudo–gestational sac (25). The absence of
the double decidual sac sign helps distinguish a
pseudo–gestational sac from a true viable ges-
tational sac (Fig 7) (26). In addition, a pseudo–
gestational sac is located centrally within the en-
dometrial canal, whereas a normal gestational sac
1666 October Special Issue 2008 RG ■ Volume 28 • Number 6

Figure 8. Interstitial pregnancy. (a) Transvaginal

US image obtained along an oblique axis shows
the yolk sac (arrowhead) within a gestational sac,
which is located in the interstitial portion of the fal-
lopian tube. The interstitial line sign (arrow) is also
seen. (b) Diagram of the interstitial pregnancy and
the interstitial line sign. (c) Transverse gray-scale
US image of the uterus in another patient shows a
gestational sac (arrow), which contains an embryo
(arrowhead), in the cornua/interstitial portion of the
fallopian tube. (Fig 8a reprinted, with permission,
from reference 25.)

is located eccentrically within the canal. A viable

gestational sac also exhibits low-resistance arte-
rial flow on color Doppler flow images.
A trilaminar endometrium is formed during
the late proliferative phase of the normal men-
strual cycle. It consists of an echogenic basal
layer and a hypoechoic inner functional layer fol-
lowed by a thin echogenic layer that represents
the interface with the endometrial lumen. When
an abnormal pregnancy is suspected based on
laboratory results, the absence of a true gesta-
tional sac in the presence of a trilaminar endo-
metrium on US images is highly suggestive of an
ectopic pregnancy (27).
Thin-walled decidual cysts are found at the
junction of the endometrium and the myome-
trium and may be seen in both normal and ab-
normal pregnancies. The thin wall of the decidual
cyst differentiates it from a true gestational sac.
Extrauterine findings of ectopic pregnancy in-
clude pelvic free fluid, hematosalpinx, and hemo-
peritoneum. Although the presence of pelvic free
fluid within the rectouterine space is nonspecific,
it is a finding that may help confirm a suspected
ectopic pregnancy in lieu of other findings. Pelvic
hemorrhage is a more specific finding, with an
86%–93% positive predictive value when β-hCG
levels are abnormal (14,28). The presence of
echogenic fluid within the right posterior sub-
hepatic space (Morrison pouch) and within the
cul-de-sac should raise concern for a ruptured
ectopic pregnancy.
Interstitial Pregnancy
Interstitial pregnancies are uncommon, account-
ing for 2%–4% of all ectopic pregnancies (19).
Risk factors for interstitial pregnancy include
prior salpingectomy and in vitro fertilization. In-
terstitial pregnancies occur when the gestational
sac implants in the intramyometrial segment of
the fallopian tube (29). Because of the increased
distensibility of this segment of the fallopian
tube, interstitial pregnancies may be seen as late
as the 16th week of gestation (30). Rupture of an
interstitial pregnancy can lead to life-threatening
hemorrhage because of the proximity of the uter-
ine artery to the fallopian tube (30).
RG ■ Volume 28 • Number 6
Figure 9. Cervical pregnancy. Transvaginal US im-
age of the uterus obtained along the longitudinal axis
reveals a gestational sac that contains the fetal pole
(arrow) within the cervix. Fu = uterine fundus. (Re-
printed, with permission, from reference 25.)
Figure 10. Abortion in progress in a patient with a
history of vaginal bleeding. Transvaginal US image of
the uterus demonstrates a low-lying gestational sac (ar-
row) with mixed hyper- and hypoechoic contents in the
endometrial cavity of the fundus (arrowheads), which
represent decidual reaction and hemorrhage. The pa-
tient experienced a complete spontaneous abortion a
few hours after the US examination. (Reprinted, with
permission, from reference 16.)
US findings of an interstitial pregnancy in-
clude an eccentrically located gestational sac
surrounded by a thin layer of myometrium that
measures less than 5 mm. At times, a normal
pregnancy that appears to be eccentrically lo-
cated because of distortion from uterine fibroids,
contractions, or anomalies may be confused with
an interstitial pregnancy. A more specific finding
is the interstitial line sign, which represents “an
echogenic line that extends into the upper re-
gions of the uterine horn and borders the margin
Lin et al 1667
of the intramural gestational sac” (Fig 8) (31).
This echogenic line most likely represents the in-
terstitial portion of the fallopian tube (31). In the
study by Ackerman et al (31), the interstitial line
sign was 80% sensitive and 98% specific for an
interstitial pregnancy.
Cornual Pregnancy
Although it is often used interchangeably with in-
terstitial pregnancy, cornual pregnancy specifically
refers to the implantation of a blastocyst within
the cornua of a bicornuate or septate uterus
(20,32). Cornual pregnancies are rare and ac-
count for less than 1% of all ectopic pregnancies
(33). Rupture of a cornual pregnancy also results
in catastrophic hemorrhage.
In a cornual pregnancy, the gestational sac is
surrounded by a thin rim (<5 mm) of myome-
trium (34). In addition, the sac is in an eccentric
position and is more than 1 cm from the lateral
wall of the endometrial cavity (34).
Ovarian Pregnancy
An ovarian pregnancy occurs when an ovum
is fertilized and is retained within the ovary.
Ovarian pregnancies account for 3% of ectopic
pregnancies (18); sometimes they manifest as
part of a heterotopic pregnancy (35,36). Ovarian
pregnancies are strongly associated with the use
of intrauterine devices (37) and often manifest at
the same time as tubal pregnancies (18).
The presence of a gestational sac, chorionic
villi, or an atypical cyst with a hyperechoic ring
within the ovary, along with the normal fallo-
pian tubes, is suggestive of an ovarian pregnancy
(38,39).
Cervical Pregnancy
Cervical pregnancy occurs when implantation
takes place within the endocervical canal. It is
rare (<1% of ectopic pregnancies) and is likely
associated with in vitro fertilization and a his-
tory of prior curettage (41). Diagnosis is typically
made at US.
In a cervical pregnancy, the uterus may be
shaped like an hourglass or a figure eight as the
fetus expands within the cervix (Fig 9) (41,42).
In addition, cardiac activity below the internal os
is highly suggestive of a cervical pregnancy (42).
When a gestational sac is visualized in the region
of the cervix, gentle manipulation of the gesta-
tional sac should be attempted to differentiate a
cervical pregnancy from an abortion in progress
(Fig 10) (43). If the sliding sign is seen (if the
transducer probe can manipulate the gestational
1668 October Special Issue 2008 RG ■ Volume 28 • Number 6

Figure 11. Scar pregnancy in a

patient with a history of cesarean
section. Transvaginal gray-scale
US image of the uterus, obtained
with M-mode scanning along
the longitudinal axis, reveals a
gestational sac with a fetal pole
(arrowhead) in the anterior wall
of the uterus. There was no fetal
cardiac activity, a finding sugges-
tive of fetal demise.

Figure 12. Intraabdominal pregnancy in a patient who went to the hospital for an abor-
tion. The intraabdominal pregnancy was missed because US was not performed before
dilation and curettage. She presented with pain and fever secondary to pyometra 1 week
later. (a) Transabdominal US image reveals an extrauterine gestational sac with a fetal head
(arrow). Laparotomy was performed, and only the fetal head was found in a pocket of pus
in a retrocecal location. No other fetal parts were identified. (b) Photograph shows the sur-
gically removed extrauterine gestational sac with the fetal head. (Scale is in centimeters.)
(Reprinted, with permission, from reference 47.)

sac), this confirms that the gestational sac is not
adherent to the cervix (excluding cervical preg-
nancy), which indicates that an abortion is in
progress (43).
Scar Pregnancy
Caesarean scar pregnancies are also rare and are
estimated to occur in less than 1% of all pregnan-
cies (44). Implantation takes place within the
scar of a prior cesarean section, separate from the
endometrial cavity (44). Within the scar, the blas-
tocyst is surrounded by myometrium and fibrous
tissue (45). A suggested mechanism is that a tract
connects the endometrial canal and the uterine
myometrium; this tract facilitates implantation
within the scar (45). Patients who have a scar
pregnancy may present with vaginal bleeding as
early as 5–6 weeks and as late as 16 weeks. Scar
pregnancies may also rupture, which can result in
severe hemorrhage and hemodynamic collapse.
In a scar pregnancy, a gestational sac may be
visualized within the anterior wall of the inferior
aspect of the uterus (Fig 11) (46). Secondary to
compression by the gestational sac, the myome-
trium may also be thinned anteriorly (46). Thin-
ning of the myometrium may predispose a patient
to uterine rupture (21).
Intraabdominal Pregnancy
In an intraabdominal pregnancy, implantation
occurs within the intraperitoneal cavity (Fig 12),
excluding tubal, ovarian, and intraligamentous lo-
cations. This is a rare cause of ectopic pregnancy,
but it is more common in patients who undergo
assisted reproduction (48), and it may represent
1.4% of ectopic pregnancies. Because of signifi-
cant hemorrhage, maternal mortality associated
with intraabdominal pregnancy is 7.7 times that
of other locations of ectopic pregnancy (49).
RG ■ Volume 28 • Number 6 Lin et al 1669

Figure 13. Heterotopic pregnancy. Trans-

vaginal gray-scale US image demonstrates a
gestational sac within the uterus (arrow) and
an extrauterine gestational sac (arrowhead).

Table 2
US Findings of Ectopic Pregnancy by Location

Type of Pregnancy Findings on US Images

Tubal pregnancy Living extrauterine gestation, adnexal mass, tubal ring sign, ring of
fire sign, pelvic hemorrhage
Interstitial pregnancy* Eccentrically located gestational sac, gestational sac surrounded by a
thin myometrium (<5 mm), interstitial line sign
Ovarian pregnancy† Serum β-hCG level >1000 mIU/mL; normal fallopian tubes; gesta-
tional sac, chorionic villi, or atypical cyst within the ovary; normal
β-hCG level after therapy
Cervical pregnancy‡ Trophoblastic flow surrounding the gestational sac within the cer-
vix, normal endometrial stripe, gestational sac within the cervix
with cardiac activity, hourglass-shaped uterus, cardiac activity
below the internal os
Cesarean scar pregnancy Gestational sac located within the lower anterior segment of the
uterus at the site of a prior cesarean section, thinning of myome-
trium anterior to the gestational sac
Abdominal pregnancy Absence of a normal intrauterine gestational sac, gestational sac locat-
ed within the intraperitoneal cavity, abdominal or pelvic hemorrhage
* Reference 37.
† References 48 and 49.
‡ Reference 40.

Heterotopic Pregnancy a known heterotopic pregnancy can potentially

Heterotopic pregnancy occurs when an intra-
uterine and an extrauterine pregnancy occur si-
multaneously (Fig 13). Knowledge of heterotopic
pregnancy is becoming increasingly important
as more women undergo assisted reproduction,
particularly ovulation induction. The prevalence
of heterotopic pregnancy in women who undergo
assisted reproduction has been reported to be
1%–3% (50). Heterotopic pregnancy remains a
diagnostic challenge and should be kept in mind
when a patient who has undergone assisted re-
production presents with pelvic pain. US images
can demonstrate the presence of an intrauterine
and an extrauterine pregnancy. Patients who have
undergo US-guided ablation or laparoscopic
removal of the extrauterine fetus to permit the
intrauterine pregnancy to continue normally. If a
patient undergoes an abortion of an intrauterine
pregnancy and continues to experience persistent
adnexal pain with abnormal β-hCG levels, het-
erotopic pregnancy should be suspected.
Although many of the intra- and extrauterine
Teaching
findings are nonspecific when they are seen in
Point
isolation, the use of diagnostic criteria may im-
prove specificity when several findings are identi-
fied in a patient suspected of having an ectopic
pregnancy (Table 2).
1670 October Special Issue 2008
Conclusions
Although mortality has significantly decreased
over the past two decades because of earlier
detection and intervention, ectopic pregnancy
remains the leading cause of death of women in
the first trimester of pregnancy. Work-up of a pa-
tient who presents with pelvic pain, amenorrhea,
and vaginal spotting entails hormonal assays and
pelvic US. When results of laboratory evaluation
suggest an abnormal pregnancy, a detailed search
for an intra- or extrauterine pregnancy should be
performed.
The most common location of an ectopic
pregnancy is the fallopian tube. US findings of
ectopic pregnancy can be categorized by location
(intra- or extrauterine). Although many of these
findings are nonspecific when they are seen sin-
gly, when several of them are seen, the specificity
of US in depicting an ectopic pregnancy substan-
tially improves. Use of these diagnostic criteria,
as was outlined previously, may therefore improve
diagnostic accuracy when abnormal β-hCG or
progesterone levels suggest an ectopic pregnancy.
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RG Volume 28 • Volume 6 • October 2008 Lin et al

Diagnostic Clues to Ectopic Pregnancy

Edward P. Lin, MD, Shweta Bhatt, MD, and Vikram S. Dogra, MD

RadioGraphics 2008; 28:1661–1671 • Published online 10.1148/rg.286085506 • Content Codes:

Page 1662
Ectopic pregnancy remains the leading cause of death during the first trimester of pregnancy, with a
9%–14% mortality rate.

Page 1663
The absence of an intrauterine gestational sac should trigger a detailed search for an ectopic
pregnancy.

Page 1663
In addition, up to 35% of ectopic pregnancies may not display any adnexal abnormalities.

Page 1663
Ninety-five percent of ectopic pregnancies are tubal.

Page 1669
Although many of the intra- and extrauterine findings are nonspecific when they are seen in isolation,
the use of diagnostic criteria may improve specificity when several findings are identified in a patient
suspected of having an ectopic pregnancy.