Endovaginal sonographic evaluation of ectopic pregnancy: a prospective study

To determine the value of endovaginal sonography for evaluating women with a suspected ectopic gestation, we prospectively studied a group of 84 pregnant women in whom conventional transabdominal sonograms failed to show a living embryo. Of 84 patients studied, 25 had an ectopic gestation, 32 had a normal intrauterine pregnancy, and 27 had an abnormal (nonviable) intrauterine pregnancy. Endovaginal sonography, compared with transabdominal sonography, provided additional information in 50 cases (60%) and less information in only three cases (4%). Of 25 ectopic gestations, endovaginal sonography provided new information in 15 cases (60%) including detection of an extrauterine gestational sac (10 cases), extrauterine embryo (two cases), or adnexal mass (three cases) not observed on transabdominal sonography. Of 32 normal intrauterine pregnancies, endovaginal sonography provided additional information in 26 cases (81%) including detection of a yolk sac (14 cases), living embryo (11 cases), or small gestational sac (one case) not seen on transabdominal sonography. Of 27 abnormal intrauterine pregnancies, endovaginal sonography showed additional information in nine cases (33%) including detection of embryonic demise (three cases), retained intrauterine products (four cases), or a yolk sac (two cases) not seen on transabdominal sonography. Patient acceptance of endovaginal sonography was excellent; 82% of the patients preferred this method to transabdominal sonography, 13% expressed no preference, and 5% preferred transabdominal sonography. We conclude that endovaginal sonography can provide significant additional information in the majority of women who are referred for sonography with a suspected ectopic gestation. We believe that this method should become a integral part of sonographic evaluation in women who are suspected of having an ectopic gestation when conventional transabdominal sonography fails to show a living embryo.     

Comparison of transvaginal and transabdominal sonography in the detection of early pregnancy and its complications

Ninety women with a positive pregnancy test and signs and symptoms of threatened abortion or ectopic pregnancy had endovaginal and abdominal sonography in order to compare the value of the two techniques for the detection of gestational abnormalities. Either a normal delivery occurred or surgical and/or pathologic confirmation of the diagnosis was available in all cases. Fifty-five women had normal intrauterine pregnancies, 22 had ectopic pregnancies, seven had blighted ova, and six had missed abortions. All 55 normal intrauterine pregnancies were detected by endovaginal sonography, while only 11 (20%) were diagnosed by transabdominal sonography. The yolk sac, fetal pole, and fetal heart motion were seen as early as 34 days from the last menstrual period with endovaginal sonography, compared with 42 days with transabdominal sonography. Fetal heart motion was detected with endovaginal sonography in fetal poles with a crown-rump length of 3 mm or greater, whereas the fetal pole had to be at least 6 mm before fetal heart motion could be detected with the transabdominal technique. In the 22 ectopic pregnancies, a specific diagnosis of an extrauterine sac containing a fetal pole with heart motion or yolk sac was possible in three cases with the endovaginal technique, but it was not possible in any case with transabdominal sonography. Both techniques showed that each of the seven patients with final diagnosis of blighted ova had a gestational sac that was 1.7 cm or larger without visualization of the fetal pole or yolk sac. All six missed abortions were detected by endovaginal sonography, but only three were diagnosed on transabdominal sonograms. Our findings show that endovaginal sonography is more sensitive than transabdominal sonography in the detection of early pregnancy and its complications.     

Early pregnancy complications: endovaginal sonographic findings correlated with human chorionic gonadotropin levels

Endovaginal sonography results were compared with quantitatively determined human chorionic gonadotropin (hCG) levels in 84 women referred for early pregnancy complications. Of the 27 with normal intrauterine pregnancies, an intrauterine gestational sac was prospectively identified in one of five cases (20%) in which hCG levels were below 500 IU/L (Second International Standard), four of five (80%) with hCG levels of 500-1,000 IU/L, and all 17 with hCG levels above 1,000 IU/L. In comparison, 17 of the 26 women with ectopic pregnancies (65%) had hCG levels greater than 1,000 IU/L, and none of the 26 had an intrauterine gestational sac. Endovaginal sonography demonstrated an adnexal mass and/or a gestational sac-like structure in 16 of the 17 cases (94%) in which hCG levels were above 1,000 IU/L, compared with only three of the nine (33%) with lower hCG levels (P less than .01). These findings indicate that an intrauterine gestational sac should be normally visualized with endovaginal sonography when the hCG level exceeds 1,000 IU/L, and that visualization of an extrauterine gestational sac and/or adnexal mass is significantly more likely in ectopic pregnancies when the hCG level exceeds 1,000 IU/L.     

Diagnosis of ectopic pregnancy: endovaginal vs transabdominal sonography

During a 25-month period, 193 women with the clinical diagnosis of suspected ectopic pregnancy had transabdominal and endovaginal sonograms. Most had quantitative determinations of serum human chorionic gonadotropin (HCG). Endovaginal sonography was diagnostic of ectopic pregnancy in 23 (38%) of the 60 patients with surgically proved ectopic pregnancies: transabdominal sonography was diagnostic in 13 patients (22%). All 83 intrauterine pregnancies were identified with endovaginal sonography, compared with 34 identified with transabdominal sonography. Endovaginal sonography was somewhat more helpful in the diagnosis of missed abortion and blighted ovum. Eighty endovaginal sonograms were classified as indeterminate as compared with 141 transabdominal studies. This indeterminate group included patients with complete abortions, ectopic pregnancies without sonographic evidence of an extrauterine gestation, incomplete abortions, and patients with subsequent negative serum levels. As in prior reports, endovaginal sonography was superior to transabdominal sonography in the evaluation of suspected ectopic pregnancies. Overall, endovaginal sonography was diagnostic in 113 patients, whereas transabdominal sonography was diagnostic in 52 patients. The finding of an extrauterine fetal pole or embryo was diagnostic for an ectopic pregnancy. Pelvic fluid, the appearance of the endometrium, and a single positive serum HCG determination were not helpful in making the diagnosis of ectopic pregnancy.     

Ectopic pregnancy: evaluation with endovaginal color flow imaging.

Endovaginal sonography and endovaginal color flow imaging were compared in 155 patients with clinical suspicion of ectopic pregnancy. Sixty-five patients (42%) had surgically confirmed ectopic pregnancies. Thirty-six of the pregnancies were diagnosed with endovaginal sonography alone, the criteria being an extrauterine sac or ectopic fetus (sensitivity, 54%). Sixty-two ectopic pregnancies were diagnosed with endovaginal color flow imaging (sensitivity, 95%) when an ectopic fetus or sac was seen or placental flow was identified in an adnexal mass separate from the ovary and uterus. The diagnosis of ectopic pregnancy was excluded with endovaginal sonography (specificity, 98%) and endovaginal color flow imaging (specificity, 98%) by finding an intrauterine gestation, nonvisualization of an adnexal mass, and absence of placental flow. Three false-positive and three false-negative diagnoses were made with endovaginal color flow imaging (positive predictive value, 97%). The addition of color Doppler flow imaging to endovaginal sonography allows increased sensitivity in the detection of ectopic pregnancy.     

Suspected ectopic pregnancy: endovaginal and transvesical US

Until the advent of endovaginal ultrasonography (US), transvesical US was the only US technique availab le for evaluation of patients with suspected ectopic gestation. A study was undertaken to assess the predictive ability of transvesical and endovaginal US and determine whether endovaginal US could be used alone. Fifty-three patients who had a positive pregnancy test finding and who were at risk for ectopic pregnancy were examined with both endovaginal and transvesical US. Twenty-nine were examined retrospectively and 24 were examined prospectively. Standard sonographic criteria were used to differentiate between intrauterine pregnancy and ectopic gestation. The clinical or pathologic diagnosis was ectopic pregnancy in 18 patients (34%), normal intrauterine pregnancy in 19 (36%), and abnormal intrauterine pregnancy in 16 (30%). Endovaginal US increased the sensitivity of detecting a live ectopic pregnancy (from 6% to 17%). Endovaginal US, by allowing early diagnosis of intrauterine pregnancy, significantly increased the diagnostic accuracy for ectopic pregnancy (from 60% to 83%). Endovaginal US provided significant additional information in women referred for sonography with a suspected ectopic gestation. On the basis of these findings it is concluded that endovaginal US can be used alone in the majority of women with suspected ectopic gestation.     

Endovaginal color Doppler sonographic evaluation of ectopic pregnancy in women after in vitro fertilization and embryo transfer

The aim of this study was to evaluate the value of endovaginal color Doppler ultrasonography in the early diagnosis of ectopic pregnancy in women after in vitro fertilization and embryo transfer, and to correlate the sonographic findings with ?-hCG serum levels. Thirty-five patients had proven ectopic pregnancies and 4 other patients had heterotopic pregnancies. The diagnosis was disclosed correctly in all cases by endovaginal color Doppler US by identifying an adnexal mass with placental flow and a nongravid uterus called a “cold uterus”. An intrauterine sac with “double ring sign” was found in all normal intrauterine pregnancies when the hCG levels exceeded 1000 IU/l but in none of the patients with ectopic pregnancy (EP). These findings suggest the efficacy of the discriminatory hCG serum level of 1000 IU/l in the investigation of EP. In conclusion, this study describes the diagnostic importance of transvaginal color Doppler US in correlation with hCG serum levels in the early detection of EP avoiding life-threatening complications and improving patient outcome. Received: 4 May 1998; Revision received: 10 August 1998; Accepted: 10 September 1998     

经阴道超声对早期未破裂型宫外孕的诊断价值

目的探讨经阴道超声在早期未破型宫外孕中的诊断价值。方法对我院2008年1月至2009年10月经阴道经腹超声对照检查并经手术病理证实的62例早期未破型宫外孕资料进行回顾分析。结果经阴道超声检查确诊59例（95%）,根据声像图特点分为输卵管环型33例（53%）,非特异性包块型20例（32%）,胎心胎囊型6例（9.6%）,无特征性声像图3例（5%）。经腹部超声检查确诊31例（50%）。结论经阴道超声分辨率高,图像清晰,是诊断早期未破型宫外孕的首选方法。     

Early gestation: correlation of HCG levels and sonographic identification

Previous reports have indicated that an intrauterine gestational sac is not usually detected when the maternal serum human chorionic gonadotropin (HCG) is less than 6000 mIU/ml. In order to evaluate this observation, maternal serum HCG concentrations were correlated with sonographic uterine findings in 49 patients with normal early intrauterine pregnancies. Of 37 patients in whom a gestational sac was seen, simultaneous HCG levels were 1800 mIU/ml or more in 36 cases and 357 mlU/ml in one case. In 12 cases in which a gestational sac was not detected, the serum HCG levels were 1400 mIU/ml or less. Thirteen patients had HCG levels of less than 6000 mlU/ml. A linear relation was found between gestational sac size and the exponential rise of HCG levels in early pregnancy (p less than 0.001). Of the 13 patients in whom HCG levels were less than 6000 mIU/ml, the gestational sac measured 10 mm or less in each case. Currently, a gestational sac is always seen when the HCG level is greater than 1800 mIU/ml. Comparison of serum HCG levels with sonographic detection of the gestational sac seems to be a useful method of evaluating early pregnancy.     

Diagnostic efficacy of endovaginal color Doppler flow imaging in an ectopic pregnancy screening program.

The authors compared the diagnostic yield of endovaginal color and pulsed Doppler ultrasound (US) in conjunction with endovaginal sonography with that of endovaginal sonography alone in patients prescreened to be at increased risk for ectopic pregnancy. Pelvic structures were evaluated for overall vascularity and for the presence of characteristic pulsed Doppler US velocity waveforms. The diagnostic sensitivity of the initial endovaginal sonographic examination increased with the addition of color and pulsed Doppler US, from 71% to 87% for ectopic pregnancy, from 24% to 59% for failed intrauterine pregnancy, and from 90% to 99% for viable intrauterine pregnancy. Specificities for endovaginal sonography with color and pulsed Doppler US ranged from 99% to 100%. Use of endovaginal color and pulsed Doppler US increased the percentage of diagnostic initial sonographic examinations from 62% to 82%. The improved diagnostic sensitivity of endovaginal color Doppler US for ectopic pregnancy may ultimately result in earlier treatment, with reduced morbidity and mortality.     

Pseudogestational sacs: Doppler US differentiation from normal or abnormal intrauterine pregnancies

Doppler ultrasound (US) evaluation of 40 empty intrauterine sac-like structures was performed to evaluate the ability of this technique to permit distinction between intrauterine pregnancy and pseudogestational sac associated with ectopic pregnancy. Proof of the location of the pregnancy was available in all cases. There were 31 intrauterine pregnancies, of which 23 were missed or incomplete abortions and eight were early normal pregnancies. With an insonating frequency of 3 MHz, the average frequency shift detected from these intrauterine pregnancies was 1.7/1.0 kHz (peak systolic/end diastolic ratio). Nine pseudogestational sacs were evaluated, of which seven demonstrated no flow and two demonstrated minimal flow that averaged 0.4/0.1 kHz. Defining intrauterine peritrophoblastic flow as a peak systolic frequency shift of 0.8 kHz or greater (equivalent to 21 cm/sec with an angle of 0 degree) correctly classifies 26 of the 31 intrauterine pregnancies and all of the nine pseudosacs. The sensitivity of the Doppler technique for the detection of intrauterine pregnancies was 84%, and the specificity was 100%.     

Pictorial essay: Transabdominal and endovaginal sonography of adnexal masses

Endovaginal sonography is rapidly becoming the diagnostic procedure of choice when evaluating patients with early pregnancy and assessing uterine abnormalities. However, there has been relatively little discussion of endovaginal sonography in the evaluation of adnexal masses. Using endovaginal sonography we studied 50 patients with clinically suspected adnexal masses, in whom transabdominal sonography was either suboptimal or failed to adequately characterize the mass. The purpose of this pictorial essay is to depict the normal anatomy of the ovaries and adnexa and highlight the unique contribution of endovaginal sonography in diagnosing a variety of adnexal masses, including tubal and ovarian lesions.     

Transvaginal sonography in the evaluation of normal early pregnancy: correlation with HCG level

Transvaginal sonography (TVS) is the procedure of choice in evaluating the viability of embryos early in pregnancy. However, viability based on TVS can be assessed more accurately when the exact gestational age from the last menstrual period is known or when the findings are correlated with beta human chorionic gonadotropin (HCG) levels. No large series has been reported with correlative data between early pregnancy findings, HCG, and gestational age. We performed 75 transvaginal examinations in 53 patients with proved normal pregnancy in the fifth through seventh weeks of gestation. The presence and size of the gestational sac, presence of a yolk sac, and identification of embryonic heart activity were correlated with the level of HCG. Sac size was correlated with yolk sac and heart activity and the three parameters correlated with gestational age in days. When the level of HCG reached 1000 mIU/ml by using the first International Reference Preparation, a gestational sac was seen sonographically in each patient. When the HCG level reached 7200 mIU/ml, a yolk sac was seen in every patient. Ten of 22 patients with HCG between 1000 and 7200 mIU/ml had a visible yolk sac. Every patient with an HCG level greater than 10,800 mIU/ml had a visible embryo with a heartbeat. A discriminatory level of 32 days was found for the presence of a gestational sac. A yolk sac was first seen in every patient between 36 and 40 days. Every patient with accurate dates greater than 40 days had an embryo with a heartbeat identified. When correlating sac size with structures within the sac, a yolk sac was first seen in a gestational sac between 6 and 9 mm and a heartbeat seen in every patient with a 9-mm or greater gestational sac diameter. These data allow identification of normal intrauterine pregnancy and distinction of normal from ectopic gestation at least 1 week earlier than is possible with transabdominal techniques.     

Expectant treatment of ectopic pregnancies: clinical and sonographic predictors

OBJECTIVE. We identified the potential clinical and sonographic predictors of the spontaneous resolution of ectopic pregnancies. SUBJECTS AND METHODS. We performed a prospective study of 78 consecutive patients with a transvaginal sonographic diagnosis of ectopic pregnancy who had either two consecutive quantitative measurements of their beta subunit of human chorionic gonadotropin (beta-hCG) more than 24 hrs apart or an embryo with a heart beat. We evaluated the patient's age, time from the last menstrual period, beta-hCG level, size of ectopic pregnancy, presence of a gestational sac or embryonic elements, vascularity on color Doppler sonography, peak systolic velocity, and resistive index of ectopic pregnancy at the time of presentation as potential independent predictors of the final outcome. Logistic regression was performed to identify the independent predictors. RESULTS. Forty-six patients had declining beta-hCG levels, and 32 ectopic pregnancies showed an embryo with a heart beat or had steady or rising beta-hCG levels. Univariate analysis indicated that a longer time from the last menstrual period (older ectopic pregnancies), lower beta-hCG levels, and the absence of gestational sac are statistically more significantly seen in ectopic pregnancies with declining beta-hCG levels (p < 0.05). Resistive index of ectopic pregnancy reached borderline significance (p = 0.05). In a multiple logistic model, the same variables were independent predictors of outcome (p < 0.05). Resistive index was also a predictor (p = 0.09). CONCLUSION. Longer times from the last menstrual period, lower beta-hCG levels, absence of gestational sacs, and higher resistive indexes of ectopic pregnancy at the time of presentation appear to be independent predictors of the spontaneous resolution of ectopic pregnancy.     

Ultrasonographic differentiation of the gestational sac of early intrauterine pregnancy from the pseudogestational sac of ectopic pregnancy

A retrospective review of 128 consecutively scanned pregnant patients who had either early intrauterine pregnancies (IUPs) or ectopic pregnancies was performed to determine the accuracy of the finding of an intrauterine double decidual sac (DDS) in distinguishing between these two groups of patients. The presence of a DDS correlated with an IUP in 59 of 60 patients (98.3%). Of 68 patients who lacked a DDS, only four had normal IUPs; the remaining patients had either ectopic pregnancies or abnormal IUPs. Results of this study suggest that the finding of a DDS at ultrasonography is useful in making an early diagnosis of IUP, while its absence strongly suggests either an ectopic pregnancy or an abnormal IUP.     

Ectopic pregnancies in caesarean section scars: 5 years experience

PurposeThe aim of the study is to evaluate our 5 years experience in diagnosis and treatment of ectopic pregnancy developing in a Caesarean section scar.Subjects & methodsThe study included twenty-one women, diagnosed with a Caesarean scar ectopic pregnancy (CSEP) in the first trimester, which was confirmed by ultrasound and treated in our hospital during 5 years between 2012 and 2016. The clinical presentations, imaging findings, and treatment outcomes of all these pregnancies were recorded.ResultsThe main complaints of the patients were vaginal bleeding in 7 (33.3%) of cases and abdominal pain in association with vaginal bleeding in 4 (19.1%) of cases. However, the remaining 10 cases (47.6%) were asymptomatic. The number of previous Caesarean sections ranged from 1 to 4 with an average of 2.14, 24% (5/21) of our patients had only one prior Caesarean section, 43% (9/21) had 2 prior Caesarean sections, 28% (6/21) had 3 prior Caesarean sections and only 5%, (1/21) had 4 prior Caesarean sections.All our 21 cases underwent successful early first trimester diagnosis with trans-vaginal color Doppler ultrasonography. All our 21 cases showed empty uterus and empty cervical canal with visualization of gestational sac at the presumed site of the Caesarean scar; however, 13 cases showed thinned myometrium (<5 mm) between the gestational sac and bladder. The mean thickness of Caesarean section incision scar was 0.3 ± 0.15 cm. 7 cases (33.3%) showed no embryo in the gestational sac while 14 cases (66.7%) showed embryonic gestational sac, 9 cases from the 14 showed heart activity.MRI studies were done in 7 patients with Caesarean scar ectopic pregnancy to confirm the diagnosis and to follow up 2 complicated cases.In all 7 cases, the diagnosis of Caesarean scar ectopic pregnancy using MRI included empty uterine and cervical cavities, and a gestational sac seen embedded within the site of caesarean scar, with thin myometrium adjacent to the sac. No bulging of the sac through the myometrium or bladder invasion was detected.Termination of pregnancy was done by systemic methotrexate administration in 14 cases, and with trans-cervical aspiration of the gestational sac in 7 cases. Intra-operative bleeding occurred in all 7 cases treated with aspiration of the gestational sac, one of the 7 cases complicated with hysterectomy, while one patient complicated with uterine rupture and was treated conservatively. The cases treated with systemic methotrexate injection showed no complication. The Caesarean scar mass was followed with trans-vaginal ultrasound and regressed within 2 months to about 1 year post treatment.ConclusionEarly imaging diagnosis and effective treatment of CSEP are critically important not only to improve outcomes, minimize maternal complications and the need for emergency extended surgery, but also to maintain treatment options, and potentially preserve future fertility.     

Early diagnosis of nonviable pregnancy with endovaginal US

The mean diameter of the gestation sac and the presence or absence of a yolk sac or embryo and/or cardiac pulsations on endovaginal ultrasound (US) images were correlated with normal and abnormal outcomes of pregnancy. Sixty-two patients who were less than 10 weeks pregnant (menstrual age) underwent endovaginal US. In 59 patients with gestation sacs greater than or equal to 8 mm, the absence of a yolk sac predicted a nonviable pregnancy with a sensitivity of 67% and a specificity of 100%. In 35 patients with gestation sacs greater than or equal to 16 mm, the absence of an embryo predicted a nonviable pregnancy with a sensitivity of 50% and a specificity of 100%. When the absence of cardiac pulsations was added to the latter group of patients, the sensitivity was 100% and the specificity was 100%. The combination of these criteria (gestation sac size; demonstration of yolk sac, embryo and/or cardiac pulsations) enabled the early (less than 10 weeks menstrual age) diagnosis of a nonviable pregnancy with endovaginal US.     

Extrauterine findings of ectopic pregnancy of transvaginal US: importance of echogenic fluid

Transvaginal ultrasound (US) studies of 232 consecutive patients with positive serum pregnancy tests who were considered to be at risk for ectopic pregnancy were prospectively evaluated to determine the significance of various extrauterine findings, including echogenic fluid in the cul-de-sac. All patients were found to have a surgically proved ectopic gestation (group 1, 68 patients [29.3%]), reliable evidence of intrauterine pregnancy at initial transvaginal US (group 2, 83 patients [35.8%]), or no evidence of pregnancy at initial transvaginal US, but subsequent proof of an intrauterine pregnancy (group 3, 81 patients [34.9%]). Adnexal findings were demonstrated in 45 (66%) group 1 patients, including a living extrauterine embryo in 10 (15%), an extrauterine gestational sac in 21 (31%), and an adnexal mass in 14 (21%). Intraperitoneal fluid was detected in 43 (63%) group 1 patients and in 81 (31%) group 3 patients. Echogenic fluid was the only abnormal finding at US in 10 (15%) group 1 patients and added confidence to the diagnosis of ectopic pregnancy in many others. Echogenic fluid correlated with hemoperitoneum at the time of surgery. The presence of echogenic fluid indicates a high risk for ectopic pregnancy in women referred with this clinical indication.     

Ectopic pregnancy: criteria and accuracy of ultrasonic diagnosis.

Of 26 ectopic pregnancies, a correct positive ultrasonic diagnosis was made in 77%, while a false negative diagnosis was made in 23%. Most commonly, the ectopic pregnancy appeared as a complex adnexal mass immediately adjacent to an enlarged "empty" uterus. Ultrasonic identification of an extrauterine gestational sac, allowing a definitive diagnosis of ectopic pregnancy, was uncommon.     

Heterotopic pregnancy: value of transabdominal sonography

The authors report a case of an heterotopic pregnancy where the transabdominal US was more useful than endovaginal US. The embryon in this case was located in upper zone of the right iliac fossa, inaccessible to endovaginal US. Both methods are complementary.