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.     

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.     

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.     

Yolk sac diameter and shape at endovaginal US: predictors of pregnancy outcome in the first trimester.

Four hundred eighty-six consecutive women who underwent endovaginal sonography when their fetuses were less than 10 weeks menstrual age (MA) were evaluated to establish the normal size and shape of the secondary yolk sac (YS) and to assess the value of YS measurement in predicting pregnancy outcome in the first trimester. A YS diameter more than two standard deviations (SDs) above the mean when compared with the mean gestational sac diameter allowed prediction of an abnormal pregnancy outcome with a sensitivity of 15.6%, a specificity of 97.4%, and a positive predictive value of 60.0%. A YS diameter more than two SDs below the mean allowed prediction of an abnormal outcome with a sensitivity of 15.6%, a specificity of 95.3%, and a positive predictive value of 44.4%. No pregnancy with a normal outcome had a YS diameter of greater than 5.6 mm at less than 10 weeks MA. In six patients, the YS diameter was greater than 5.6 mm. All six had an abnormal outcome. Of seven patients with abnormal YS shape at initial sonography, three had abnormal YS shape at follow-up examinations. All three had an abnormal outcome.     

Anal incontinence: diagnosis by endoanal US or endovaginal MRI

Preoperative evaluation was made of the diagnostic value of endoanal ultrasound (EAUS) and endovaginal magnetic resonance imaging (EVMRI) in diagnosing anal sphincter defects as the cause of anal incontinence. Nineteen female individuals with anal incontinence were examined clinically with EAUS and with EVMRI at 1.5 T using a prostatic coil. The findings were evaluated independently and compared with findings at surgery. In diagnosing external anal sphincter defects, EAUS and EVMRI showed almost similar agreement with surgical findings, 12 (63%) out of 19 vs 11 (58%), respectively. Internal anal sphincter defects were equally detected by EAUS and EVMRI as compared with surgical diagnosis. There was considerable variation between radiologists in diagnosing defects by EVMRI. EAUS and EVMRI are equal in diagnosing anal sphincter defects.Abbreviations IAS Internal anal sphincter - EAS External anal sphincter - EAUS Endoanal ultrasound - MR Magnetic resonance - PPV Positive predictive value - NPV Negative predictive value - EVMRI Endovaginal magnetic resonance imaging - EAMRI Endoanal magnetic resonance imaging     

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.     

Complicated first-trimester pregnancies: evaluation with endovaginal US versus transabdominal technique

Endovaginal ultrasound (US) was performed in 38 pregnant women at 5-12 menstrual weeks, when the initial transabdominal sonograms had been considered inconclusive or equivocal. Clinical follow-up disclosed 32 intrauterine pregnancies (12 living, 18 spontaneous incomplete abortions, and two embryonic demises) and six ectopic pregnancies. In the 32 intrauterine pregnancies (normal and abnormal), the correct diagnosis was made in all cases with endovaginal US. The endovaginal images demonstrated the intrauterine embryo, its heart motion, and the yolk sac more clearly and more often when these structures were not apparent on the transabdominal scans. Abnormal gestational sacs were better resolved. In the six cases of ectopic pregnancy, while an extrauterine ectopic sac was visualized in only three, absence of an intrauterine gestational sac was confirmed in all cases with endovaginal scanning. No endovaginal study yielded less information than its transabdominal counterpart. Endovaginal sonography is likely to be diagnostic when transabdominal images fail to yield a definitive diagnosis in early pregnancies.     

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.     

Chronic ectopic pregnancy. A comparison with acute ectopic pregnancy

An ectopic tubal pregnancy that undergoes repeated minor ruptures instead of a single episode of rapid bleeding frequently develops into a pelvic hematocele. The hematocele, which contains old blood, clots and gestational tissue, is surrounded by adhesions and is misleadingly called a "chronic" ectopic pregnancy. The term "chronic" describes only the appearance of the pelvic mass and does not necessarily imply chronicity of duration. Its incidence was 28% in our series of 149 ectopic pregnancies. Fifty percent of our patients with chronic ectopic pregnancy had a negative serum beta human chorionic gonadotrophin (HCG). This entity has a sonographic appearance distinctly different from acute ectopic pregnancy.     

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.     

Suspected appendicitis in children: US and CT--a prospective randomized study

PURPOSE: To evaluate the accuracy of ultrasonography (US) and of abdominal computed tomography (CT) performed in addition to US in the diagnosis of childhood appendicitis. MATERIALS AND METHODS: Six hundred children with suspected appendicitis were included in a prospective randomized study. After clinical examination, the patients were randomly assigned to undergo US only (283 patients) or US with abdominal CT (317 patients). Radiologic findings were correlated with surgical, histopathologic, and clinical follow-up findings. RESULTS: Two hundred forty-four (40.7%) of all patients had appendicitis. In the US only group, US had a sensitivity of 86%, specificity of 95%, positive predictive value of 91%, negative predictive value of 92%, and diagnostic accuracy of 92%. The combination of US and CT performed in the other group yielded a sensitivity of 99%, specificity of 89%, positive predictive value of 87%, negative predictive value of 99%, and diagnostic accuracy of 93%. Analysis of data on US performed in all 600 patients and on CT performed in 317 patients revealed, respectively, sensitivities of 80% and 97%, specificities of 94% and 93%, positive predictive values of 91% and 92%, negative predictive values of 88% and 98%, and diagnostic accuracies of 89% and 95%. The overall negative appendectomy rate was 3.7%; and the perforation rate, 21%. CONCLUSION: US is valuable in the diagnosis of appendicitis in children. In inconclusive cases, performing additional abdominal CT can improve diagnostic accuracy and thereby decrease the negative appendectomy rate without an increase in the perforation rate.