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Diagnosis of ectopic pregnancy with ultrasound

https://doi.org/10.1016/j.bpobgyn.2008.12.010Get rights and content

Transvaginal sonography (TVS) is now the imaging modality of choice for the diagnosis of ectopic pregnancy with overall reported sensitivities of > 90%. Specific sonographic criteria exist for the diagnosis of tubal and non-tubal pregnancies including cervical and caesarean section scar pregnancies. Diagnosis is based on the visualization of an ectopic mass rather than the inability to visualize an intra-uterine pregnancy.

This chapter discusses the specific criteria used for the diagnosis of ectopic pregnancy and examines the literature assessing the accuracy of ultrasound as a diagnostic tool.

Section snippets

Criteria for the TVS diagnosis of ectopic pregnancy

A diagnosis of ectopic pregnancy should be made on the basis of the positive visualization of an extra-uterine pregnancy.8 If neither an intra-uterine or extra-uterine pregnancy is visualized on TVS, the woman should be classified as having a “pregnancy of unknown location” and then followed up until the final pregnancy outcome is known. Although the majority of women will be subsequently diagnosed with a failing “pregnancy of unknown location” (PUL) or an intra-uterine pregnancy, data from

Accuracy of TVS in the diagnosis of ectopic pregnancy

The majority of studies on the accuracy of TVS for the diagnosis of ectopic pregnancy relate to the diagnosis of tubal ectopic pregnancies. These studies show TVS to be an accurate diagnostic test for ectopic pregnancy with a high sensitivity (87.0-99.0%) and specificity (94.0-99.9%).*14, *17, 33, 34, 35, *36Table 2 summarizes some of the published studies assessing the performance of TVS in the diagnosis of ectopic pregnancy. However, the results should be interpreted with caution as the

Why are some ectopic pregnancies not visualized on TVS?

While TVS has a high sensitivity for the detection of ectopic pregnancy, not all of those ectopic pregnancies visualized on TVS are visualized initially and indeed, some are never visualized at all. A quarter of women with ectopic pregnancies are classified as PULs at the time of their first scan.36 There may be a number of reasons why an ectopic pregnancy may not be visualized on TVS. These include poor quality ultrasound equipment or technique, an inexperienced ultrasound operator, increased

Summary

Transvaginal sonography (TVS) is now the imaging modality of choice for the diagnosis of ectopic pregnancy. More than 90% of ectopic pregnancies should be visualized on TVS prior to treatment. The majority of these (∼75%) will be visualized on the initial TVS examination. Women with a positive pregnancy test in whom neither an intra-uterine or extra-uterine pregnancy is visualized on the initial TVS should be classified as having a PUL. A proportion of these women will subsequently have an

Conflict of interest

None declared.

Practice points

  • Transvaginal sonography (TVS) is the imaging modality of choice for the diagnosis of ectopic pregnancy

  • Diagnosis should be based on the positive visualization of an ectopic mass rather than the inability to visualize an intra-uterine pregnancy

  • More than 90% of ectopic pregnancies should be visualized on TVS prior to treatment

Research agenda

  • Identify features that will enable patients to be selected for medical or expectant management

References (38)

  • F.A. Aleem et al.

    Endovaginal sonography for the early diagnosis of intrauterine and ectopic pregnancies

    Hum Reprod

    (1990)
  • M. Valenzano et al.

    Transabdominal and transvaginal ultrasonographic diagnosis of ectopic pregnancy: clinical implications

    Gynecol Obstet Invest

    (1991)
  • S. Banerjee et al.

    The expectant management of women with pregnancies of unknown location

    Ultrasound Obstet Gynecol

    (1999)
  • G. Condous et al.

    Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location

    Ultrasound Obstet Gynaecol

    (2005)
  • M. Hahlin et al.

    The expectant management of early pregnancies of uncertain site

    Hum Reprod

    (1995)
  • E. Kirk et al.

    Rationalizing the follow-up of pregnancies of unknown location

    Hum Reprod

    (2007)
  • G. Condous et al.

    The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery

    Hum Reprod

    (2005)
  • S. Goldstein et al.

    Ultrasound in gynecology

    (1995)
  • D.L. Brown et al.

    Transvaginal sonography for diagnosing ectopic pregnancy: positivity criteria and performance characteristics

    J Ultrasound Med

    (1994)
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