An ectopic pregnancy occurs when a fertilized egg implants outside of the uterus, most commonly in the fallopian tubes. Symptoms can include abdominal pain and bleeding. Diagnosis is made through ultrasound and beta-hCG blood tests. Treatment depends on the location and stability of the patient, and may include surgery, medication with methotrexate, or expectant management. Complications can include tubal rupture in 20-30% of cases.

1. ECTOPIC PREGNANCY
Dr. Abhijeet Bhambure
Junior Resident,
Department of Radiology,
KIMS , Karad.

2. • Ectopic pregnancy
• Ectopic pregnancy refers to the implantation of a
fertilised ovum outside of the uterine cavity.
• Epidemiology
- increased over the last few decades (1-2% of
pregnancies).
- The risk is as high as 18% for first trimester pregnancies
with bleeding .
- There is an increased incidence associated with in-vitro
fertilisation (IVF) pregnancies.
• Clinical presentation
• The classic presentation abdominal pain and bleeding.
However in first trimester the symtoms may not be
severe like mild pelvic pain with PV spotting.

3. • Locations
• In the vast majority of cases, the ectopic implantation site
is within a Fallopian tube.
• tubal ectopic: 93-97%
– ampullary ectopic: most common ~70% of tubal ectopics and
~65% of all ectopics
– isthmal ectopic: ~12% of tubal ectopics and ~11% of all
ectopics
– fimbrial ectopic: ~11% of tubal ectopics and ~10% of all
ectopics
• interstitial ectopic/cornual ectopic: 3-4%; also essentially
a type of tubal ectopic
• ovarian ectopic: ovarian pregnancy; 0.5-1%
• cervical ectopic: cervical pregnancy; rare <1%
• scar ectopic: site of previous Caesarian section scar; rare
• abdominal ectopic: rare ~1.4%

5. • Risk factors
- in vitro fertilisation (IVF)
- prior ectopic pregnancy
- tubal injury or surgery / tubal ligation
- pelvic inflammatory disease
- salpingitis isthmica nodosa
- endometrial injury or congenital anomalies
- use of intrauterine contraceptive devices
- Endometriosis
- history of placenta praevia
• Markers
• Serum beta HCG levels
- Normal pregnancy doubling time is 48hrs.
- an increase of 50% or less in 48 hours is strongly suggestive of a non-
viable (either intra- or extra-uterine) pregnancy.
• Serum progesterone levels
- Non viable pregnancy/ pregnancy failure includes 5 ng/ml or less
- Viable pregnancy, progesterone is usually 20 ng/ml or more. (large grey
zone thus not considered protocols for managing suspected cases.)

7. RADIOLOGICAL FEATURES
• Ultrasound
• The ultrasound exam should be
performed both transabdominally
and transvaginally. The
transabdominal component provides
a wider overview of the abdomen,
whereas a transvaginal scan is
important for diagnostic sensitivity.
• Positive sonographic findings include:
• uterus
– empty uterine cavity or no evidence of
intrauterine pregnancy
– pseudogestational sac or decidual cyst:
may be seen in 10-20% of ectopic
pregnancies
• current evidence suggests that one
should not initiate treatment for an
ectopic pregnancy in a
haemodynamically stable woman on the
basis of a single hCG value 10
– decidual cast
– thick echogenic endometrium
Intrauterine fluid collection
in UPT + pts, centrally
placed without content
sometimes with debris,
irregular margins.

8. • tube and ovarysimple adnexal cyst:
10% chance of an ectopic
• complex extra-adnexal cyst/mass:
95% chance of a tubal ectopic (if no
IUP)
– an intra-adnexal cyst/mass is more likely
to be a corpus luteum
• solid hyperechoic mass is possible,
but non-specific
• tubal ring sign
– 95% chance of a tubal ectopic if seen
– described in 49% of ectopics and in 68%
of unruptured ectopics
• ring of fire sign: can be seen on colour
Doppler in a tubal ectopic, but can
also be seen in a corpus luteum
• absence of colour Doppler flow does
not exclude an ectopic
• live extrauterine pregnancy (i.e. extra-
uterine fetal cardiac activity): 100%
specific, but only seen in a minority of
cases
Adnexa an hyperechoic ring structure in absence of IUG

10. • peritoneal cavity
– free pelvic fluid or
haemoperitoneum in the
pouch of Douglas
• the presence of free
intraperitoneal fluid in the
context of a positive beta HCG
and empty uterus is
– ~70% specific for an ectopic
pregnancy 4
– ~63% sensitive for ectopic
pregnancy 4
– not specific for ruptured
ectopic (seen in 37% of intact
tubal ectopics)
– live pregnancy: 100% specific,
but only seen in a minority of
cases
• In vitro fertilization pt have
increased chances of
heterotopic pregnancy

11. -our goal is to identify an IUP.
-If we can’t, and the BHCG is positive,
this is an ectopic until proven otherwise

12. COMPLICATION. TREATMENT
• Tubal rupture in 20-30% cases.
• Management depends on the location of the
ectopic pregnancy and the patient's haemodynamic
status. In general, the options are:
• surgical: open or laparoscopic salpingectomy
or salpingotomy
• medical
– Methotrexate either administered systemically or by
direct ultrasound guided injection or potassium chloride
• conservative or expectant management is being
recognised as an option for those ectopics where
rupture has not occurred (i.e. no haemoperitoneum) and
fetal demise has already taken place

13. Differential diagnosis
• The differential diagnosis of abdominal pain in a
pregnant patient is broad. An ectopic pregnancy
must be excluded with ultrasound. Other
common diagnoses in this setting include:
• ruptured corpus luteum
• exophytic corpus luteum of pregnancy
• intrauterine pregnancy
• incidental adnexal mass
• appendicitis (negative beta-hCG)