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Understand diagnostic and treatment algorithms to make appropriate dispositions for patients suspected of having an ectopic pregnancy. Patients at greatest risk for developing an ectopic pregnancy are those with anatomic abnormalities impairing the ability of a fertilized egg to implant in the uterus.
Symptoms of an ectopic pregnancy develop as the fetus grows by distorting surrounding tissue or rupturing causing peritoneal irritation. In one study, only 10% of physicians were able to identify the presence of less than 400cc of free intraperitoneal fluid, suggesting that a positive FAST typically indicates a large amount of acute blood loss. All women of childbearing age presenting to the ED with abdominal or pelvic pain should have a urine pregnancy test performed immediately on arrival.
Stable patients in the first trimester of pregnancy with abdominal pain and vaginal bleeding can be further evaluated in the ED. The earliest sign of an IUP by transvaginal ultrasound is the double decidual sac sign (click on Figure to the left), occurring at around 4.5-5 weeks after the last menstrual period (LMP).
The β-hCG is a glycoprotein hormone produced by trophoblasts that doubles approximately every 48-72 hours in the first trimester.
Although rarely used since the advent of ultrasound, culdocentesis is a simple, bedside procedure that can be performed when ultrasonography is not rapidly available on a potentially unstable patient to detect the presence of intraperitoneal blood.
Any patient strongly suspected of having an ectopic pregnancy needs to be medically or surgically managed in conjunction with OB-GYN.
Methotrexate is the most successful method to medically manage a patient with ectopic pregnancy and may preserve fertility better than surgical interventions. All patients suspected of having an ectopic pregnancy are managed in conjunction with OB-GYN.
The presentation of ectopic pregnancy can be highly variable, so maintaining a high index of suspicion is paramount to making the diagnosis. Serum β-hCG values should not be used to determine which patients should have transvaginal ultrasound. An ectopic pregnancy can be 'ruled out' in the presence of an IUP in a patient not undergoing infertility treatment. Ectopic pregnancy is managed surgically in cases of clinical instability, contraindications to medical therapy, or failure of medical therapy.
Any patient discharged from the ED with a potential ectopic pregnancy should understand "ectopic precautions" and have the means to return immediately to the ED.
The purpose of this document is to present evidence regarding methodology, indications, benefits, and risks of obstetric ultrasonography in specific clinical situations.
Although there is no reliable evidence of physical harm to human fetuses from diagnostic ultrasound imaging, public health experts, clinicians, and industry representatives agree that casual use of ultrasonography, especially during pregnancy, should be avoided. In an attempt to answer these concerns over the safety of ultrasound, studies are initiated to determine if there is an association between diagnostic ultrasound imaging in utero and chromosomal abnormalities, altered fetal growth, learning disabilities, or even malignancy.
The American College of Obstetricians and Gynecologists uses the terms "standard," "limited," and "specialized" to describe various types of ultrasound examinations performed during the second or third trimesters. Limited Examination: A limited examination is performed when a specific question requires investigation. Specialized Examination: A detailed or targeted anatomic examination is performed when an anomaly is suspected on the basis of history, biochemical abnormalities or clinical evaluation, or suspicious results from either the limited or standard ultrasound examination. The primary goal of ultrasound evaluation in the first trimester is to determine whether the pregnancy is intrauterine and whether the embryo is living. There is no question that, with a careful examination, the true number of embryos can be accurately determined in the first trimester.
Although evaluating the number of fetuses may be difficult during early pregnancy, it should be extremely easy and accurate in the second- and third-trimesters. A second-trimester specialized ultrasound examination may be targeted to detect fetal aneuploidy. Ultrasound Assessment of Cervical Length: Preterm birth is the main cause of perinatal morbidity and mortality. Cervical ultrasonography has yet no appreciable clinical usefulness in low-risk populations because of its poor positive predictive value and the absence of preventive therapy. The American Institute of Ultrasound in Medicine (AIUM) advocates the responsible use of diagnostic ultrasound. Ultrasound examination is an accurate method of determining gestational age, fetal number, viability, and placental location.
Depending on the age of the gestation, these graphs can be used to determine the correct EDD.
Mean Sac Diameter measurement is used to determine gestational age before a Crown Rump length can be clearly measured.The average sac diameter is determined by measuring the length,width and height then dividing by 3 . The following image is using a transvaginal approach the gestational sac can be seen during week 4-5. The Crown Rump Length (CRL) measurement in a 6 week gestation.A mass of fetal cells, separate from the yolk sac, first becomes apparent on transvaginal ultrasound just after the 6th week of gestation. The fetal pole grows at a rate of about 1 mm a day, starting at the 6th week of gestational age. Using a transvaginal approach the fetal heart beat can be seen flickering before the fetal pole is even identified. Sometimes there is difficulty distinguishing between the maternal pulse and fetal heart beat. Until 53 days from the LMP, the most caudad portion of the fetal cell mass is the caudal neurospone, followed by the tail.
Until 60 days from the LMP, the most cephalad portion of the fetal cell mass is initially the rostral neurospore, and later the cervical flexure. What is really measured during this early development of the fetus is the longest fetal diameter. The outer chorion with the developing placenta and the inner amnion which will "inflate" with the production of fetal urine,to adhere to the chorion obliterating the residual yolk sac. Initially twins may be identified as 2 separate gestational sacs (ie diamniotic, dichorionic) They may be 2 fetal poles within the same gestational sac (monochorionic). It is a sad situation when a "vanishing twin" occurs, which is about 20% of twin pregnancies. Ultrasound is essentially used for assessing gestational age, current viability and maternal wellbeing. If multiple pregnancy, confirm number of foetuses, number of sacs, and number of placentas present to determine chorionicity.
Measure CRL to calculate gestational age and Estimated Date of Delivery(EDD).If too early to see the foetal pole measure the average sac diameter.
Plain abdominal radiography is often the first diagnostic study performed in these patients. Volume-rendered sagittal and coronal CT scans may improve the visualization of the fistula. Possible complications such as strangulation of bowel or an underlying neoplastic process can be detected.
2 clicks for more privacy: On the first click the button will be activated and you can then share the poster with a second click. Ectopic pregnancy is defined as any pregnancy implanted outside the uterus, with approximately 97% occurring in the fallopian tube. Tubal factors including history of salpingitis, tubal surgery, and previous ectopic pregnancy are the most important risk factors for ectopic pregnancy.
The classic triad of abdominal pain, delayed menses, and vaginal bleeding is neither sensitive nor specific for ectopic pregnancy. A pregnancy test should be obtained on all female patients of childbearing age (consider ages 10-60) who present to the ED with complaint of abdominal pain, amenorrhea, or vaginal bleeding. The combination of positive FAST and positive pregnancy test should prompt an immediate call to OB-GYN to take the patient to the OR for a presumptive diagnosis of ruptured ectopic pregnancy. If you have a strong suspicion of pregnancy and the patient provides a dilute urine, a serum pregnancy test should be considered. A transvaginal ultrasound should be obtained to evaluate for the presence or absence of an IUP. A yolk sac (click the Figure just below the one to the left) is typically identified at 5-6 weeks and the presence of a yolk sac has 100% predictive value for an intrauterine pregnancy.
The likelihood of finding a live extrauterine embryo with positive heart motion using ultrasound is only 8-26%. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience. Clinical Policy: Critical issues in the initial evaluiation and mananagement of patients presenting to the emergency department in early pregnancy. Although the almost universal enthusiasm for this modality is exciting, it has raised a new series of questions and problems.

Sections of the document addressing physician qualifications and responsibilities, documentation, quality control, infection control and patient education are the recommendations of Women's Health and Education Center (WHEC). It has been shown, for example that 90% of infants with congenital anomalies are born to women with no risk factors. The most common transducers, which are the "work horses" of the ultrasound laboratory, are a linear array, a sector transducer (3 to 7 MHz) for abdominal transducers, or vaginal transducers, with frequency ranging from 5 to 10 MHz are used. Viewed in this light, exposing the fetus to ultrasonography with no anticipation of medical benefit is not justified (3). Two of the most often cited long-term studies evaluating the effect of ultrasound on the fetus are the work of Stark et al and Salvensen et al. Although the standard and limited examinations are defined by their components, the specialized examination is defined by the indications for the examination, that is, the circumstances that suggest a more thorough ultrasound examination is needed (5).
It includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and an anatomic survey.
In an emergency, for example, a limited examination can be performed to evaluate heart activity in a bleeding patient. Other specialized examinations might include fetal Doppler, biophysical profile, fetal echocardiography, or additional biometric studies. With present day equipment, particularly transvaginal transducers, both of these tasks should be readily accomplished at very early stages of gestation. Amnionicity and chorionicity should be documented for all multiple pregnancies when possible. For multiple pregnancies, additional information should be documented: chorionicity, amnionicity, comparison of fetal sizes, estimation of amniotic fluid volume (increased, decreased, or normal) on each side of the membrane, and fetal genitalia (when visualized). This type of examination has been offered in some centers for the past several years and is aimed at the detection of a range of minor anatomic features associated with an increased risk of fetal aneuploidy. A short cervical length on transvaginal ultrasonography has been shown to be one of the best predictors of spontaneous preterm birth. Gestational age at which transvaginal ultrasound cervical length is measured significantly affects the calculation of risk of spontaneous preterm birth. The AIUM strongly discourages the non-medical purposes (eg, solely to create "keepsake" photographs or videos) for psychosocial or entertainment purposes. Even though centers that perform non-medical ultrasonography and create "keepsake" photographs and videos of the fetus may offer disclaimers about the limitations of their product, customers may interpret an aesthetically pleasing image or entertaining video as evidence of fetal health and appropriate development.
Thus, a simple way to "date" an early pregnancy is to add the length of the fetus (in mm) to 6 weeks. Often technicians will take the mothers pulse at the same time to check if it is the fetus or the mothers .
This is the result of normal midgut proliferation and will resolve by 11 weeks as the fetus lengthens.
The rhombencephalon of the developing brain is visible as a prominent fluid space posteriorly. The accuracy of this is increased by factoring in the levels of bHCG and PappA in the maternal blood. It is easier to determine chorionicity earlier in the pregnancy depending on the chorionicity and amnionicity. Over the next hour, drink at least 1 litre of water and do not go to the toilet until instructed. It is a life threatening condition complicating 1 in 80 pregnancies presenting to emergency departments.
It is important to recognize that many ectopic pregnancies occur in women without any recognized risk factors, so maintaining a high index of suspicion is paramount to making an accurate diagnosis.
Symptoms and physical findings are highly variable among patients, making the diagnosis extremely challenging. If an IUP is visualized, a concurrent ectopic pregnancy (heterotopic pregnancy) is statistically unlikely unless the patient has received fertility treatments. An ectopic pregnancy cannot be excluded until the patient has a yolk sac demonstrated within the gestational sac. ACEP's clinical policy on patients presenting to the ED in early pregnancy states that a transvaginal ultrasound should be performed on all patients in whom the diagnosis of ectopic pregnancy is considered despite the β-hCG level, as both IUP's and ruptured ectopics have been diagnosed at very low levels.
Ultrasound signs of an ectopic include an empty uterus, extraovarian mass, tubal ring sign (click Figure to the left), and pelvic free fluid.
Greater than 2ml of nonclotting blood is suggestive of hemoperitoneum and ruptured ectopic pregnancy.
Patients with significant pain without signs of rupture should be admitted for close observation and serial reassessments. It has now been nearly 5 decades since sonography was first used to evaluate the obstetric patient. However, several studies conducted between 1985 and 1994 found routine ultrasound screening yielded no consistent impact on perinatal mortality or morbidity. The higher-frequency transducers are most useful in achieving high-resolution scans, and the lower-frequency transducers are useful in those circumstances in which increased penetration of the sound beam is necessary. Stark et al studied 425 children at birth and between 7 and 12 years of age who were exposed to diagnostic ultrasound in utero. First-trimester obstetric ultrasonography is distinct from these and is discussed separately. This evaluation also would be appropriate for verifying fetal presentation in a laboring patient; however, in most cases, a limited examination is appropriate only when the patient has had a prior complete examination. Specialized examinations are performed by an operator with experience and expertise in such ultrasonography who determines the components of the examination on a case-by-case basis. When multiple gestations are missed using ultrasound assessment, it is usually from a less than optimal first trimester examination.
Advanced maternal age or an abnormal first- or second-trimester multiple marker screen indicating and increased risk for Down syndrome are among the indications for a specialized ultrasound examination. Screening for a short cervical length has been studied in several populations, including asymptomatic women with singleton gestations at either low or high risk for preterm birth, multiple gestations, and symptomatic women with either preterm labor or preterm premature rupture of the membranes. The spontaneous preterm birth risk increases as the length of the cervix declines and as the gestational age decreases. The use of either two-dimensional (2D) or three-dimensional (3D) ultrasound to only view the fetus, obtain a picture of the fetus or determine the fetal gender without a medical indication is inappropriate and contrary to responsible medical practice. Ultrasonography performed for psychosocial or entertainment purposes may be limited by the extent and duration of the examination, the training of those acquiring the images, and the quality control in place at the ultrasound facility.
Using this method, a fetal pole measuring 5 mm would have a gestational age of 6 weeks and 5 days.
It may be below 100 beats per minute but this will increase to between 120- 180 beats per minute by 7 weeks. Instead, its development arrests and it is reabsorbed, with no evidence at delivery of the twin pregnancy. Supine and erect plain abdominal radiographies show an ectopic gallstone in the left lower quadrant of the abdomen (red arrow), colonic dilatation (green arrows) with competent ileocecal valve and pneumobilia (blue arrow).
Abdominal TC scan shows pneumobilia (blue arrow) and air in the gallbladder due to a bilio-enteric fistula (white arrows). CT scan shows the classic Rigler’s triad: pneumobilia (blue arrow) with dilatation of the intrahepatic bile ducts, ectopic gallstone in terminal ileum (red arrow), and small bowel dilatation (green arrow).
Abdominal pain is the most common symptom and is reported in as many as 98.6% of patients, but its severity and quality is highly variable. This occurs spontaneously at a rate of only 1 in 10,000 pregnancies, but the incidence is much higher for women using infertility drugs or assisted reproductive technologies .
An ectopic pregnancy is highly likely in patients with a β-hCG level greater than 1500 with the absence of intrauterine pregnancy on transvaginal ultrasound. It works by interfering with syntheses of DNA and cell replication of fetal cells, resulting in involution of the pregnancy. Clinically stable patients with an ectopic pregnancy may be managed medically with methotrexate if they have an excellent follow up plan. Through the education process of the healthcare providers will help alleviate errors in diagnosis. In the screened population, the detection rate for congenital anomalies ranged from 16% to 85%.
Variations of transducer technology include convex linear transducers and multi-frequency probes. Birth-weight, Apgar scores, and neurologic and cognitive testing revealed no biologically significant differences between exposed and unexposed children. Fetal anatomy, may be assessed adequately by ultrasonography after approximately 16-20 weeks of gestation.
It is for these reasons that some investigators prefer that if one ultrasound examination is to be done concentrating on fetal number, it should be done in the early to middle second trimester of pregnancy.

The use of the ultrasound markers developed in high-prevalence patient populations in screening for Down syndrome in a low-risk population in the second trimester currently is premature. In a study of 188 women with histories of a prior preterm delivery who underwent serial endovaginal sonography between 22-24 weeks of gestation, Durnwald and colleagues found that, of the women with cervixes shorter than 25 mm, 36% delivered before 35 weeks (7).
These spontaneous preterm birth risks are important for counseling and management for women with various degrees of short cervical length at different gestational age (9). Although there are no confirmed biological effects on patients caused by exposures from present diagnostic ultrasound instruments, the possibility exists that such biological effects may be identified in the future.
An ectopic pregnancy will appear the smae but it will not be within the endometrial cavity. Despite the improved diagnostic modalities, ectopic pregnancy is still frequently misdiagnosed on initial presentation with up to 40-50% of patients correctly diagnosed on repeat visits.
Amenorrhea is present in almost 75% of women with ectopic pregnancies, and irregular vaginal bleeding occurs in 56.4%, but may be minimal even in the critically ill patient. Treatment failure with single dose methotrexate occurs in up to 36% of patients necessitating administration of a second dose of methotrexate if β-hCG values are not decreasing as expected. For those hemodynamically stable patients with inconclusive ultrasound findings where the diagnosis is in doubt, they may be managed as an outpatient with serial ultrasound examinations and β-hCG levels. At its inception it was difficult to convince clinicians as to the usefulness of this new diagnostic modality. A subsequent secondary analysis of these studies concluded that routine screening was cost-effective. Food and Drug Administration views the promotion sale, or lease of ultrasound equipment for making "keepsake" fetal videos are and unapproved use of a medical device; use of ultrasonography without a physician's order may be a violation of state or local law or regulations regarding the use of a prescription medical device.
Salvensen et al found no difference in dyslexia between ultrasound-exposed and control groups.
It may be possible to document normal structures before this time, although some structures can be difficult to visualize because of fetal size, position, movement, abdominal scars, and increased maternal wall thickness. Another study of 69 women with prior preterm delivery and serial endovaginal sonography every 2 weeks between 16 and 30 weeks of gestation showed that women at less than 20 weeks with cervical length less than the 10th percentile (22 mm) or funneling of internal os had an increased risk of recurrent preterm birth, with 33% delivering within 2 weeks, 66% delivering within 4 weeks, and 100% delivering before 35 weeks. Thus ultrasound should be used in a prudent manner to provide medical benefit to the patient (10). Abnormalities may be detected in settings that are not prepared to discuss and provide follow-up for concerning findings. Failure to identify fetal cardiac activity in a fetus whose overall length is greater than 4 mm is an ominous sign.
Overall, it accounts for about 9% of all pregnancy-related maternal deaths, and is one of the leading causes of maternal death in the first trimester. Tenderness on pelvic exam is the most common physical exam finding, but few patients will have a palpable pelvic mass. Contraindications for receiving methotrexate include hemodynamic instability, inability to return for follow-up, breastfeeding, immunodeficiency, renal, liver or pulmonary disease, peptic ulcer disease, and blood dyscrasias. Now, it is not unusual for a patient to have one or even several ultrasound examinations during her pregnancy. Before an ultrasound examination is performed, patients should be counseled about the limitations of ultrasonography for diagnosis. Using a mathematical model to evaluate further the published results, other researchers concluded that routine screening at tertiary centers would be cost-effective, but screening in non-tertiary centers resulted in a net loss (1). Two measurements of acoustic output are displayed on-screen with contemporary ultrasound equipment. At the present time, based on available studies, there is little evidence to indicate ultrasonography as causing abnormalities in the human fetus. A second- or third-trimester ultrasound examination may pose technical limitations for an anatomic evaluation because of imaging artifacts from acoustic shadowing. Without the ready availability of appropriate prenatal health care professionals, customers at sites for non-medical ultrasonography may be left without necessary support, information, and follow-up for concerning findings. Failure to identify (with transvaginal ultrasound) a yolk sac when the gestational sac has grown to 12 mm is also usually indicative of a failed pregnancy. Early diagnosis and treatment is essential in reducing maternal mortality and preserving future fertility. The diagnosis of ectopic pregnancy should be considered in female patients presenting to the ED with syncope or unexplained hypotension.
All patients discharged from the ED who have the potential to have an ectopic pregnancy must receive and understand the "ectopic precautions" and be instructed to return to the ED immediately if they develop worsening pain, vaginal bleeding, dizziness, syncope, or weakness.
The appeal of ultrasound examination is that it is a non-invasive, safe procedure that has a high degree of patient acceptance and can yield a wealth of information. In some countries, as many as 90% to 100% of women seeking obstetric care will have at least one ultrasound examination during pregnancy.
The thermal index is an estimate of possible tissue temperature increase that may be caused by ultrasound absorption. The major biologic effects of ultrasonography are believed to be thermal (a rise in temperature) and cavitation (production and collapse of gas-filled bubbles). When this occurs, the report of the ultrasound examination should document the nature of this technical limitation. The cul-de-sac should be evaluated by ultrasonography for the presence or absence of fluid. Obstetric ultrasonography is most appropriately obtained as part of an integrated system for delivering prenatal care.
The optimal timing for a single ultrasound examination in the absence of specific indications for a first-trimester examination is at 16-20 weeks of gestation. The majority of patients with an ectopic pregnancy have normal vital signs until they have experienced significant blood loss. If ultrasound evaluation is relatively safe and non-invasive and has the potential for yielding important diagnostic information, then why not use this modality in every pregnant patient?
The mechanical index is a measure of the interaction of ultrasonography with microscopic gas bubbles that are present in all tissues.
Although it has been shown that a rise in temperature of less than 1o C may occur during diagnostic ultrasound evaluation, this is unlikely to have any clinical impact in humans.
Serial ultrasonograms to determine the rate of growth should be obtained approximately every 2-4 weeks.
Paradoxic bradycardia can occur in ectopic pregnancy, thus vital signs should not be reassuring and all patients with ectopic pregnancy should be considered potentially unstable. The mechanical index incorporates cavitations with other possible non-thermal effects of ultrasonography.
Likewise, cavitation (which requires the preexistence of stable gas-filled nuclei) may occur in humans. When the thermal index and mechanical index are adjusted by the user to values of less than unity, the likelihood of tissue effect is very low (2).
In the past 5 years, there has been concern raised over the use of pulsed Doppler imaging when applied to the developing embryo. Most machines allow adjustment of output and will instantly recalculate and display the new thermal index and mechanical index. Spectral or pulsed Doppler imaging uses high-amplitude transmit pulses due to the fact that the signal reflected from blood is small.
Appropriate documentation of an obstetric or gynecologic ultrasound examination is essential to both direct clinical care and quality assurance. Most manufacturers now offer machines capable of 3-dimensional surface rendering of fetal anatomy, and some offer near real-time 3-dimensional imaging. All of those factors when taken together mean that spectral Doppler has a high likelihood of producing a bioeffect in tissue. Ideally, quality control is accomplished through careful recordkeeping of obstetric ultrasound examination results, reliable archival of reports and images, and clinical correlation with clinical outcomes. Although the potential for embryonic effects from Doppler imaging exists, there is little evidence that ultrasound is teratogenic. Any practice active in obstetric ultrasonography should maintain such records and make every effort to correlate imaging results with ultimate clinical outcome data. Ledoux began her career as an ObGyn nurse practitioner prior to becoming a practicing midwife in the Santa Cruz community. Working together with ObGyn physicians in her own practice, she has over 20 years experience in women's health, pregnancy and childbirth.

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