Ultrasonographic Imaging in the Diagnosis of Ectopic Pregnancy

Updated: Sep 23, 2015
  • Author: Timothy Jang, MD; Chief Editor: Gowthaman Gunabushanam, MD, FRCR  more...
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Clinicians should consider the diagnosis of ectopic pregnancy in any woman in the first trimester of pregnancy who has abdominal or pelvic pain, vaginal bleeding, or both. [1] Ectopic pregnancy is the most common cause of pregnancy-related death in the first trimester and accounts for about 10% of all pregnancy-related deaths. Missed ectopic pregnancy is a leading cause of emergency medicine malpractice claims. [2, 3, 4]

High-risk features for the possibility of ectopic pregnancy include history of ectopic pregnancy, history of pelvic inflammatory disease, use of an intrauterine device, and history of tubal surgery. Unfortunately, clinical findings alone cannot reliably diagnose or exclude ectopic pregnancy. [5]

Several studies have validated pelvic ultrasonography in the acute care setting, specifically in the emergency department (ED), as diagnostically accurate and beneficial for flow. [6, 7, 8, 9, 10, 11]

One meta-analysis of emergency physician–performed ultrasonography as a diagnostic test for ectopic pregnancy found that it had a sensitivity of 99.3% and a negative predictive value of 99.96% for detecting an intrauterine pregnancy. Given a disease prevalence of 7.5% and a negative likelihood ratio of 0.08, visualization of intrauterine pregnancy by an emergency physician yields a posttest probability of ectopic pregnancy of 0.6%. [12]

In a first-trimester study of ultrasound features for diagnosis of ectopic pregnancy, an empty uterus was found to predict an ectopic pregnancy with a sensitivity of 32.4% and a specificity of 93.3%. Sensitivity and specificity for a pseudosac, adnexal mass, and free fluid were as follows: 3.3% and 95.0%; 66.2% and 91.3%; and 41.2% and 90.6%. [13]

Bedside ultrasonography is an important tool for emergency medicine clinicians and other acute care clinicians to use in assessing patients’ risk for potential ectopic pregnancy. Early diagnosis can be very valuable in lessening morbidity and mortality. Diagnosis before tubal rupture can prevent life-threatening hemorrhage and increase the probability that the patient may be managed medically or via tube-conserving surgery.

However, use of ultrasonographic imaging should never preclude adequate resuscitation or definitive surgical therapy in a patient who is hemodynamically unstable and in whom ectopic pregnancy is strongly suspected.

The goal of bedside ultrasonography is to diagnose an intrauterine pregnancy (IUP). Ectopic pregnancy can be reliably excluded in patients with a demonstrated IUP; heterotopic pregnancy remains very rare in patients who are not taking fertility agents. Heterotopic pregnancies occur in approximately 1 in 5,000 pregnancies, but the incidence increases to as high as 1 in 100 in women undergoing fertility stimulation or procedures.

This limited diagnostic focus differs from that of the ultrasonography performed by the radiology department and has also been called point-of-care limited ultrasonography (PLUS). When the serum level of beta human chorionic gonadotropin (β-hCG) is higher than 1500 mIU/mL, the level known as the discriminatory zone, transvaginal ultrasonographic findings of an IUP should be present (see the image below).

Transverse picture of intrauterine pregnancy. Transverse picture of intrauterine pregnancy.

Diagnostic, Suggestive, and Indeterminate Ultrasonographic Findings

The first developmental structure big enough to be visualized by transvaginal ultrasonography is the gestational sac, which appears in the endometrial cavity at around 4.5-5 weeks’ gestation (corresponding to a β-HCG level of 1000-1500 mIU/mL). Measurement of the mean sac diameter (MSD) is important for estimating the gestational age, as well as for confirming subsequent normal embryonic development. A conservative definition of a sonogram diagnostic for an IUP involves demonstration of a clearly defined yolk sac within the gestational sac (see the images below).

Picture of gestational sac with yolk sac. Picture of gestational sac with yolk sac.
Transverse picture of gestational sac with yolk sa Transverse picture of gestational sac with yolk sac.

The yolk sac appears by 5-6 weeks’ gestation and should definitely be present when the MSD is greater than 8 mm. The embryo, or fetal pole, can be visualized on transvaginal ultrasonography by 6 weeks’ gestation and on transabdominal ultrasonography by 7 weeks’ gestation, and it should be present when the MSD exceeds 16 mm. Embryonic cardiac activity starts to be visible at around 7 weeks’ gestation and should be visible if the crown-rump length, or fetal pole length, is greater than 5 mm. [14, 15]

Definitive ultrasonographic diagnosis of an ectopic pregnancy is made in only about 20% of cases, when an extrauterine pregnancy is clearly identified (ie, an extrauterine gestational sac with a yolk sac or fetal pole is visualized). There exist, however, numerous findings that are highly suggestive of ectopic pregnancy, including an empty uterus in a patient with a β-hCG level above the discriminatory zone, an adnexal mass other than a simple cyst (see the image below), echogenic fluid in the cul-de-sac, or anything more than a small amount of fluid in the cul-de-sac.

Picture of uterus without a fetal pole and a compl Picture of uterus without a fetal pole and a complex adnexal mass consistent with ectopic pregnancy.

Patients who exhibit such findings should be managed in consultation with an obstetrician; they likely will need surgical exploration or medical therapy with methotrexate.

Ultrasonographic findings that are neither diagnostic nor highly suggestive of an IUP or ectopic pregnancy are classified as indeterminate. These findings include an empty uterus, an abnormal gestational sac (eg, a sac with an irregular border or an MSD large enough that a secondary structure such as a yolk sac would be expected), a normal gestational sac without a yolk sac or embryo, a nonspecific intrauterine fluid collection, and ill-defined echogenic material within the endometrial cavity (see the image below).

Picture of abnormal endometrium in a patient with Picture of abnormal endometrium in a patient with an ectopic pregnancy.

Patients who exhibit these findings are generally monitored closely with serial β-HCG testing and clinical assessments, as about 10-25% of such patients have normal pregnancies.


Bedside ultrasonography is indicated in the presence of vaginal bleeding or abdominal pain in a patient in the first trimester of pregnancy.


Do not perform bedside ultrasonography if it delays resuscitation or definitive surgical care in an unstable patient.




Anesthesia is generally not necessary for sonographic evaluation. However, patients may experience discomfort from the pressure of the transducer.


Equipment includes the following:

  • Ultrasonograph with 3.5-5 MHz abdominal transducer and 7.5-10 MHz transvaginal transducer
  • Gloves
  • Acoustic gel
  • Transvaginal transducer probe cover
  • Lubricating jelly - Because acoustic gel causes an intravaginal dermatitis, the lubricating jelly Surgilube should be used on the outside of the transducer cover.


The patient should be in a hospital gown, undressed from the waist down. For transabdominal ultrasonography, position the patient in the supine recumbent position. For transvaginal ultrasonography, position the patient in the supine lithotomy position.

Complication Prevention

Be sure to scan systematically and widely, including the entire uterus and cervix in the transverse and sagittal planes. Failure to scan through the entire uterus, cervix, and adnexa can lead to missed ectopic pregnancies.

Explain the procedure, benefits, risks, and complications to the patient or the patient’s representative. Ask the patient or the patient’s representative if he or she would like others to be present for the procedure.




The primary role of emergency department (ED) obstetric ultrasonography is to demonstrate an intrauterine pregnancy (IUP). When the beta human chorionic gonadotropin (β-hCG) level is greater than 1500 mIU/mL, transvaginal ultrasonographic evidence of an IUP should exist. The first visible structure is the gestational sac. Subsequent yolk sac, embryo, and fetal cardiac activity should appear at predictable time intervals and mean sac diameter sizes.

An extrauterine gestational sac with yolk sac or fetal pole is definitive evidence of an ectopic pregnancy. (Note that a pseudogestational sac can be confused with a genuine gestational sac.) Other suggestive ultrasonographic findings include a complex adnexal mass, echogenic fluid in the cul-de-sac, a moderate to large amount of fluid in the cul-de-sac, and an empty uterus in a patient with a β-HCG level above the discriminatory zone. (Note also that intrauterine fluid is one of the most common ectopic findings misinterpreted as an early normal IUP.)

Transabdominal Ultrasonography

Transabdominal ultrasonography is best performed on a patient who has a full bladder.

Expose the abdomen from xiphoid to pubis. Apply a generous amount of acoustic gel to the patient’s lower abdomen, the abdominal transducer, or both.

The uterus is a muscular hollow organ behind the bladder and anterior to the colon, with a moderately echogenic, homogenous myometrium and a relatively hyperechoic endometrium.

First, scan the uterus in the transverse plane. Hold the probe perpendicular to the patient’s long axis, with the indicator of the probe pointing toward the patient’s right, and sweep from fundus to cervix (see the image below).

Transverse probe placement for transabdominal obst Transverse probe placement for transabdominal obstetric examination.

Next, scan the uterus in the sagittal plane. Hold the probe parallel to the patient’s long axis, with the indicator of the probe pointing toward the patient’s head, and sweep from side to side (see the images below). Be sure to identify the landmarks: the bladder, the vaginal stripe, and the uterus.

Sagittal or longitudinal probe placement for trans Sagittal or longitudinal probe placement for transabdominal obstetric examination.
Sagittal viewing showing bladder, uterus (behind t Sagittal viewing showing bladder, uterus (behind the bladder), and endometrial stripe (within the uterus).

When scanning in the sagittal plane, assess for free fluid in the cul-de-sac, also known as the rectouterine pouch or the pouch of Douglas. A small amount of hypoechoic free fluid can be considered physiologic. Fluid tracking two thirds of the way up the posterior wall of the uterus is regarded as moderate. A larger amount of fluid, or fluid that tracks anteriorly and interposes between the uterus and the bladder, is considered large. [16]

Apply acoustic gel to the patient’s right upper quadrant, scanning in the transverse and sagittal planes again to visualize the Morison pouch. Free fluid is generally not visualized until at least 500 mL of free fluid has accumulated; such accumulation is highly suggestive of ruptured ectopic pregnancy (see the image below). [17]

Free fluid in the Morison pouch from a ruptured ec Free fluid in the Morison pouch from a ruptured ectopic pregnancy.

Transvaginal Ultrasonography

Transvaginal ultrasonography is best performed on a patient who has an empty bladder.

Position the patient in the supine lithotomy position, preferably on a stretcher equipped for pelvic exams (ie, with stirrups). Scan the uterus in both long and short axial planes. [18]

The cul-de-sac is formed by the peritoneal reflection anterior and posterior to the uterus. A small amount of anechoic fluid in the cul-de-sac is physiologic. Echogenic fluid in the cul-de-sac is highly suggestive of a ruptured ectopic pregnancy.

Upon visualization of a round anechoic structure in the endometrial cavity that is consistent with a gestational sac, acquire pictures and measure the length, height, and width of the gestational sac to obtain the mean sac diameter (MSD). These measurements are taken from the inner aspects of the echogenic border of the sac.

Visualization of a double decidual ring (ie, 2 echogenic rings around the gestational sac) is pathognomonic for an early IUP. In radiology literature, this is considered the earliest reliable sign of an IUP. Double decidual signs, however, are not consistently seen, and caution should be used in terms of using them to determine the presence or absence of an IUP. Prior to this stage, demonstration of a simple gestational sac is an indeterminate ultrasonographic finding.

The yolk sac is a round echogenic ring with an anechoic center located within the gestational sac. The yolk sac can generally be used to determine the presence or absence of an IUP.

The embryo is measured using crown-rump length, which is measured end-to-end (not including the yolk sac).

An extraovarian adnexal echogenic ring (tubal ring sign), highly suggestive of an ectopic pregnancy, occurs when the fallopian tube develops a trophoblastic reaction to an ectopic gestational sac.

Interstitial ectopic pregnancy is rare but has a higher mortality rate following rupture, as the area is richly vascular. An eccentrically located gestational sac with a thin or incomplete myometrial mantle around the sac is suggestive of an interstitial gestation; this is the interstitial line sign.




No major complications exist with the performance of emergency department (ED) ultrasonography to evaluate first-trimester pregnancy.

Sometimes, Doppler ultrasonography is used in early pregnancy evaluation to detect fetal cardiac activity or to better delineate the adjacent vascular anatomy. The energy output of Doppler ultrasonography is substantially higher than that of conventional ultrasonography and may be harmful to the embryo. [17]

Complications can ensue if an obstetrician is not consulted early in the treatment of a patient with early pregnancy and hemodynamic instability, acute abdomen, or falling hematocrit level.