eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Surgery

Surgical Management of Ectopic Pregnancy: Workup

Author: Allahyar Jazayeri, MD, PhD, Medical Director of Perinatal Services, Bellin Health Hospital Center
Coauthor(s): Herbert S Coussons, MD, FACOG, Private Practice in Obstetrics and Gynecology, Women's Specialty Care
Contributor Information and Disclosures

Updated: Jan 7, 2008

Workup

Laboratory Studies

  • Human chorionic gonadotropin (quantitative)
    • The quantitative level of β-hCG found in ectopic pregnancy varies. Serum β-hCG levels correlate with the size and gestational age in normal embryonic growth. In a normal pregnancy, the β-hCG level doubles every 48-72 hours until it reaches 10,000-20,000 mIU/mL. With ectopic pregnancies, β-hCG levels usually increase less.
    • The discriminatory zone of β-hCG is the level above which a normal intrauterine pregnancy (IUP) is reliably visualized. Once β-hCG has reached a level of 700-1000 mIU/mL, a gestational sac should be seen within the uterus on transvaginal ultrasonographic images. Once it has reached 6000 mIU/mL, a gestational sac should be visualized within the uterus on abdominal scan images.
    • The lack of an IUP when the β-hCG level is above the discriminatory zone represents an ectopic pregnancy or a recent abortion.
  • Measure serial hemoglobin or hematocrit levels to quantify blood loss.
  • Blood type, Rh type, and antibody screen should be done in all pregnant patients with bleeding to identify patients in need of Rhogam and to ensure availability of blood products in case of excessive blood loss.

Imaging Studies

  • Endovaginal ultrasonography to exclude an IUP can be performed in the outpatient clinic or emergency department. Transvaginal ultrasonography has been reported to have sensitivity of 90%, specificity of 99.8%, with positive and negative predictive values of 93% and 99.8% respectively.1
    • Definite IUP: A gestational sac with a sonolucent center (>5 mm in diameter) is surrounded by a thick, concentric, echogenic ring located within the endometrium and contains a fetal pole, yolk sac, or both.
    • Probable abnormal IUP: The gestational sac is larger than 10 mm in diameter without a fetal pole or with a definite fetal pole but without cardiac activity. This frequently has an irregular or crenelated border.
    • Definite ectopic pregnancy: A thick, brightly echogenic, ringlike structure is located outside the uterus, with a gestational sac containing an obvious fetal pole, yolk sac, or both. This is an unusual finding.
    • No definite IUP (empty uterus): An empty uterus on endovaginal ultrasound images in patients with a serum β -hCG level greater than the discriminatory cut-off value is an ectopic pregnancy until proven otherwise. An empty uterus also may represent a recent abortion.
    • Other ultrasonographic findings: These include an adnexal mass (usually a corpus luteum, occasionally hematoma), free cul-de-sac fluid, and/or severe adnexal tenderness with probe palpation. Patients with no definite IUP and the above-mentioned findings may be at high risk for an ectopic pregnancy.
  • An appreciation for the sonographic spectrum of ultrasound findings in ectopic pregnancy may allow physicians to recognize an early ectopic pregnancy. The spectrum of sonographic findings in ectopic pregnancy includes the following:
    • Tubal ring: An echogenic ringlike structure found outside of the uterus represents an early ectopic pregnancy.
    • Extrauterine mass: The presence of a tender adnexal mass on ultrasound images suggests an ectopic pregnancy. One study suggested that the presence of any adnexal mass other than a simple cyst was the most significant ultrasound finding for the diagnosis of ectopic pregnancy.
    • Interstitial ectopic pregnancy: An interstitial ectopic pregnancy implants at the highly vascular region of the uterus near the insertion of the fallopian tube. These types can grow larger than those within the fallopian tube because the endometrial tissue is more expandable. Because of the increased size and partial endometrial implantation, these advanced ectopic pregnancies can be misdiagnosed as IUPs. An aid in the diagnosis of an interstitial ectopic pregnancy is the eccentric location of the gestational sac. Evaluating the amount of uterine myometrium surrounding the gestational sac and echogenic decidual layer is important. This is termed the myometrial mantle. At least 5 mm of myometrium should be present. The presence of less than 5 mm suggests the diagnosis. Another sonographic finding is the interstitial line sign.
    • Heterotopic pregnancy: This is a combined IUP and ectopic pregnancy. It may occur in approximately 1 in 30,000 pregnancies and is more common in patients taking fertility agents.
    • Extrauterine empty gestational sac: The presence of an extrauterine mass with a thick, brightly echogenic band (ring) also may represent an ectopic pregnancy.
    • Hemosalpinx: Fallopian tubes may fill with blood or free fluid.
    • Ruptured ectopic pregnancy: Findings on ultrasonographic images include free fluid or clotted blood in the cul-de-sac or in the intraperitoneal gutters, such as in the Morrison pouch.

Other Tests

Progesterone has been used by some in assessment of an ectopic pregnancy. While a value of 25 ng/mL is associated with normal pregnancies in 98% of cases, a value of less than 5 ng/mL identifies a nonviable pregnancy without regard to location of the pregnancy. Unfortunately, most women with an ectopic pregnancy will fall somewhere in between these 2 values, limiting the clinical usefulness of progesterone in diagnosing an ectopic pregnancy.

Other serum markers have been studied as potential biochemical markers for an ectopic pregnancy. These markers that are usually either early pregnancy proteins or markers for inflammation and damage in smooth muscles have not been sufficiently sensitive to be useful. 

Diagnostic Procedures

  • Culdocentesis can be performed to help diagnose blood in the cul-de-sac. No clotting blood is diagnostic of chronic hemorrhage in the abdomen and may suggest a ruptured ectopic pregnancy.
  • Products of conception passed through the cervix in an inevitable abortion can be used to confirm the diagnosis of an intrauterine pregnancy if fetal or placental tissue can be identified. 

More on Surgical Management of Ectopic Pregnancy

Overview: Surgical Management of Ectopic Pregnancy
Workup: Surgical Management of Ectopic Pregnancy
Treatment: Surgical Management of Ectopic Pregnancy
Follow-up: Surgical Management of Ectopic Pregnancy
Multimedia: Surgical Management of Ectopic Pregnancy
References
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References

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Further Reading

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Keywords

tubal pregnancy, ovarian pregnancy, abdominal pregnancy, heterotopic pregnancy, extrauterine pregnancy, maternal mortality, pregnancy complications, problem pregnancy, ectopic, beta hCG, beta-hCG, culdocentesis, salpingitis, failed tubal surgical sterilization, failed sterilization, tubal ligation, progestin-containing intrauterine device, progestin-containing IUD, pelvic pain, vaginal spotting, EP, tubal ring, extrauterine mass, interstitial EP, interstitial ectopic pregnancy, interstitial line sign, cervical pregnancy, hemosalpinx, salpingectomy, salpingotomy, laparoscopy, fimbrial evacuation

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Contributor Information and Disclosures

Author

Allahyar Jazayeri, MD, PhD, Medical Director of Perinatal Services, Bellin Health Hospital Center
Allahyar Jazayeri, MD, PhD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Association of Professors of Gynecology and Obstetrics, Society for Gynecologic Investigation, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Herbert S Coussons, MD, FACOG, Private Practice in Obstetrics and Gynecology, Women's Specialty Care
Herbert S Coussons, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, Christian Medical & Dental Society, Idaho Medical Association, Washington State Medical Association, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

Medical Editor

John J Kavanagh Jr, MD, Chief, Professor, Department of Internal Medicine, Section of Gynecological and Medical Therapeutics, MD Anderson Cancer Center, University of Texas College of Medicine
John J Kavanagh Jr, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association for the History of Medicine, American College of Physicians, American Federation for Medical Research, American Medical Association, American Society of Clinical Oncology, Society of Gynecologist Oncologists, Southern Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

 
 
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