1. Radiological imaging
of ectopic pregnancy.
Dr/ ABD ALLAH NAZEER. MD.

2. Ectopic pregnancy is a major health problem for women
of childbearing age and a leading cause of pregnancy-
related death in the first trimester. Untreated, ectopic
pregnancy can lead to massive hemorrhage, infertility and
death. With the advent of high-resolution transvaginal
sonography, in conjunction with serum assays for the ß-
subunit of human chorionic gonadotropin (ß-hCG), rapid and
accurate diagnosis of this entity is now routinely possible.
Ectopic pregnancy is defined as implantation of a fertilized
ovum outside the endometrial lining of the uterus. Based on
data from the Centers for Disease
Control and Prevention, ectopic pregnancy has an incidence
of approximately 2% of all reported pregnancies
and accounts for 9% of pregnancy related deaths.

3. Locations of ectopic pregnancy. (A) ampullary/isthmic, (B) infundibulum, (C)
fimbria, (D) interstitial, (E) intra-abdominal, (F) ovarian and (G) cervical.

7. Etiology of ectopic pregnancy.
Congenital.
Tubal hypoplasia, Tubal turtuosity, Congenital diverticulae,
Accessory ostia, Partial stenosis, Elongation, Intra-mural
polyp and Entrap the ovum on its way.
Acquired.
Pelvic inflammatory disease.
Chlamydia trachomatis is most common.
Contraceptive failure.
Smoking.
Multiple sexual partners.
Endometriosis.
History of tubal surgery.
Endometriosis and leiomyoma.
Recent use of in vitro fertilization.

14. Magnetic Resonance Imaging.
MRI findings that can suggest an ectopic pregnancy
include the presence of a tubal gestational sac; a
tubal hematoma, which is a hematoma suggested by
the ring sign (peripheral hyperintensity) on T1-
weighted images; tubal wall enhancement; and an
adnexal mass with hemorrhagic fluid in the
peritoneum. Blood is suggested by the presence of
high-signal-intensity fluid on T1-weighted images.
The MRI characteristics of an ectopic pregnancy and
its rupture are seen in the T2-weighted images.

16. Live cervical ectopic pregnancy at 6 weeks gestational age. Sagittal view of
the cervix shows the gestational sac with an embryo (arrow) within the cervix.

23. Heterotopic pregnancy in an in vitro fertilization patient at 15 weeks gestational age. (a)
Transabdominal view shows no myometrium (arrows) around the ovarian ectopic pregnancy.
(b) Coronal T2-weighted magnetic resonance (MR) image IUP and ectopic pregnancy (EP). P =
placenta. MR was used for surgical planning to show the blood flow to the heterotopic
pregnancy. Note the flow void in vessels (arrows) supplying the ovarian ectopic pregnancy.
After surgical removal of the ectopic pregnancy, the IUP continued to term.

24. Tubal ring of ectopic pregnancy. (a) Transvaginal transverse view of the left adnexa shows
an echogenic ringlike mass (arrows) medial to the left ovary. Within the left ovary is a
thick-walled corpus luteum cyst (arrowheads). Note that the wall of the ectopic pregnancy
is more echogenic than the wall of the corpus luteum cyst. (b) Color Doppler image shows
more blood flow (arrowheads) to the corpus luteum than to the ectopic pregnancy (arrow).
Note that the “ring of fire” (hypervascular ring) appearance in the adnexa can be seen with
both ectopic pregnancy and corpus luteum.

25. Interstitial ectopic pregnancy 8 weeks after LMP. Sagittal transvaginal view
of the uterus (UT) demonstrates a thick-walled mass arising from the
interstitial portion of the uterus. The embryo is measured with calipers.

27. Ectopic pregnancy. Abdominal/pelvic CT. Image compatible with gestational sac in
the left adnexal region (arrow on A), separated from the uterine image (stars on A
and B) and from the ipsilateral ovary identified by visualization of the corpus
luteum (hollow arrow on B). Also, note the presence moderate amount of fluid in
the peritoneal cavity with foci of high density characterizing hematic content (L).
(A,B: contrast-enhanced axial sections in the portal phase).

28. Axial T2-weighted fast spin-echo magnetic resonance image of the pelvis.
This image shows an abnormal fluid-containing fallopian tube (red arrow)
on the right side. A simple right ovarian cyst (white arrow) is also present.

29. Ectopic pregnancy. Pelvic MRI. The presence of a gestational sac is observed in the
left adnexal region (arrows on A and B), in association with a heterogeneous mass
(arrow on C). Note the uterine and ovarian images (stars on A and D) separated
from the adnexal mass, as well as the presence of placenta showing contrast
enhancement (hollow arrow on D). (A: axial T2-weighted; B: coronal T2-weighted;
C: sagittal T2- weighted; D: post-contrast axial T1-weighted images).

30. Ectopic pregnancy. Pelvic MRI. Expansile, heterogeneous mass in the right adnexal
region (arrows on A to D), separated from the uterine (star on B) and ovarian
(hollow arrows on A and B) images. Also, note the presence of moderate amount of
free fluid in the pelvis, with intermediate signal intensity on T1-weighted images,
suggesting hematic contents (stars on A and C). (A,B: axial T2- weighted image with
fat saturation; C,D: axial T1-weighted, in phase and out-phase images).

31. Cornual ectopic pregnancy. Pelvic MRI. The presence of a heterogeneous mass is
observed in the cornual segment of the left uterine tube (white arrows on A to D).
Note the communication with the uterine cavity (white hollow arrows on B and C). The
myometrium is indicated by the black hollow arrow on C. (A,B: axial T1- weighted and
T2-weighted images, respectively; C: post-contrast, axial T1-weighted image with fat
saturation; D: coronal T2-weighted image).

32. Ectopic pregnancy with enhancing papillary solid components with a nonenhancing
necrotic portion and high signal intensity on outer surface on sagittal T1-weighted
turbo spin echo spectral presaturation with inversion recovery with contrast imaging
(A), on coronal T1-weighted fast field echo spectral presaturation with inversion
recovery with contrast imaging (B), on transverse T1-weighted fast field echo in-
phase with contrast imaging (C) (black arrows).

33. Tubal pregnancy in a 41-
year-old woman with acute
abdominal pain and
positive results of a
pregnancy test.

34. CONCLUSION.
Sonography plays a central role in the diagnosis and management
of ectopic pregnancy. If an extraovarian mass is present in a
pregnant patient with pain and bleeding, and no intrauterine
gestational sac is seen, the diagnosis of ectopic pregnancy should be
considered until proved otherwise. Therapy is determined by a
combination of clinical symptoms, sonographic findings, and serum
β-hCG values. While an intrauterine gestational sac is typically seen
when the β-hCG value is greater than 2000 mIU/mL (IRP), this value
should be used as a guideline and not an absolute threshold. Since
the fallopian tube is the most common location of ectopic
pregnancy, care should be taken while scanning to search between
the uterus and ovary for a tubal mass. Surgery is being performed
less often for ectopic pregnancy since the alternative treatments of
expectant management, methotrexate, and percutaneous injection
are now available. With these conservative treatments, there is an
increased role for sonography in patient follow-up.

35. Thank You.