ª Springer Science+Business Media New York 2017 Abdom Radiol (2017) 42:1524–1542
Abdominal Published online: 31 January 2017
Radiology
Pitfalls and tips in the diagnosis of ectopic
pregnancy
E. Mausner Geffen , C. Slywotzky, G. Bennett
Department of Radiology, NYU Langone Medical Center, 550 1st Avenue, New York, NY 10016, USA
Abstract
Women of reproductive age with pelvic pain, vaginal
bleeding, and a positive pregnancy test often require
evaluation with pelvic ultrasound. In these situations, the
primary role of pelvic ultrasound is to differentiate an
ectopic pregnancy from either a normal or abnormal
intrauterine pregnancy. While an accurately performed
and interpreted pelvic ultrasound results in rapid diag-
nosis and management, numerous diagnostic pitfalls can
lead to negative outcomes. Therefore, familiarity with
the appropriate laboratory tests, sonographic technique,
and imaging features of ectopic pregnancy is essential for
all radiologists. We present a review of ectopic pregnancy
cases from our institution with attention to common
pitfalls and troubleshooting tips for physicians who
perform and interpret pelvic ultrasounds. We also pre-
sent recently published literature to aid in the manage-
ment of first trimester pregnancy.
Key words: Ectopic pregnancy—Pregnancy of unknown
location—Human chorionic gonadotropin (HCG)
Ectopic pregnancy is an increasingly common occur-
rence reported in approximately 1.5–2.0% of all preg-
nancies [1]. Since ruptured ectopic pregnancy accounts
for 6% of pregnancy-related deaths and is the leading
cause of first trimester maternal death, early perfor-
mance and accurate interpretation of pelvic ultrasonog-
raphy are essential [1, 2]. In this review, we demonstrate
the various types of ectopic pregnancies and the associ-
ated ultrasound findings, common diagnostic imaging
pitfalls, and indications for further imaging with 3D
ultrasound or dedicated MRI of the pelvis (Fig. 1).
Correspondence to: E. Mausner Geffen; email: evm221@nyumc.org
DOI: 10.1007/s00261-016-1020-4
General principles
Obtaining a history
When screening patients for possible ectopic pregnancy,
it is important to document a complete history and
physical examination, including the patient’s last men-
strual period (LMP). Particular attention should be paid
to risk factors associated with ectopic pregnancy such as
pelvic inflammatory disease, endometriosis, smoking,
presence of an intrauterine contraceptive device, use of
assisted reproductive techniques (ART), and a history of
prior ectopic pregnancy [2]. In addition to past medical
and reproductive history, a thorough surgical history
including prior tubal surgery, dilatation and curettage
(D&C), and Cesarean sections should be addressed [2].
However, it should be remembered that approximately
fifty percent of ectopic pregnancies occur in patients
without any clear risk factors [1].
Tip Patients may be unaware of pertinent details or
may not be forthcoming with sensitive information, and
therefore clinical suspicion for ectopic pregnancy should
not be dismissed in the absence of historical data.
Nonspecific lower abdominal/pelvic pain
The evaluation of a female patient with abdominal or
pelvic pain often begins with a broad differential. We
urge clinicians to consider, and evaluate the possibility
of, ectopic pregnancy in all women of reproductive age.
This includes women with a known history of gyneco-
logic pathology as well as teenage girls who present with
right lower quadrant pain in whom alternative diagnoses
such as appendicitis are favored. Because of the potential
danger of a delayed diagnosis and rupture of an ectopic
pregnancy, a urine pregnancy test (qualitative beta-hu-
man chorionic gonadotropin test) should be obtained
prior to cross-sectional imaging with MRI or CAT scan.
In cases with a positive beta-human chorionic gonado-
tropin (beta-HCG), a pelvic ultrasound should always be
the initial test of choice. Thus, early beta-HCG testing
E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
Fig. 1. Diagram summarizing the possible locations where ectopic pregnancies may occur.
helps guide physicians to the best imaging test, and can
potentially avoid inappropriate imaging (Figs. 2, 3).
Tip In women with right lower quadrant pain and a
positive beta-HCG, the first imaging test performed
should be a pelvic ultrasound to rule out ectopic preg-
nancy even in cases where appendicitis was the original
leading diagnosis. A graded compression ultrasound of
the right lower quadrant can be performed simultane-
ously with a pelvic ultrasound to look for appendicitis.
Beta-HCG values—what do they mean?
When interpreting a quantitative beta-HCG value, it is
essential to know the reference range and laboratory
preparation used at a given institution. In general,
transvaginal ultrasound is capable of detecting an
intrauterine pregnancy (IUP) when the quantitative beta-
HCG level is greater than 2000 mIU/mL (discriminatory
zone, Third International Standard); however, physi-
cians should be aware that three different reference
ranges exist [3]. The three standards, referred to as the
First, Second, and Third International Standard (IS),
1525
respectively, may cause confusion if they are compared
to one another. Additionally, the discriminatory zone
will vary based on the beta-HCG assay used [3]. While
much of the older literature on the discriminatory zone
was written using the Second IS, most hospitals are
currently using the Third IS. The conversion between the
two systems is as follows: Second IS 1.8 = Third IS.
Of note, the Third IS was originally referred to as the
First International Reference Preparation (IRP) and
these two terms may be used interchangeably.
Tip Always make sure that the beta-HCG discrimi-
natory zone reference range being used is correct for your
laboratory preparation as values can vary across insti-
tutions.
Qualitative vs. quantitative beta-HCG
and trending the beta-HCG level
A commonly encountered problem in the clinical setting
occurs when only the qualitative beta-HCG (i.e., the
urine pregnancy test) is positive, but there is no quanti-
tative beta-HCG blood test available at the time of
1526 E. Mausner Geffen et al.: Pitfalls and tips in the diagnosis of ectopic pregnancy
ultrasound interpretation. In this situation, an indeter-
minate ultrasound showing that there is no ectopic
pregnancy or IUP visualized is of unclear significance.
Fig. 2. Teenage female presented to ED with abdominal
pain and a CT scan was performed to evaluate for appen-
dicitis. Beta-HCG found to be positive only after the CT scan
was performed. Axial CT with oral contrast demonstrates
heterogeneous complex fluid collection and hemorrhage in
the pelvis with a left adnexal mass ( ). At surgery, this
was found to represent a ruptured ectopic pregnancy. Normal
appendix (not shown).
Fig. 3. 34-year-old female with known uterine fibroids was
referred to MRI for lower abdominal pain and continuous
uterine bleeding for one month. MRI was intended for surgical
planning prior to myomectomy. Axial T2 TSE image demon-
strated a right adnexal mass ( ) separate from the
With only a qualitative result, it is unknown whether the
beta-HCG value is above the discriminatory zone and in
a range where an IUP could reliably be identified [4].
When this occurs, radiologists should request a quanti-
tative beta-HCG blood test; if the quantitative beta-
HCG value is below the discriminatory zone, close fol-
low-up with serial beta-HCGs and ultrasounds is re-
quired to determine pregnancy viability.
A second common problem is seen when patients
present emergently with a single isolated beta-HCG va-
lue. The difficulty in this scenario is that an indetermi-
nate ultrasound in a patient with a single beta-HCG
value above the discriminatory zone (in one series as high
as 4336 mIU/mL Third IS) does not preclude an IUP [5].
As such, a similar conservative management strategy
with serial beta-HCGs and ultrasounds should be em-
ployed in a stable patient with a desired pregnancy, as
per the recommendations of the Society of Radiologists
in Ultrasound (SRU). [6].
A common misconception is that ectopic pregnancies
are only visible when the beta-HCG level is above the
discriminatory zone of 2000 mIU/mL. This is dangerous
as either high or low beta-HCGs can be seen at the time
of diagnosis of an ectopic pregnancy (Fig. 4). In fact,
more than 50% of patients with a visible ectopic preg-
nancy on ultrasound have a beta-HCG less than
2000 mIU/mL [7].
Tip Though a pelvic ultrasound is unlikely to
demonstrate an IUP if the beta-HCG is below the dis-
criminatory zone, a low beta-HCG should not deter
ovary ( ) (A). Post-contrast T1 GRE images (con-
trast was given as the patient was not known to be pregnant)
demonstrated peripheral enhancement in the adnexal mass
(B). Surgical pathology revealed a right adnexal ectopic
pregnancy.