1. An early pregnancy ultrasound aims to confirm the location and number of pregnancies, with tubal ectopic pregnancies occurring outside the uterus. 2. Types of ectopic pregnancies include tubal (interstitial, isthmic, ampullary), cervical, and caesarean scar pregnancies. 3. Diagnosis involves transvaginal ultrasound identifying signs like a gestational sac outside the uterus with or without embryonic heart activity.

1. Tubal Ectopic pregnancy
DR MUAHMED AL BELLEHY MD

2. An early pregnancy
ultrasound examination main
objectives to confirm the
location and number of
pregnancies
ultrasound examinations undertaken in early pregnancy
• Mostly performed using a transvaginal route (TVUS).
• TVUS facilitates earlier and more accurate detection of early
pregnancy than a transabdominal scan
• transabdominal (TAUS) scan is indicated, such as in those with a large
fibroid uterus or adhesions fixing the uterus to the anterior abdominal
wall.
DR MUAHMED AL
BELLEHY

3. An early pregnancy
ultrasound examination main
objectives to confirm the
location and number of
pregnancies
ectopic pregnancy  any pregnancy outside the uterine cavity
normally sited (eutopic) pregnancy  A pregnancy which is located
within the uterine cavity.
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BELLEHY

4. Outcome of any early pregnancy either
• Normally sited pregnancy
• ectopic Pregnancy
• pregnancy of unknown location (PUL)
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BELLEHY
ESHRE 2020
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BELLEHY

5. • A pregnancy which is located within
the uterine cavity should be described
as a normally sited (eutopic)
pregnancy.
A pregnancy which is located within the
uterine cavity .
• with embryonic/foetal heart
pulsations should be described as a
live normally sited (eutopic)
pregnancy.
• without a visible embryo which has
the potential to develop normally
should be described as an early
normally sited (eutopic) pregnancy
The normally sited pregnancy
DR MUAHMED AL
BELLEHY

6. When there is more than one pregnancy, they can be
heterotopic
all in abnormal locations
(co-existent ectopic)
all normally sited
(twin, triplet, etc.),
one/more normally
sited and one/more
ectopic (heterotopic)
ESHRE 2020
DR MUAHMED AL
BELLEHY

7. Pregnancy of unknown location
missed period + ve serum hCG + TVUS  no intrauterine or extrauterine pregnancy can be seen.
• when no pregnancy is visualized on transvaginal scan in clinically stable women
with a positive urine pregnancy test
• ultrasound examination should be carried out in a systematic manner and all
possible locations for an implanted pregnancy are examined.
• all women presenting with PUL should be followed-up to determine a final clinical
outcome.
– a normally sited pregnancy (ongoing or failed)
– an ectopic pregnancy
– spontaneously resolved PUL
• when hCG declines to pre-pregnancy levels without the pregnancy being identified on any of
the follow-up scans.
• Management of PULs

8. Pregnancy of unknown location
missed period + ve serum hCG + TVUS  no intrauterine or extrauterine pregnancy can be seen.
Take 2 serum hCG measurements 48 hours apart (but no earlier)
serum hCG
increase >
63%
decrease >
50%
decrease levels less than 50%, or an
increase less than 63%
NICE 2019
likely a developing intrauterine
pregnancy (ectopic cannot be
excluded).
Failing pregnancy unlikely
to continue
• urine pregnancy test 14
days after second serum
hCG :
• if test is negative
no further action
• if test is positive 
return to assessment
within 24 hours.
refer for clinical review
within 24 hours.
TVS to determine location of
pregnancy 7 -14 days later.
an earlier scan when
hCG ≥ 1500 IU/litre
If a viable intrauterine pregnancy is
confirmed  routine ANC.
If a viable intrauterine pregnancy is
not confirmed  review by a senior
gynaecologist
Dr Muhamed Al Bellehy

10. various locations of an ectopic pregnancy

11. Types of ectopic Pregnancy
DR MUAHMED AL
BELLEHY
ectopic pregnancy  any pregnancy outside the uterine cavity
a live ectopic pregnancy
• An ectopic pregnancy which
contains an embryo/foetus
with heart pulsations
a failing ectopic pregnancy
• Ectopic pregnancy with
clinical, ultrasound and/or
biochemical signs of
regression should be
described as
ESHRE 2020
DR MUAHMED AL
BELLEHY

12. Types of ectopic Pregnancy
DR MUAHMED AL
BELLEHY
ectopic pregnancy  any pregnancy outside the uterine cavity
Previous classification of
ectopic pregnancies
• tubal
• non-tubal

13. • uterine ectopic pregnancies  located
outside the uterine cavity, but within the
confines of the uterus such as
• The uterine cavity is a virtual space
lined by extends from the orifices of the
Fallopian tubes at the uterine fundus to the
internal cervical os.
• caesarean scar
• intramural
These types of pregnancies are caused by scarring or incomplete uterine healing following surgical trauma to the uterus during
procedures such as caesarean section, myomectomy and operative hysteroscopy.
• One of the main challenges is detection and timely treatment of uterine ectopic pregnancies

14. • A gestational sac can implant in any
part of the Fallopian tube.
• Depending on their locationcan be
divided into
– Interstitial and Isthmic
– ampullary
– Fimbrial ectopic
• they can only be diagnosed at surgery and on
ultrasound scan they are indistinguishable from
ampullary ectopic pregnancies
• On Ultrasound Tubal ectopic should be
described as either interstitial, isthmic
or ampullary.
(Kayatas et al., 2014).
Tubal Ectopic Pregnancy

15. Tubal ectopic:
1. interstitial
2. isthmic
3. ampullary
Tubal Ectopic Pregnancy
interstitial
isthmic
ampullary
DR MUAHMED AL
BELLEHY

16. ectopic pregnancy
• The rate is 11 per 1,000 pregnancies
• maternal mortality of 0.2 per 1,000 estimated ectopic pregnancies.
• About two-thirds of these deaths are associated with substandard care.
Symptoms and signs of ectopic pregnancy
Symptoms of ectopic pregnancy
• haemodynamically unstable or a significant degree of
pain or bleeding
• common symptoms:
• abdominal or pelvic pain
• amenorrhoea or missed period
• vaginal bleeding with or without clots
• other reported symptoms:
• breast tenderness
• gastrointestinal symptoms
• dizziness, fainting or syncope
• shoulder tip pain
• urinary symptoms
• passage of tissue
• rectal pressure or pain on defecation.
Signs of ectopic pregnancy
• more common signs:
• pelvic tenderness
• adnexal tenderness
• abdominal tenderness
• other signs:
• cervical motion tenderness
• rebound tenderness or peritoneal signs
• pallor
• abdominal distension
• enlarged uterus
• tachycardia (> 100 bpm) or hypotension (< 100/
60 mmHg)
• shock or collapse
• orthostatic hypotension.
DR MUAHMED AL
BELLEHY

17. embryo in the adnexa next to the empty uterus
yolk sac
Intrauterine pregnancy
gestational sac
Dr Muhamed Al Bellehy
Ectopic Pregnancy
DR MUAHMED AL
BELLEHY

18. the right adnexa reveals an extraovarian adnexal mass with a
hyperechoic tubal ring (arrow). A tubal pregnancy
Tubal ring sign. the left adnexa reveals an extraovarian GS with a yolk sac
(arrow). yolk sac is surrounded by a thick echogenic ring (arrowhead).
Ring of fire sign. color Doppler of a tubal pregnancy show peripheral hypervascularity surrounding the GS (a) and a hemorrhagic ovarian
cyst (b), a finding that is a mimic of the ring of fire sign
DR MUAHMED AL
BELLEHY

19. empty
uterus
±
pseudo-sac
a d n e xa l m a s s
m o v i n g
s e p a ra t e t o
t h e o v a r y t h e
' s l i d i n g s i g n '
GS containing a yolk
sac or a fetal pole (±
fetal heartbeat)
an thick walled cyst
(empty GS (a 'tubal
ring' or 'bagel sign')
or
complex,
inhomogeneous
mass
Other checklist
• scan the uterus and adnexae to see if there
is a heterotopic pregnancy.
• free fluid in the peritoneal
cavity or Pouch of Douglas
(haemoperitoneum)
Dx of tubal
ectopic
signs of possible
missed period + ve serum hCG before making a DX
+ TVUS
Dr Muhamed Al Bellehy
NICE 2019
Sure signs of
signs of a high
probability of
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BELLEHY

20. 'bagel sign
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BELLEHY

22. Pseudo–gestational sac
in an ectopic pregnancy
This is a collection of fluid
a double decidual sac sign
in a normal intrauterine pregnancy
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BELLEHY

23. double decidual sac sign (DDSS)
• Used to confirm an early intrauterine pregnancy (IUP) when the yolk sac or embryo is not visualized.
• It consists of the decidua parietalis (lining the uterine cavity) and decidua capsularis (lining the gestational sac)
• seen as two concentric rings surrounding an anechoic gestational sac. Where the two adhere is the decidua
basalis, and is the site of future placental formation.
• If a DDSS is present highly suggestive that the intrauterine fluid collection is an IUP.
• It is absent in many IUPs
• its absence does not define a pseudo gestational sac .
• Should a definite IUP not be confirmed then repeat scanning and serial quantitative beta-HCGs are required, until either an IUP is established,
an ectopic pregnancy is visualized, or beta-HCGs returns to zero (implying miscarriage).
DR MUAHMED AL BELLEHY

24. • an early intrauterine sac  in the endometrium an eccentrically located
hypoechoic structure + double decidual sign.
• double decidual sign  gestational sac surrounded by 2
concentric echogenic rings
DR MUAHMED AL
BELLEHY

25. Pseudo–gestational sac
Pseudo–gestational sac must be differentiated from an early intrauterine sac,
DR MUAHMED AL
BELLEHY

26. Interstitial and Isthmic 
• Both are located closer to the uterus have
a higher potential to grow larger and to
contain a live embryo/foetus which
increases the risk of serious
complications.
Outcome of Interstitial pregnancies
1 expand into the isthmic part of
the Fallopian tube (Most)
2 spread out medially and protrude into the
upper lateral aspect of the uterine cavity
3 stay confined to the interstitial
segment of the tube (relatively rare).
interstitial
Interstitial Tubal Ectopic Pregnancy
DR MUAHMED AL
BELLEHY

27. Interstitial tubal ectopic pregnancy
diagnostic feature
• an eccentrically located gestational sac surrounded by a thin (less than 5 mm) or incomplete
myometrial mantle
• an empty uterine cavity
• the interstitial line sign  the “interstitial line” sign: an echogenic line extending from the
endometrium into the cornual region and abutting the midportion of the interstitial mass or
gestational sac ----- adjoining the medial aspect of the gestational sac and the lateral aspect of the
uterine cavity
DR MUAHMED AL BELLEHY

28. DR MUAHMED AL BELLEHY

29. DR MUAHMED AL BELLEHY

31. diagnostic feature of
isthmic Ectopic
• A pregnancy close to
the uterus but not
surrounded by
myometrium
Tubal Ectopic Pregnancy
diagnostic feature of
ampullary Ectopic
• pregnancy located
further away and
close to the ovary
DR MUAHMED AL BELLEHY

32. diagnostic feature of
isthmic Ectopic
• A pregnancy close to
the uterus but not
surrounded by
myometrium
Tubal Ectopic Pregnancy
diagnostic feature of
Ampullary Ectopic
• pregnancy located
further away and
close to the ovary
DR MUAHMED AL BELLEHY