Tubal ectopic pregnancy (unruptured)

Ultrasound
evaluation of ectopic pregnancy. Colour Doppler of the lesion shows ring of fire sign in the periphery (green arrow) with the fetus inside (yellow arrow).
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Ultrasound
evaluation of ectopic pregnancy. A well-defined complex adnexal mass seen on the left side adjacent to the uterus on the outside, with thick hyperechoic wall and internal cystic component with fetal pole inside (arrow).
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Ruptured
ectopic pregnancy. Axial post-contrast MDCT revealed a pelvic rounded cyst-like structure with peripheral enhancement due to the extrauterine gestational sac (white arrow).
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Imaging for
acute pelvic pain in pregnancy. A 27-year-old woman presenting at the emergency department with acute pelvic pain. Abdominal US (a) shows a rounded lesion adjacent to the uterus, clearly separate from the left ovary. Axial CT scan shows a voluminous mass in the pelvic cavity (b); for the characterisation an MRI was required. Axial (c) and coronal (d) T2-weighted and T1-weighted images (e) of the pelvis show a right heterogeneous adnexal mass (arrow) with fallopian tube haematoma. Note the normal ovary (short arrow) in (c). Pre-contrast T1-weighted fat-saturated image (f) shows bloody ascites (short arrows). These findings are due to ectopic pregnancy with tubal rupture and haemoperitoneum
insightsimaging.springeropen.com • Open Access
Imaging for
acute pelvic pain in pregnancy. A 35-year-old woman presented with amenorrhea for 7 weeks, abdominal pain and vaginal bleeding; the B-HCG level was elevated. Transvaginal 3D sonogram in sagittal scan shows the interstitial portion of the tube (arrow) located between the gestational sac (GS) and endometrium (e). CT of the pelvis (b) shows a small lesion on the left side of the uterus. Axial (c) and coronal (d) T2-weighted images and axial contrast T1-weighted image (e) of the pelvis show a left gestational-like structure measuring 10 mm in diameter, surrounded by a thick wall according to interstitial pregnancy
insightsimaging.springeropen.com • Open Access
Radiopaedia • CC-by-nc-sa 3.0 • de

Tubal ectopic pregnancy (or adnexal ectopic pregnancy) is the most common location of an ectopic pregnancy.

Epidemiology

It is the most common type of ectopic by far, accounting for 93-97% of cases.

Pathology

Although the fallopian tube has many anatomical parts, for the purposes of ectopic location it can be divided into :

Radiographic features 

Ultrasound
  • an adnexal mass that is separate from the ovary is the most common finding and may be seen on in up to 89-100% of cases
    • the presence of an adnexal mass becomes more specific for an ectopic pregnancy when it contains a yolk sac or a living embryo or when it moves independently from the ovary
    • an extrauterine mass may not be sonographically detected in up to 35% of patients with an ectopic pregnancy
  • usually, the corpus luteum is on the same side as ectopic gestational sac ; rupture of the cyst can present with abdominal pain and hemoperitoneum mimicking ectopic rupture  
  • there may be evidence of a hematosalpinx (a tubal ectopic is the commonest cause for a hematosalpinx)
  • tubal echogenic ring
    • typically a 1-3 cm mass consisting of a 2-4 mm concentric, echogenic rim of tissue surrounding a hypoechoic center
    • represents an echogenic ring surrounding an extrauterine gestational sac
  • color Doppler interrogation may show peripheral vascularity giving a "ring of fire sign"
    • a corpus luteum may have similar color Doppler flow
  • there may be evidence of a large hemoperitoneum or large amount of free fluid, especially in cases of rupture

Diagnosis

On transvaginal imaging, findings indicating definitive diagnosis of a tubal ectopic pregnancy :

  • extraovarian adnexal mass comprising a gestational sac containing a yolk sac
  •  extraovarian adnexal mass comprising a gestational sac and fetal pole (with or without cardiac activity)

On transvaginal imaging,  findings indicating a high probability of a tubal ectopic pregnancy :

  • extraovarian adnexal mass with an empty gestational sac (tubal ring sign or bagel sign), or
  • extraovarian heterogeneous adnexal mass (blob sign)

Take into account clinical presentation, serum hCG levels, uterine and adnexal findings.

On transvaginal imaging,  findings indicating possible tubal ectopic pregnancy:

  • empty uterus
  • fluid within the uterine cavity (pseudo sac)

Take into account clinical presentation, serum hCG levels, uterine and adnexal findings.

Treatment and prognosis

Compared to an interstitial ectopic or cervical ectopic, the risk of uncontrollable hemorrhage is fortunately lower. Nonetheless, expedient diagnosis is required.

Management was previously only surgical, with open and then laparoscopic salpingectomy being favored. Salpingotomy (thus preserving the tube) is increasingly performed.

Medical management includes methotrexate (a folate antagonist) either administered systemically or by direct ultrasound-guided injection. After methotrexate therapy, the ectopic pregnancy may show a paradoxical increase in size and vascularity on subsequent imaging even with successful methotrexate.

Increasingly 'conservative' management is being recognized as an option for ectopic pregnancy where rupture has not occurred (i.e no hemoperitoneum) and fetal demise has already taken place.

Complications

Differential diagnosis

  • other forms of ectopic pregnancy 
  • corpus luteum
    • may also present as an "adnexal mass" in a patient in whom there is clinical suspicion for ectopic pregnancy and may have similar color Doppler flow
    • should be attached to the ovary, whereas a tubal ectopic will slide separately from the ovary with transducer pressure
Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu tubal ectopic pregnancy:
Extrauteringravidität
 
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Tubenruptur
 
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