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Year : 2019  |  Volume : 14  |  Issue : 2  |  Page : 86-89

Transvaginal sonography and elastography evaluation of ectopic pregnancy

1 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission15-Jan-2019
Date of Decision11-Mar-2019
Date of Acceptance28-Aug-2019
Date of Web Publication25-Nov-2019

Correspondence Address:
Dr. Suresh Phatak
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_13_19

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Aim: The aim of the study is to assess the effectiveness of ultrasound and elastography in the detection of ectopic pregnancy in women presenting for ultrasound with a clinical suspicion of ectopic pregnancy. Subjects and Methods: Prospective analysis of 40 women presenting for sonography over a 2.5-year period was performed. Women were classified as having a confirmed ectopic pregnancy on the basis of surgery and laparoscopy. Results: The sensitivity and specificity of transvaginal ultrasound for the detection of confirmed ectopic pregnancy was 95.2% and 94.4%, and accuracy was 94.9%. Elastography revealed one case of ectopic pregnancy which was not diagnosed on sonography. Blue eye sign was positive in 100% of patients with transvaginal elastography. Conclusions: Transvaginal sonography elastography in the radiology setting of a tertiary hospital has excellent diagnostic performance for the detection of ectopic pregnancy.

Keywords: Ectopic pregnancy, elastography, transvaginal ultrasonography, tubal pregnancy

How to cite this article:
Phatak S, Shrivastav D, Marfani G, Daga S, Madurwar K, Samad S. Transvaginal sonography and elastography evaluation of ectopic pregnancy. J Datta Meghe Inst Med Sci Univ 2019;14:86-9

How to cite this URL:
Phatak S, Shrivastav D, Marfani G, Daga S, Madurwar K, Samad S. Transvaginal sonography and elastography evaluation of ectopic pregnancy. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2023 Mar 28];14:86-9. Available from: http://www.journaldmims.com/text.asp?2019/14/2/86/271546

  Introduction Top

The word ectopic is derived from the Greek word ektopos that means out of place. Ectopic pregnancy is characterized by pregnancy implantation occurring outside of the uterine cavity. Ectopic pregnancy is broadly divided into two main categories, namely tubal and nontubal. The vast majority of ectopics are tubal in origin (95%). Nontubal types are a small group which make up approximately 5% but significantly associated with morbidity and mortality associated with them. List of the nontubal sites includes uterine interstitium (cornual or angular), cervix, ovary, and previous cesarian section scar. In case of rare heterotopic pregnancy, there is the presence of intrauterine and extrauterine pregnancies both.[1] Accurate and timely diagnosis of ectopic pregnancy are the essential factors responsible for reducing maternal mortality and morbidity in the first trimester. Pain, vaginal bleeding, and inappropriately rising β-human chorionic gonadotropin (HCG) in the early pregnancy are considered hallmarks of an ectopic pregnancy. Nowadays, ultrasound is accepted as a best modality for imaging in patients presenting with symptoms of ectopic, mainly due to its easy and universal availability, excellent diagnostic performance, safety, as well as affordability. However, it is definitely an operator-dependent investigation, and the success of an ultrasound examination is decided by many factors including the operator's level of experience.[2] Recently, ultrasound elastography has been added to the list of investigations available to the radiologist. This has many indications in obstetrics and gynecology.

The introduction of transvaginal sonography (TVS) has given high reward in the diagnosis of many conditions related to early pregnancy and gynecological diseases. Numerous studies have shown that it is an acceptable diagnostic procedure for women presenting with pain and bleeding in the early pregnancy.[3],[4] TVS facilitates the diagnosis of ectopic pregnancy by ruling out an intrauterine pregnancy as well as by identifying ectopic mass. Confirmed diagnosis of intrauterine pregnancy is possible much earlier and with lower levels of serum HCG levels with TVS when compared to transabdominal sonography (TAS). It reported that while using TAS, the intrauterine sac can be visualized when the serum HCG is >6500 IU/l.[5] Whereas, with TVS, an intrauterine sac should be visualized with serum HCG levels of 1000 IU/l.[6] A comparison of TAS and TVS in the diagnosis of ectopic pregnancy has demonstrated sensitivities up to 77% and 88%, respectively.[7] Diagnosis of ectopic pregnancy is made on the basis of the positive visualization of an extrauterine pregnancy.[8] If neither an intrauterine or extrauterine pregnancy is visualized on TVS, the woman are classified as having a “pregnancy of unknown location” (PUL) and followed up until the final pregnancy outcome is known. Although the majority of women will be subsequently diagnosed with a failing PUL or an intrauterine pregnancy, data from specialized ultrasound-based units show that between 7% and 20% will subsequently be diagnosed with an ectopic pregnancy.[9],[10],[11] A number of other ancillary findings may suggest the presence of an ectopic pregnancy, they are not diagnostic. There may be anechoic- or echogenic-free fluid within the Pouch of Douglas. Echogenic fluid within the Pouch of Douglas or Morison's Pouch may suggest hemoperitoneum secondary to a ruptured ectopic pregnancy or a tubal miscarriage, but it may also be caused due to rupture of an hemorrhagic ovarian cyst. There may also be a collection of fluid within the endometrial cavity often referred to as a pseudosac. Using TVS, it is not difficult to distinguish this from an early intrauterine gestational sac, which is seen as an eccentrically placed hyperechoic ring within the endometrial cavity.[12]

The aim of the present study is to evaluate the diagnostic performance of TVS and sonoelastography in diagnosis of ectopic pregnancy. In this study, we are presenting our initial experience with elastography.

  Subjects and Methods Top

Collection of data

This prospective study was conducted with approval by the Institutional Legal Ethical Committee. Forty cases were analyzed from July 2016 to December 2018. Patients included were in the age group of 24–36 years. Transvaginal ultrasound (TVUS) followed by strain elastography was performed with the Hitachi Aloka Arietta S70 with 5–11 MHz transvaginal transducer.

Conventional sonographic examination

Each lesion was analyzed as per ultrasound descriptors such as presence of extrauterine gestational sac, presence of fetus and yolk sac, presence of fetal cardiac pulsations, free fluid in the abdomen, presence of pseudogestational sac, and tubal ring sign. All sonograms were reviewed for the presence and characteristics of an adnexal mass and for the presence and amount of free fluid. Adnexal masses were graded using a tiered approach, based on their appearance and contents, as follows: (1) nonspecific mass (no tubal ring, yolk sac, or heartbeat); (2) tubal ring (echogenic ring with a hypoechoic center but no yolk sac or heartbeat); (3) yolk sac but no embryonic heartbeat; and (4) embryo with heartbeat.[13]

Elastography technique

Once the optimum B-mode image was obtained on transvaginal sonography and adnexal mass is suspected, gentle pressure is applied with the transvaginal probe and elastogram was obtained. The images from conventional sonography and sonographic elastography were displayed side by side as a single image. On elastography, a careful search was done for blue eye sign.

Final diagnosis

Women were classified as having a confirmed ectopic pregnancy on the basis of surgery and laparoscopy.[14],[15],[16],[17],[18]

  Results Top

Forty patients presented to the radiology department with suspected clinical diagnosis of ectopic pregnancy. Thirty patients were in the age group of 21–30 years (75%), while ten patients were in the age group of 31–40 years (30%). Nineteen cases were diagnosed as ectopic pregnancy on TVUS. Transvaginal strain elastography revealed blue eye sign an important feature of ectopic pregnancy in twenty cases of ectopic pregnancy including one case, in which ultrasonography (USG) did not show features of ectopic pregnancy. All 20 patients had tubal ectopic pregnancy. Twenty cases did not show features of ectopic pregnancy [Table 1], [Table 2], [Table 3], [Table 4], [Table 5].
Table 1: Age group of patients

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Table 2: Adnexal characteristics seen on ultrasonography in patients with ectopic pregnancy

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Table 3: Doppler findings

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Table 4: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of transvaginal sonography ultrasound

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Table 5: Elastographic features

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In transvaginal sonographic findings, tubal ring sign was the most common finding seen in 50% cases followed by nonspecific adnexal mass in 27% cases. A variable amount of free fluid was noted in the abdomen in all cases. Ring of fire was seen in all patients on color Doppler. Transvaginal strain elastography revealed blue eye sign in 19 cases of ectopic pregnancy diagnosed on USG, and in one other case, in which USG did not show features of ectopic pregnancy. On follow-up, one case was found to false positive and one false was found to be negative on the ultrasound. Elastography was able to diagnose all cases of ectopic pregnancy accurately [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].
Figure 1: Ultrasonography image showing hematoperitoneum

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Figure 2: Sagittal image of the uterus showing gestational pseudosac. Right adnexal ectopic was present

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Figure 3: Left adnexal ectopic showing gestational sac containing fetal pole and yolk sac

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Figure 4: Tubal ectopic pregnancy was seen between uterus and ovary showing characteristic double ring sign

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Figure 5: Power Doppler showing ring of fire appearance indicating hypervascularity

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Figure 6: Elastography image showing classical blue eye sign (shown by white arrow) in the area of nonspecific adnexal mass

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Kirk and Bourne reported a sensitivity of >90% sensitivity of TVUS in diagnosis of ectopic pregnancy.[12] Young et al. stated in 2017 that the sensitivity and specificity of ultrasound for the detection of confirmed ectopic pregnancy were 88.5% and 96.5% on the initial TVUS and 93.1% and 95.7% with an additional rescan.[2] Condous et al. showed sensitivity and specificity of TVS to detect ectopic pregnancy were 90.9% and 99.9%.[14] In our study, sensitivity was 95.2% and specificity was 94.4%. Blue eye sign was seen in 100% cases of ectopic on elastography.


One of the main limitations of this study is that the acquisition of elastograms as well as analysis is observer dependent. The magnitude of initial compression could affect the elasticity map. Hence, interobserver and intraobserver variability is another factor which needs to be studied. Small number of cases is also a limitation. A large series is required for its further evaluation.

  Conclusions Top

Transvaginal elastography has high diagnostic yield and promises to be an excellent tool in the early diagnosis of ectopic pregnancy, which can help in reducing mortality and morbidity and aids in better patient management.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Winder S, Reid S, Condous G. Ultrasound diagnosis of ectopic pregnancy. Australas J Ultrasound Med 2011;14:29-33.  Back to cited text no. 1
Young L, Barnard C, Lewis E, Jones M, Furlan J, Karatasiou A, et al. The diagnostic performance of ultrasound in the detection of ectopic pregnancy. N Z Med J 2017;130:17-22.  Back to cited text no. 2
Dutta RL, Economides DL. Patient acceptance of transvaginal sonography in the early pregnancy unit setting. Ultrasound Obstet Gynecol 2003;22:503-7.  Back to cited text no. 3
Basama FM, Crosfill F, Price A. Women's perception of transvaginal sonography in the first trimester; in an early pregnancy assessment unit. Arch Gynecol Obstet 2004;269:117-20.  Back to cited text no. 4
Romero R, Kadar N, Jeanty P, Copel JA, Chervenak FA, DeCherney A, et al. Diagnosis of ectopic pregnancy: Value of the discriminatory human chorionic gonadotropin zone. Obstet Gynecol 1985;66:357-60.  Back to cited text no. 5
Aleem FA, DeFazio M, Gintautas J. Endovaginal sonography for the early diagnosis of intrauterine and ectopic pregnancies. Hum Reprod 1990;5:755-8.  Back to cited text no. 6
Valenzano M, Anserini P, Remorgida V, Brasca A, Centonze A, Costantini S, et al. Transabdominal and transvaginal ultrasonographic diagnosis of ectopic pregnancy: Clinical implications. Gynecol Obstet Invest 1991;31:8-11.  Back to cited text no. 7
Condous G. The management of early pregnancy complications. Best Pract Res Clin Obstet Gynaecol 2004;18:37-57.  Back to cited text no. 8
Banerjee S, Aslam N, Zosmer N, Woelfer B, Jurkovic D. The expectant management of women with early pregnancy of unknown location. Ultrasound Obstet Gynecol 1999;14:231-6.  Back to cited text no. 9
Condous G, Kirk E, Lu C, Van Huffel S, Gevaert O, De Moor B, et al. Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location. Ultrasound Obstet Gynecol 2005;26:770-5.  Back to cited text no. 10
Kirk E, Condous G, Van Calster B, Van Huffel S, Timmerman D, Bourne T, et al. Rationalizing the follow-up of pregnancies of unknown location. Hum Reprod 2007;22:1744-50.  Back to cited text no. 11
Kirk E, Bourne T. Diagnosis of ectopic pregnancy with ultrasound. Best Pract Res Clin Obstet Gynaecol 2009;23:501-8.  Back to cited text no. 12
Frates MC, Doubilet PM, Peters HE, Benson CB. Adnexal sonographic findings in ectopic pregnancy and their correlation with tubal rupture and human chorionic gonadotropin levels. J Ultrasound Med 2014;33:697-703.  Back to cited text no. 13
Condous G, Okaro E, Khalid A, Lu C, Van Huffel S, Timmerman D, et al. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery. Hum Reprod 2005;20:1404-9.  Back to cited text no. 14
Wankhade A, Vagha S, Shukla S, Bhake A, Laishram S, Agrawal D, et al. To correlate histopathological changes and transvaginal sonography findings in the endometrium of patients with abnormal uterine bleeding. J Datta Meghe Inst Med Sci Univ 2019;14:11-5. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85068650239&doi=10.4103%2fjdmimsu.jdmimsu_70_18&partnerID=40&md5=0f120705d85820c532affc37603a863c. [Last accessed on 2019 Jun 27].  Back to cited text no. 15
Marfani G, Phatak SV, Madurwar KA, Samad S. Role of sonoelastography in diagnosing endometrial lesions: Our initial experience. J Datta Meghe Inst Med Sci Univ 2019:14;31-5. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85068818030&doi=10.4103%2fjdmimsu.jdmimsu_89_18&partnerID=40&md5=d420acd28b628a5fb55621fdd37838fa. [Last accessed on 2019 Jun 27].  Back to cited text no. 16
Gulve SS, Phatak SV. Parathyroid adenoma: Ultrasonography, Doppler, and elastography imaging. J Datta Meghe Inst Med Sci Univ 2019;14:47-9. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85068703326&doi=10.4103%2fjdmimsu.jdmimsu_91_18&partnerID=40&md5=f9fb90ea92a03e3d196f1d182ea0eb8a. [Last accessed on 2019 Jun 27].  Back to cited text no. 17
Phatak S, Marfani G. Galactocele ultrasonography and elastography imaging with pathological correlation. J Datta Meghe Inst Med Sci Univ 2018;13;1-3. Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85053321619&doi=10.4103%2fjdmimsu.jdmimsu_51_18&partnerID=40&md5=bfd00f99b99a6b702b42f5957dfcb4ab. [Last accessed on 2019 Jun 27].  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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