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Semin Reprod Med 2008; 26(5): 373-382
DOI: 10.1055/s-0028-1087103
© Thieme Medical Publishers

Ultrasound Criteria for Diagnosis of Early Pregnancy Failure and Ectopic Pregnancy

Lisa Perriera1 , 3 , Matthew F. Reeves2 , 3
  • 1Clinical Instructor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 3Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Publication History

Publication Date:
29 September 2008 (online)

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ABSTRACT

Early pregnancy failure and ectopic pregnancy are common clinical diagnoses for which ultrasound can provide useful information. This review explores the use of ultrasound to diagnose early pregnancy failure and ectopic pregnancy. By documenting the developmental milestones of early normal pregnancy using ultrasound, clinicians can distinguish normal from abnormal intrauterine pregnancies. An early pregnancy failure can be diagnosed by the absence of a visible yolk sac with a mean sac diameter of 13 mm; the absence of a visible embryo with a mean sac diameter of 13 mm; the absence of cardiac motion with an embryo measuring 5 mm or more in maximal length; or the presence of an empty amnion. In most settings, documentation of a normal intrauterine pregnancy effectively eliminates the possibility of ectopic pregnancy. The presence of an adnexal mass in the absence of an intrauterine gestational sac may indicate an ectopic pregnancy.

KEYWORDS

Transvaginal ultrasound - early pregnancy failure - ectopic pregnancy

REFERENCES

  • 1 CDC . Ectopic pregnancy—United States, 1990–1992.  MMWR Morb Mortal Wkly Rep. 1995;  44 46-48
    PubMedSearch in Google Scholar
  • 2 Coste J, Bouyer J, Ughetto S et al.. Ectopic pregnancy is again on the increase. Recent trends in the incidence of ectopic pregnancies in France (1992–2002).  Hum Reprod. 2004;  19 2014-2018
    CrossrefPubMedSearch in Google Scholar
  • 3 Grimes D A. Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999.  Am J Obstet Gynecol. 2006;  194 92-94
    CrossrefPubMedSearch in Google Scholar
  • 4 Chang J, Elam-Evans L D, Berg C J et al.. Pregnancy-related mortality surveillance—United States, 1991–1999. Surveillance summaries.  MMWR Morb Mortal Wkly Rep. 2003;  52 1-8
    PubMedSearch in Google Scholar
  • 5 Wilcox A J, Weinberg C R, O'Connor J F et al.. Incidence of early loss of pregnancy.  N Engl J Med. 1988;  319 189-194
    CrossrefPubMedSearch in Google Scholar
  • 6 Miller J F, Williamson E, Glue J, Gordon Y B, Grudzinskas J G, Sykes A. Fetal loss after implantation. A prospective study.  Lancet. 1980;  2 554-556
    PubMedSearch in Google Scholar
  • 7 Ellish N J, Saboda K, O'Connor J, Nasca P C, Stanek E J, Boyle C. A prospective study of early pregnancy loss.  Hum Reprod. 1996;  11 406-412
    PubMedSearch in Google Scholar
  • 8 Cullen M T, Green J J, Reece E A, Hobbins J C. A comparison of transvaginal and abdominal ultrasound in visualizing the first trimester conceptus.  J Ultrasound Med. 1989;  8 565-569
    PubMedSearch in Google Scholar
  • 9 Warren W B, Timor-Tritsch I, Peisner D B, Raju S, Rosen M G. Dating the early pregnancy by sequential appearance of embryonic structures.  Am J Obstet Gynecol. 1989;  161 747-753
    PubMedSearch in Google Scholar
  • 10 Rossavik I K, Torjusen G O, Gibbons W E. Conceptual age and ultrasound measurements of gestational sac and crown-rump length in in vitro fertilization pregnancies.  Fertil Steril. 1988;  49 1012-1017
    PubMedSearch in Google Scholar
  • 11 Bradley W G, Fiske C E, Filly R A. The double sac sign of early intrauterine pregnancy: use in exclusion of ectopic pregnancy.  Radiology. 1982;  143 223-226
    CrossrefPubMedSearch in Google Scholar
  • 12 Rowling S E, Langer J E, Coleman B G, Nisenbaum H L, Horii S C, Arger P H. Sonography during early pregnancy: dependence of threshold and discriminatory values on transvaginal transducer frequency.  AJR Am J Roentgenol. 1999;  172 983-988
    PubMedSearch in Google Scholar
  • 13 Hadlock F P, Shah Y P, Kanon D J, Lindsey J V. Fetal crown-rump length: reevaluation of relation to menstrual age (5–18 weeks) with high-resolution real-time US.  Radiology. 1992;  182 501-505
    CrossrefPubMedSearch in Google Scholar
  • 14 Goldstein S R, Wolfson R. Endovaginal ultrasonographic measurement of early embryonic size as a means of assessing gestational age.  J Ultrasound Med. 1994;  13 27-31
    PubMedSearch in Google Scholar
  • 15 Tannirandorn Y, Sangsawang S, Manotaya S, Uerpairojkit B, Samritpradit P, Charoenvidhya D. Fetal loss in threatened abortion after embryonic/fetal heart activity.  Int J Gynaecol Obstet. 2003;  81 263-266
    PubMedSearch in Google Scholar
  • 16 Deaton J L, Honore G M, Huffman C S, Bauguess P. Early transvaginal ultrasound following an accurately dated pregnancy: the importance of finding a yolk sac or fetal heart motion.  Hum Reprod. 1997;  12 2820-2823
    CrossrefPubMedSearch in Google Scholar
  • 17 Blaas H G, Eik-Nes S H, Bremnes J B. The growth of the human embryo. A longitudinal biometric assessment from 7 to 12 weeks of gestation.  Ultrasound Obstet Gynecol. 1998;  12 346-354
    PubMedSearch in Google Scholar
  • 18 Levi C S, Lyons E A, Lindsay D J. Early diagnosis of nonviable pregnancy with endovaginal US.  Radiology. 1988;  167 383-385
    CrossrefPubMedSearch in Google Scholar
  • 19 Tongsong T, Wanapirak C, Srisomboon J, Sirichotiyakul S, Polsrisuthikul T, Pongsatha S. Transvaginal ultrasound in threatened abortions with empty gestational sacs.  Int J Gynaecol Obstet. 1994;  46 297-301
    CrossrefPubMedSearch in Google Scholar
  • 20 Rowling S E, Coleman B G, Langer J E, Arger P H, Nisenbaum H L, Horii S C. First-trimester US parameters of failed pregnancy.  Radiology. 1997;  203 211-217
    CrossrefPubMedSearch in Google Scholar
  • 21 Lindsay D J, Lovett I S, Lyons E A et al.. Yolk sac diameter and shape at endovaginal US: predictors of pregnancy outcome in the first trimester.  Radiology. 1992;  183 115-118
    CrossrefPubMedSearch in Google Scholar
  • 22 Ferrazzi E, Brambati B, Lanzani A et al.. The yolk sac in early pregnancy failure.  Am J Obstet Gynecol. 1988;  158 137-142
    PubMedSearch in Google Scholar
  • 23 McKenna K M, Feldstein V A, Goldstein R B, Filly R A. The empty amnion: a sign of early pregnancy failure.  J Ultrasound Med. 1995;  14 117-121
    PubMedSearch in Google Scholar
  • 24 Lee W, Deter R L, McNie B et al.. Quantitative and morphological assessment of early gestational sacs using three-dimensional ultrasonography.  Ultrasound Obstet Gynecol. 2006;  28 255-260
    PubMedSearch in Google Scholar
  • 25 Goldstein S R. Significance of cardiac activity on endovaginal ultrasound in very early embryos.  Obstet Gynecol. 1992;  80 670-672
    PubMedSearch in Google Scholar
  • 26 Levi C S, Lyons E A, Zheng X H, Lindsay D J, Holt S C. Endovaginal US: demonstration of cardiac activity in embryos of less than 5.0 mm in crown-rump length.  Radiology. 1990;  176 71-74
    PubMedSearch in Google Scholar
  • 27 Brown D L, Emerson D S, Felker R E, Cartier M S, Smith W C. Diagnosis of early embryonic demise by endovaginal sonography.  J Ultrasound Med. 1990;  9 631-636
    PubMedSearch in Google Scholar
  • 28 Benson C B, Doubilet P M. Slow embryonic heart rate in early first trimester: indicator of poor pregnancy outcome.  Radiology. 1994;  192 343-344
    PubMedSearch in Google Scholar
  • 29 Chittacharoen A, Herabutya Y. Slow fetal heart rate may predict pregnancy outcome in first-trimester threatened abortion.  Fertil Steril. 2004;  82 227-229
    CrossrefPubMedSearch in Google Scholar
  • 30 Qasim S M, Sachdev R, Trias A, Senkowski K, Kemmann E. The predictive value of first-trimester embryonic heart rates in infertility patients.  Obstet Gynecol. 1997;  89 934-936
    CrossrefPubMedSearch in Google Scholar
  • 31 Doubilet P M, Benson C B. Embryonic heart rate in the early first trimester: what rate is normal?.  J Ultrasound Med. 1995;  14 431-434
    PubMedSearch in Google Scholar
  • 32 Bromley B, Harlow B L, Laboda L A, Benacerraf B R. Small sac size in the first trimester: a predictor of poor fetal outcome.  Radiology. 1991;  178 375-377
    CrossrefPubMedSearch in Google Scholar
  • 33 Leung S W, Pang M W, Chung T K. Retained products of gestation in miscarriage: an evaluation of transvaginal ultrasound criteria for diagnosing an “empty uterus”.  Am J Obstet Gynecol. 2004;  191 1133-1137
    CrossrefPubMedSearch in Google Scholar
  • 34 Alcazar J L, Baldonado C, Laparte C. The reliability of transvaginal ultrasonography to detect retained tissue after spontaneous first-trimester abortion, clinically thought to be complete.  Ultrasound Obstet Gynecol. 1995;  6 126-129
    PubMedSearch in Google Scholar
  • 35 Kurtz A B, Shlansky-Goldberg R D, Choi H Y, Needleman L, Wapner R J, Goldberg B B. Detection of retained products of conception following spontaneous abortion in the first trimester.  J Ultrasound Med. 1991;  10 387-395
    PubMedSearch in Google Scholar
  • 36 Pedersen J F, Mantoni M. Prevalence and significance of subchorionic hemorrhage in threatened abortion: a sonographic study.  AJR Am J Roentgenol. 1990;  154 535-537
    PubMedSearch in Google Scholar
  • 37 Bennett G L, Bromley B, Lieberman E, Benacerraf B R. Subchorionic hemorrhage in first-trimester pregnancies: prediction of pregnancy outcome with sonography.  Radiology. 1996;  200 803-806
    PubMedSearch in Google Scholar
  • 38 Kohn M A, Kerr K, Malkevich D, O'Neil N, Kerr M J, Kaplan B C. Beta-human chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding.  Acad Emerg Med. 2003;  10 119-126
    CrossrefPubMedSearch in Google Scholar
  • 39 Barnhart K, Mennuti M T, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emergency department setting.  Obstet Gynecol. 1994;  84 1010-1015
    PubMedSearch in Google Scholar
  • 40 Cacciatore B, Stenman U H, Ylostalo P. Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum hCG level of 1000 IU/l (IRP).  Br J Obstet Gynaecol. 1990;  97 904-908
    PubMedSearch in Google Scholar
  • 41 Shalev E, Yarom I, Bustan M, Weiner E, Ben-Shlomo I. Transvaginal sonography as the ultimate diagnostic tool for the management of ectopic pregnancy: experience with 840 cases.  Fertil Steril. 1998;  69 62-65
    CrossrefPubMedSearch in Google Scholar
  • 42 Condous G, Okaro E, Khalid A et al.. The accuracy of transvaginal ultrasonography for the diagnosis of ectopic pregnancy prior to surgery.  Hum Reprod. 2005;  20 1404-1409
    CrossrefPubMedSearch in Google Scholar
  • 43 Hill L M, Kislak S, Martin J G. Transvaginal sonographic detection of the pseudogestational sac associated with ectopic pregnancy.  Obstet Gynecol. 1990;  75 986-988
    PubMedSearch in Google Scholar
  • 44 Paul M, Schaff E, Nichols M. The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice.  Am J Obstet Gynecol. 2000;  183 S34-S43
    PubMedSearch in Google Scholar
  • 45 Nyberg D A, Filly R A, Laing F C, Mack L A, Zarutskie P W. Ectopic pregnancy. Diagnosis by sonography correlated with quantitative HCG levels.  J Ultrasound Med. 1987;  6 145-150
    PubMedSearch in Google Scholar
  • 46 Barnhart K T, Simhan H, Kamelle S A. Diagnostic accuracy of ultrasound above and below the beta-hCG discriminatory zone.  Obstet Gynecol. 1999;  94 583-587
    CrossrefPubMedSearch in Google Scholar
  • 47 Chen P C, Sickler G K, Dubinsky T J, Maklad N, Jacobi R L, Weaver J E. Sonographic detection of echogenic fluid and correlation with culdocentesis in the evaluation of ectopic pregnancy.  AJR Am J Roentgenol. 1998;  170 1299-1302
    PubMedSearch in Google Scholar
  • 48 Chandra P, Koenigsberg M, Romney S L, Koren Z, Schulman H. Unruptured interstitial pregnancy. Diagnosis and treatment.  Obstet Gynecol. 1978;  52 612-615
    PubMedSearch in Google Scholar
  • 49 Fleischer A C, Pennell R G, McKee M S et al.. Ectopic pregnancy: features at transvaginal sonography.  Radiology. 1990;  174 375-378
    PubMedSearch in Google Scholar
  • 50 Ackerman T E, Levi C S, Dashefsky S M, Holt S C, Lindsay D J. Interstitial line: sonographic finding in interstitial (cornual) ectopic pregnancy.  Radiology. 1993;  189 83-87
    PubMedSearch in Google Scholar
  • 51 Jurkovic D, Hacket E, Campbell S. Diagnosis and treatment of early cervical pregnancy: a review and a report of two cases treated conservatively.  Ultrasound Obstet Gynecol. 1996;  8 373-380
    PubMedSearch in Google Scholar
  • 52 Creinin M D, Feldstein V A. Conservative management options for cervical pregnancy; case reports and literature review.  Int J Fertil Menopausal Stud. 1995;  40 175-186
    PubMedSearch in Google Scholar
  • 53 Frates M C, Benson C B, Doubilet P M et al.. Cervical ectopic pregnancy: results of conservative treatment.  Radiology. 1994;  191 773-775
    PubMedSearch in Google Scholar
  • 54 Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson C J. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar.  Ultrasound Obstet Gynecol. 2003;  21 220-227
    CrossrefPubMedSearch in Google Scholar
  • 55 Ben Nagi J, Ofili-Yebovi D, Marsh M, Jurkovic D. First-trimester cesarean scar pregnancy evolving into placenta previa/accreta at term.  J Ultrasound Med. 2005;  24 1569-1573
    PubMedSearch in Google Scholar

Matthew F ReevesM.D. M.P.H. 

Department of Obstetrics, Gynecology, and Reproductive Sciences

300 Halket Street, Pittsburgh, PA 15213-3180

Email: mreeves@upmc.edu