Early Pregnancy US

i
Early Pregnancy Ultrasound

A Practical Guide
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iii
Early Pregnancy Ultrasound

A Practical Guide
Edited by
Emma Kirk
Royal Free Hospital, London
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Names: Kirk, Emma, editor.
Title: Early pregnancy ultrasound: a practical guide / edited by Emma Kirk.
Description: Cambridge, United Kingdom; New York, NY: Cambridge University Press, 2017. |
Includes bibliographical references and index.
Identifiers: LCCN 2017034626 | ISBN 9781316503867 (paperback)
Subjects: | MESH: Ultrasonography, Prenatal | Pregnancy Trimester, First |
Pregnancy Complications – diagnostic imaging | Early Diagnosis
Classification: LCC RG107.5.U4 | NLM WQ 209 | DDC 618.207/543–dc23
LC record available at https://lccn.loc.gov/2017034626
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v
Contents
List of Contributors page vii
Preface ix
1 Introduction to Early Pregnancy 8 The Adnexa and Other Pathology 59

Ultrasound 1 Wouter Froyman and Dirk Timmerman
Emma Kirk
9 Uterine Anomalies and Early Pregnancy 69
2 The Normal Early Intrauterine Matthew Prior and Nick Raine-Fenning
Pregnancy 4–11 Weeks 11
10 The Use of 3D Ultrasound and Colour
Aslı’ S. Üçyiğit and Jackie A. Ross
Doppler in Early Pregnancy 75
3 Diagnosis of Miscarriage 17 Venetia Goodhart and Davor Jurkovic
Nicola Mitchell-Jones and Cecilia Bottomley
11 Ultrasound and the Surgical Management
4 Gestational Trophoblastic Disease 23 of Early Pregnancy Complications 82
Anna Graham and Jemma Johns Tom Holland
5 Pregnancy of Unknown Location 33
Shabnam Bodiwala and Tom Bourne
6 Tubal Ectopic Pregnancy 39 Index 85
Emma Kirk
7 Nontubal Ectopic Pregnancy 50
Dimitrios Mavrelos and Davor Jurkovic
vii
Contributors
Shabnam Bodiwala, BSc MBBS, Queen Emma Kirk BSc MD MRCOG, Department of
Charlotte’s & Chelsea Hospital, Imperial College Obstetrics & Gynaecology, Royal Free Hospital,
London, Hammersmith Campus, London, UK London, UK
Cecilia Bottomley, MD MRCOG, Department of Dimitrios Mavrelos MD MRCOG, Department
Obstetrics & Gynaecology, Chelsea & Westminster of Obstetrics & Gynaecology, University College
Hospital, London, UK London Hospital, London, UK
Tom Bourne PhD FRCOG, Queen Charlotte’s & Nicola Mitchell-Jones MRCOG, Department of
Chelsea Hospital, Imperial College London, Obstetrics & Gynaecology, Chelsea & Westminster
Hammersmith Campus, London, UK Hospital, London, UK
Wouter Froyman MD, Department of Obstetrics & Matthew Prior MRCOG DFSRH, Department of
Gynaecology, University Hospitals Leuven, Obstetrics & Gynaecology, University of
Netherlands Nottingham, UK
Venetia Goodhart BSc MBBS, Department of Nick Raine-Fenning MRCOG, Department of
Obstetrics & Gynaecology, University College Obstetrics & Gynaecology, University of Nottingham
London Hospital, London, UK Queen’s Medical Centre, Nottingham, UK
Anna Graham MBBS MA, King’s College Hospital Jackie A. Ross BSc FRCOG, Early Pregnancy &
NHS Foundation Trust, London, UK Gynaecology Assessment Unit, King’s College
Hospital NHS Foundation Trust, London, UK
Tom Holland MD MRCOG, Department of
Obstetrics & Gynecology, St Thomas’s Hospital, Dirk Timmerman MD PhD, Department of
London, UK Obstetrics & Gynecology, University Hospital
Leuven, Leuven, Belgium
Jemma Johns MD MRCOG, Department of
Obstetrics & Gynecology, Imperial College School of Aslı’ S. Üçyiğit BSc MRCS MRCOG, Early
Medicine, London, UK Pregnancy & Gynaecology Assessment Unit,
King’s College Hospital NHS Foundation Trust,
Davor Jurkovic MD PhD FRCOG, Department
London, UK
of Obstetrics & Gynaecology, University College
London Hospital, London, UK
vii
ix
Preface
The use of ultrasound has revolutionised the diagnosis pregnancy as well as chapters on abnormal pregnan-
and management of most early pregnancy complica- cies and adnexal pathology. It includes sample ultra-
tions. It is now a key multi-disciplinary tool in the pro- sound images, with explanatory annotated diagrams
vision of early pregnancy care, with nurses, midwives, as well as expert practical advice on conducting ultra-
sonographers and doctors often conducting the ultrasound examinations and managing certain clinical sit-
sound examinations. This book is aimed as a practi- uations. It is anticipated that the guide will be useful to
cal guide in this important area, not just for all those both UK and international healthcare professionals.
undertaking such examinations but all those with a At the end of each chapter there is a list of key learn-
general interest in early pregnancy. There are chapters ing points and suggested further reading for readers
on what to expect to see with a normal intra-uterine who require additional information.
ix
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1
Chapter
Introduction to Early Pregnancy
1 Ultrasound
Emma Kirk
Ultrasound is the most commonly used medical imag- output power and the shortest scan time consistent
ing method in pregnancy. In the United Kingdom, all with acquiring the required diagnostic information.
women are routinely offered ultrasound examina- This is referred to as the ALARA (‘as low as reason-
tions at around 12 weeks and 20 weeks of gestation. ably achievable’) principle.
However, the use of ultrasound prior to 12 weeks has
become central to the management of women with Safety Indices
suspected early pregnancy problems. In particu-
Ultrasound examination of the developing embryo
lar, earlier ultrasound examinations are indicated in
or fetus exposes it to both mechanical and thermal
women after assisted conception and those in whom
stress. The potential effects of these forms of stress
an ectopic pregnancy or miscarriage is suspected.
are represented by the mechanical index (MI) and
The aims of an early pregnancy ultrasound
thermal index (TI) respectively. These two indices are
scan (USS) are to confirm the presence of an intra-
summarised in Table 1.2. They are displayed on the
uterine pregnancy, establish viability, determine
ultrasound screen during the examination, as shown
number of embryos, determine gestational age and
in Figure 1.1.
reassure a woman and her partner of the absence of
complications.
Scanning Modes
Evidence suggests that the most commonly used
Setting B-Mode ultrasound is safe in early pregnancy
In the United Kingdom, the majority of early preg-
when using standard obstetric presets on modern
nancy ultrasound examinations are carried out in
machines. Colour Doppler and pulsed wave Doppler
Early Pregnancy Units. These are specialist units for
involve greater average intensity and power outputs
the provision of care for women with suspected early
as shown by higher TIS (TI soft tissue) levels com-
pregnancy complications. It is a recommendation of
pared to B-Mode imaging. There is therefore a greater
the Royal College of Obstetricians and Gynaecologists
risk to the developing fetus of overheating. If Doppler
that all maternity units should have such a unit.
ultrasound is used in early pregnancy, the operator
Table 1.1 summarises some of the standards that
should aim to keep the TIS < 1.0 and limit the scan
should be expected in an Early Pregnancy Unit.
exposure time. Currently it is not recommended that
Doppler be routinely used in early pregnancy ultra-
Safety sound assessments. The M-Mode is a low-energy
In recent years, there has been much interest in the alternative to pulsed wave Doppler, which can be
safety of early ultrasound examinations. The evidence used to insonate the embryonic heart if required in
so far suggests that ultrasound used for clinical rea- early pregnancy.
sons with standard presets during embryonic devel- There is no current evidence that three-dimensional
opment (conception to ten weeks’ gestation) is safe (3D) ultrasound leads to higher ultrasound exposure
and the benefits outweigh any theoretical risks. It is, than two-dimensional (2D) examinations. In fact,
however, essential that whoever is carrying out the scanning and exposure times may actually be reduced,
ultrasound examination is aware of the safety indices as the data set can be analysed offline. The routine use
and scanning modes. A fundamental approach to the of 3D examinations, however, is also not routinely
safe use of diagnostic ultrasound is to use the lowest recommended. 1
Chapter 1: Introduction to Early Pregnancy Ultrasound
Table 1.1 Standards for provision of care in early pregnancy units
Essential Desirable
Accessibility • Minimum five-day opening. • Is Open seven days a week.
• Access to transvaginal and transabdominal ultrasound.
• Acceptance of direct referrals from general practitioners
(GPs), accident and emergency responders and other health care
professionals seeing women in early pregnancy. • Accepts self-referral from all
• Acceptance of self-referrals from women with a previous women.
history of ectopic pregnancy or recurrent miscarriage.
Environment • Units should have a designated reception and waiting area. • Unit separate from the main
• Appropriately furnished room for breaking bad news and counseling. maternity unit.
• System for capturing all patient information and creating written reports.
Process • Clear protocols for carrying out a pregnancy test and performing
an ultrasound examination in any woman of reproductive age
presenting with any type of abdominal pain, irregular vaginal
bleeding or amenorrhoea.
• Direct laboratory access to same-day serum human chorionic • Serum hCG results available
gonadotropin (hCG) and blood group results. within two hours.
• Clear guidelines and algorithms for the management of pregnancies of • Access to serum progesterone
unknown location and of uncertain viability. levels.
• A full range of management options (expectant, medical
and surgical) for women diagnosed with miscarriage or
ectopic pregnancy.
Communication • Clear patient information leaflets. • Direct access to bereavement
• A written report of the outcome of a woman’s ultrasound examination, counselling.
with a copy sent to their GP or referring health professional.
Source: Adapted from Moody, ed., RCOG Standards for Gynaecology, 2008.
Table 1.2 Ultrasound safety indices
Explanation Recommended levels *

Mechanical index MI MI is an on-screen indicator of the relative potential for An MI of < 1.0 indicates that
ultrasound to induce an adverse bioeffect by a nonthermal effects arising from acoustic
or mechanical mechanism. This includes cavitation (which cavitation are very unlikely.
refers to the development of gas bubbles in an acoustic field Ideally aim for levels < 0.7 in
at high negative pressures) and streaming (the expansion and early pregnancy scanning.
contraction, or collapse, of gas bubbles during the
oscillatory cycle).
Thermal index TI TI provides an indication of the relative potential for a rise in The higher the TI, the shorter
tissue temperature. It is intended to give a rough guide to the the ultrasound exposure should
likely maximum temperature rise that might be produced after be. TIS < 0.7 – no restriction on
long exposure. There are three types: scan time.
TIS – thermal index for soft tissue. The index used during TIS 0.7–1.0 – restrict scan time
scanning < ten weeks of gestation. to < 60 minutes.
TIB – thermal index for bone. TIS 1.0–1.5 – restrict scan time to
TIC – thermal index for cranial bone. < 30 minutes.
TIS > 3.0 – scanning not
recommended.
* Recommended by the British Medical Ultrasound Society.
3
Similarly, when examining in the longitudinal plane,

some will have the bladder on the left and some will
have it on the right, as indicated in Table 1.4. The most
important thing is that the examiner is aware of his or
her own orientation when performing the ultrasound
examination.
Figure 1.1 Image showing on-screen display of mechanical index

Image Optimisation
(MI) and thermal index (TI). Whilst most modern ultrasound machines are now
programmed with suggested presets for the examina-
tion type intended in order to obtain the best images,
Scanning Route there are still some things that usually need to be
There are a number of advantages of the transvaginal changed during every examination.
route over the transabdominal route in early preg-
nancy, as indicated in Table 1.3. There is plenty of 1. Depth
evidence in the literature suggesting that in the early Usually the examination is started using high depth
first trimester a transvaginal scan (TVS) can reliably or a low magnification. Increasing the depth allows
identify normal and abnormal pregnancies and vari- deeper structures to be viewed. Reducing the depth
ous developmental markers at an earlier stage than a allows more superficial structures to be viewed.
transabdominal scan (TAS). A TVS has been shown
to be acceptable to women attending Early Pregnancy 2. Magnification
Units and in fact some women do actually prefer it to
For superficial structures it is usually easiest to mag-
a TAS. The reasons for this include the discomfort and
nify the image by reducing the depth of the image. For
time needed to fill the bladder to adequately examine
deeper structures or to get an even bigger image, the
the pelvis abdominally. TVS is also superior in obese
zoom function can be used. This zoom function just
patients and those with a retroverted uterus.
takes a portion of the screen and magnifies it. It can
Occasionally it may be necessary to perform a
be used whilst scanning or whilst the image is frozen.
transrectal ultrasound scan. This may be used as an
alternative to a TVS if either a TVS is not possible and 3. Focus
insufficient information is obtained by a TAS.
The focus can be adjusted to manipulate the pulse
of the ultrasound to be at its narrowest at a par-
Ultrasound Technique ticular depth. This means that the image quality is
Whether performing a TVS or TAS, it is essential that maximised at this level. It allows the best lateral res-
the examination is performed in a systematic fashion olution (ability to see two things as two things) to be
and the image is optimised to enable the examiner to achieved.
get the most information from the procedure.
4. Gain
Image Orientation The overall brightness of the image can be adjusted
There is a general agreement that when in transverse by altering the gain. This is usually one of the most
section, the patient’s right side should be seen on the important changes to make to optimise the image, as
left side of the ultrasound screen. With a TAS, in the if the image is too light or too dark, it is difficult to see
longitudinal view the cranial structures should be seen subtle changes in texture.
on the left side of the screen and the caudal structures The ultrasound waves change and get smaller as
on the right side. Superficial structures should be they pass through tissues (attenuation). In order to
seen on the top half of the screen and deeper struc- make structures look the same even if they are located
tures on the bottom half, as indicated in Table 1.4. in different depths, the time gain compensation (TGC)
With TVS, there is no agreement on image orienta- can be adjusted. Usually there is lower gain superfi-
tion. Some scan with the transducer head in the upper cially and higher gain deeper in the image where the
part of the screen and some with it at the bottom. image quality is weaker. 3
Table 1.3 Advantages and Disadvantages of Transvaginal Sonography and Transabdominal Sonography
Advantages Disadvantages
Transvaginal (TVS) • Higher frequencies • Depth of penetration is limited due to high-
• Superior resolution of images frequency of the ultrasound
Less ultrasound penetration is needed as probe • Lack of probe mobility.
is closer to pelvic structures, therefore higher Due to the confines of the introitus and vagina, the
frequencies can be used to obtain higher resolution probe cannot be moved in all dimensions
of images.
• Requires an empty bladder, so often more
comfortable.
• The probe can be used to exert localised
pressure on the pelvic organs to test for pain.
• The pelvic organs can be moved with the probe
to see if they slide easily.
If the organs do not slide easily, this suggests that
adhesions may be present. The TVS can actually
be combined with a bimanual examination.
The examiner can place his or her hand on the
patients abdomen while operating the vaginal
probe with the other.
• The probe can be moved in and out of the
vagina to adjust the depth of the organs on the
screen.
• Allows better imaging in obese patients.
Transabdominal (TAS) • May allow better visualisation of a pregnancy • Decreased resolution.
in a large fibroid uterus. This is due to:
1. The lower frequency of abdominal probes
compared to vaginal probes
2. The scan being performed through the abdominal
wall which contains fat, muscle and tendons which
distorts the ultrasound image
3. The relative greater distance bowel which may
contain air and block visualisation of deeper
structures.
• Often requires a full bladder.
• Poor views in obese patients.
5. Frequency front of the patient, before the procedure. The probe

The highest ultrasound frequency possible should be should be covered with a protective sheath. There
chosen. However, the higher the frequency, the lower should be a layer of ultrasound gel between the trans-
the depth of penetration. Therefore, if the object of ducer head and the probe cover, with all air expelled.
interest is situated far away from the transducer, the Extra lubricating gel should then be put on the covered
frequency may need to be reduced to get the best probe. The operator should introduce the probe slowly
image. A disadvantage of the lower frequency, how- into the vagina whilst watching the screen. It is some-
ever, is a reduction in the image resolution. times helpful to ask the woman to take a deep breath
at this point. The scan should then be performed in a
systematic manner. A suggested method of doing this
Transvaginal Scan (TVS) is shown in Table 1.5. After the examination is com-
A TVS should be performed when the patient has an pleted, the probe should be removed from the vagina,
empty bladder. The procedure should be explained to the probe cover removed and the probe cleaned.
the woman and consent taken. The probe should be If a transrectal scan is performed, the same exami-
4 thoroughly cleaned by a gloved operator, ideally in nation technique should be used as for a TVS.
5
Table 1.4 Image orientation
Transabdominal Scan Transvaginal Scan Transvaginal Scan

Transducer head at top of Transducer head at bottom of
image image
Transverse view
The right ovary will be on the left

of the screen.
Longitudinal view
The fundus of the uterus

Anteverted uterus The fundus of the uterus will be on
appears on the left side of the
the right side of the screen and the
screen and the external os of the
cervix points down to the left side
cervix points to the right side of
of the screen, as in the anatomical
the screen.
position.
Retroverted uterus
The fundus of the uterus appears The fundus of the uterus will
on the right side of the screen and be on the left side of the screen
the cervix points towards the left and the cervix points down to the
side of the screen. right.
Transabdominal Scan (TAS) Documentation and Storage of Images

A TAS should be performed when the patient has a full It is important to carefully document all findings in
bladder. A full bladder displaces the bowel and allows a systematic fashion when providing a report of the
the ultrasound beam to travel through the urine until ultrasound examination. Suggested information
it reaches the uterus and ovaries. Again, it should be to include in a report is given in Table 1.6. It is also
performed in the same systematic way suggested for important to store copies of the USS images taken.
TVS (see Table 1.5). When writing the report and storing images, it is 5
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Table 1.5 Systematic approach to the TVS
Ultrasound image Schematic drawing Details

1. Longitudinal View of • It is important to obtain a longitudinal view of the uterus, ideally
the Uterus Uterus visualising the whole of the endometrial cavity down to the
cervix.
• The uterus should be scanned from one side to the other in the
Gestational sac
Yolk sac Endometrium longitudinal plane.
• An image should be saved, showing, if present, the intrauterine
gestational sac within the endometrial cavity, which should be
seen continuous with the cervical canal (thus confirming an
intrauterine pregnancy).
• If no intrauterine pregnancy is visualised, the endometrial thickness
should be measured where it appears to be at its thickest.
• The endometrium should be measured from the endometrial-
myometrial border on one side to that on the other.
2. Transverse View of • After examination in the longitudinal plane, the probe should
the Uterus Uterus be rotated 90o so that the uterus can be examined in the
Endometrium transverse plane.
Gestational sac
• The uterus should then be scanned from the fundus down to the
cervix.
Yolk sac
• Even if a gestational sac is immediately visible, it is important to
pan through the uterus in the longitudinal and transverse planes
to check for the presence of an additional sac, fibroids or
uterine anomalies.
• State if the sac appears low in the cavity.
3. Visualisation of the Longitudinal Transverse • The gestational sac should be visualised and measured in the
Gestational Sac longitudinal and transverse planes.
• The height and length of the sac should be measured in the
longitudinal plane and the width of the sac in the transverse
plane.
• It should be stated if the sac appears low in the cavity.
4. Assessment of • The sac should be examined in both planes for the presence or
Embryonic Structures absence of a yolk sac, embryo/fetus and amniotic sac.
Yolk sac • Measurements should be taken if present.
Fetal pole
7
7
5. Visualisation of the Longitudinal Transverse • The ovaries should be visualised in 2 planes and measured.
right ovary • The value of measuring ovarian size is unclear, however if it
is documented that both ovaries have been visualised and
measured, it implies that there has been a thorough
Right ovary
examination.
6. Visualisation of the Longitudinal Transverse • The presence of any ovarian cysts should be mentioned and their
Left Ovary size in 3 planes documented.
Corpus luteum
• The side of the corpus luteum and its morphology (cystic,
haemorrhagic, solid) should be recorded.
Left ovary
7. Assessment of the • Both adnexa should be fully examined for masses.

Adnexa • If present the size of the mass and its morphology should be
documented.
Left ovary
• It should be documented whether the mass moved separately to
the ovary or not.
Paraovarian cyst
8. Inspection of the • The Pouch of Douglas should be examined and inspected for the
Pouch of Douglas Uterus
presence of any free fluid. It should be commented on whether
the fluid is anechoic or echogenic.
• The deepest pool should be measured.
Free fluid
9. Other sites • In a woman with a previous caesarean section it will be

LSCS Scar important to visualise and examine the site of the uterine scar.
Uterus • If a pregnancy is not obviously seen on scan, it is also
important to visualise the interstitial portions of the Fallopian
tubes.
Table 1.6 Suggested information to be included in the structured ultrasound report

General information
Maternal age
Previous obstetric history • Parity – include live births and stillbirths
• Number of miscarriages
• Number of terminations of pregnancy
• Number of ectopic pregnancies – include mode of management
Conception • Spontaneous
• Assisted
Pregnancy
Gestational age • According to last menstrual period (LMP) or USS measurements as
appropriate
Gestational sac • Present or absent
• Number of gestational sacs
• Intrauterine or extrauterine (and site – tubal, interstitial, Caesarean section
scar, cervical etc.)
• Size in three orthogonal dimensions
Yolk sac • Present or absent
• Size
Amniotic sac • Present or absent
• Size
• Present or absent
• number
Embryo/fetus • Measurement of crown rump length (CRL)
Fetal cardiac pulsations • Present or absent (may include heart rate)
Other • Presence of retained products of conception in the uterine cavity
• Documentation if any tissue appears cystic and suggestive of a possible
molar pregnancy
• Presence or absence of a:
○ Subchorionic haematoma
○ Chorionic bump
○ Caesarean section scar niche
• Presence of fluid in the Pouch of Douglas, measurement of the deepest
pool, and a description of whether it appears anechoic or echogenic
Maternal structures
Uterus • Anteverted
• Retroverted
• Axial
• Presence of a uterine anomaly
• Fibroids – including location and size
• Intrauterine contraceptive device (IUCD) if present with exact location and
relationship to pregnancy
• Cervical length if clinically indicated
Ovaries • Size in three dimensions
• Side of corpus luteum
• Morphology of corpus luteum
• Size and morphology of any ovarian cysts if present
Other • Presence of a paraovarian/fimbrial cyst
• Presence of a hydrosalpinx or other tubal pathology
Serum biochemistry • Serum hCG and progesterone levels if clinically indicated and known
8
9
Table 1.6 (continued)

Diagnosis
• Single/multiple viable intrauterine pregnancy
• Intrauterine pregnancy of uncertain viability
• Missed miscarriage
• Incomplete miscarriage
• Complete miscarriage (only if the patient had a previously visualised
pregnancy on USS)
• Pregnancy of unknown location
• Ectopic pregnancy
• Suspected molar pregnancy
Follow-up/recommendation
• Further follow-up scan if indicated and suggested time interval
• Recommendations for serial hCG or progesterone estimations if indicated
• Advice to book for antenatal care if indicated
• Referral to discuss management of ectopic pregnancy or miscarriage
important to document all findings and to label all Learning Points

images taken and stored.
Specialist computer programs are available that • The aims of an early pregnancy ultrasound scan
allow the storage of USS images and offer the abil- are to confirm pregnancy location, establish
ity to generate a structured report as soon as the viability, determine number of embryos, and
examination is complete. As all reports and images determine gestational age.
are saved under a patient’s particular identification • Ideally all women with suspected complications
number, all previous scan images and reports can should be seen in a dedicated Early Pregnancy
be reviewed easily. This is extremely useful when Assessment Unit.
a patient is returning for a follow-up scan after a • Ultrasound used with standard presets for
previous inconclusive scan. Normal values for USS clinical reasons during embryonic development
measurements such as gestational sac size and crown (conception to ten weeks’ gestation) is safe and
rump length (CRL) are contained within the pro- the benefits outweigh any theoretical risks.
grams, allowing them to assist with pregnancy dat- • A transvaginal scan has a number of advantages
ing. Another advantage of such a program is that over a transabdominal scan in early pregnancy.
they can enable a clinic to run efficiently by becom- • It is essential to provide a structured written report
ing paperless. However, the most important thing of the ultrasound scan examination findings.
is that they allow a patient to leave the clinic with a
written report in her hand.
Further Reading
1. Moody J, ed. (2008). RCOG Standards for Gynaecology.
Auditable Standards RCOG Press.
It is good practice for all those performing ultra- 2. Joy J, Cooke I, Love M (2006). Is ultrasound safe? The
sound examinations in early pregnancy to attend Obstetrician & Gynaecologist 8: 222–227.
regular departmental meetings to review guidelines 3. RCOG ultrasound from conception to 10+0
and protocols and discuss difficult cases. Regular weeks of gestation. Scientific Impact Paper No. 49.
audits should also be performed on the rates of March 2015.
pregnancy of unknown locations and number of 4. World Federation for Ultrasound in Medicine and
ectopic pregnancies diagnosed on ultrasound prior Biology. Safety statements. www.wfumb.org/about/
to treatment. statements.aspx. Accessed 20 October 2014.
5. British Medical Ultrasound Society. Statement on transbdominal ultrasonography. J Pharm Bioallied Sci
the safe use, and potential hazards of diagnostic 3: 329–338.
ultrasound. https://www.bmus.org/static/uploads/ 7. Dutta R L, Economides D L. (2003). Patient
resources/STATEMENT_ON_THE_SAFE_USE_ acceptance of transvaginal sonography in the early
AND_POTENTIAL_HAZARDS_OF_DIAGNOSTIC_ pregnancy unit setting. Ultrasound Obstet Gynecol 22:
ULTRASOUND.pdf 503–507.
6. Kaur A. (2011). Transvaginal ultrasonography in
first trimester of pregnancy and its comparision with
10
11
Chapter
The Normal Early Intrauterine Pregnancy
2 4–11 Weeks
Aslı’ S. Üçyiğit and Jackie A. Ross
The use of transvaginal ultrasound (TVS) has facili- sac wall. The amniotic sac is comparatively thinner,
tated the earlier detection and assessment of the first- and therefore three perpendicular diametres should
trimester intrauterine pregnancy, such that evidence be measured from the centre of the membrane, and
of a normally developing pregnancy may be seen as the mean diametre calculated.
early as four weeks and three days of gestation. An The ‘crown’ and ‘rump’ are not distinguishable in
appreciation of the normal landmarks and character- very early pregnancy and therefore the crown rump
istic features of a normal early pregnancy is essential length (CRL) should be taken as the greatest measur-
for enabling the accurate diagnoses of early pregnancy able length of the embryo. From seven weeks onwards,
complications and for the communication of the the measurement should be obtained in the sagittal
ultrasound findings to patients. section of the embryo, ensuring that the yolk sac is
It is widely accepted that measurement of the not included in the length. Useful lengths to recall are
crown rump length (CRL) in the first trimester is the listed in Table 2.2.
most accurate parameter for the ascertainment of Embryonic cardiac activity is generally evident as
embryonic age, and that the transvaginal scanning soon as the embryo itself is visible. Heart rate mea-
route will usually detect pregnancies at an earlier ges- surements should be obtained using the M-mode
tation than the transabdominal route. Symptomatic feature in the first trimester, as the time-averaged
women are at risk of early pregnancy complications, acoustic intensity delivered to the embryo is lower
so care must be taken to first identify the normal pel- with M-mode than with spectral Doppler. The embry-
vic anatomy before focusing on the pregnancy; oth- onic heart rate peaks at 9+0 to 10+0 weeks at around
erwise, the risk is that accurate measurements of the 170–180 beats per minute (bpm) (Figure 2.1).
embryo are made without appreciating that the preg-
nancy is abnormally located. Diagnosis of Multiple Pregnancy
In early multiple pregnancy, the chorionicity can
Landmarks for Diagnosis simply be determined by counting the number of
A normally developing early intrauterine pregnancy gestational sacs (in Figure 2.2). Undercounting can
will display specific ultrasound features that can be occur if the endometrial cavity is not systematically
used as the landmarks for diagnosis. These are sum- examined, so care should be taken to pan through
marised in Table 2.1. the uterus both transversely and longitudinally so
as not to miss higher-order multiple pregnancies.
Between 7 and 12 weeks, the chorionic and amniotic
Early Pregnancy Ultrasound membranes are yet to fuse, thereby enabling clear
Measurements visualisation of the amniotic cavity and diagnosis of
The gestational (chorionic) sac should be measured in amnionicity (in Figure 2.3). An image demonstrat-
three planes, from the inner edges of trophoblast. The ing both embryos on the screen at the same time
maximum and mean diameters should be recorded should be obtained when possible.
and the volume can be calculated using the formula The number of yolk sacs in monochorionic preg-
for ellipsoid (V = A x B X C x 0.523). nancies is variable and should not be used for diagno-
The yolk sac should be measured by taking three sis. It is important to note that dichorionic twins are
perpendicular diameters from the centre of the yolk not always dizygotic (nonidentical), as up to 15 per cent 11
Chapter 2: The Normal Early Intrauterine Pregnancy 4–11 Weeks
Table 2.1 Week-by-week landmarks for the diagnosis of early pregnancy on scan
Gestation Ultrasound findings Ultrasound image Diagram

4+3 to 5+0 A small gestation sac (GS) (2–5 mm) is visible
within the endometrium. It is spherical, regular
in outline and surrounded by an echogenic ring
of trophoblast. It is eccentrically located towards
the fundus and implanted just beneath the
endometrial surface (midline echo).
5+1 to 5+5 The GS should be visible by 5+2. The yolk sac

becomes visible within the GS (chorionic cavity).
The yolk sac should be seen when the mean GS
diameter is > 12 mm.
5+6 to 6+0 The embryonic pole is visible as a straight line,

adjacent to the YS. It measures 2–4 mm in
length. Fetal heart activity is detectable. The
embryo is usually visible with a mean
GSD > 18 mm.
6+1 to 6+6 The embryo appears kidney bean-shaped. It is

separated from the YS by the vitelline duct. The
CRL measures 4–10 mm. Care should be taken
not to include the YS when measuring the CRL.
Fetal heart activity should be detectable.
7+0 to 7+6 The CRL measures 11–16 mm. The

rhombencephalon is visible (diamond-shaped),
enabling distinction of cephalad and caudal
ends. The spine is visible as double echogenic
parallel lines. The amniotic cavity is visible within
the chorionic cavity and contains the embryo.
The umbilical cord can be seen.
12
13
Gestation Ultrasound findings Ultrasound image Diagram
8+0 to 8+6 The CRL measures 17–23 mm. The

forebrain, midbrain, hindbrain, and skull
are distinguishable. The limb buds and first
movements are seen. The umbilical cord and
vitelline duct lengthen. The chorion frondosum
and chorion laevae are visible.
9+0 to 10+0 The CRL measures 23–32 mm. The limbs

lengthen and hands, feet, and eyes are visible.
The midgut hernia is present. Choroid plexae
can be seen.
Abbreviations: GS = gestational sac; YS = yolk sac; GSD = gestational sac diameter; CRL = crown rump length.
Table 2.2 Mean CRL in relation to gestational age

of dichorionic twins are monozygotic (identical),
CRL Gestational age depending on how early cleavage occurs. The presence
10 mm = mean for 7+2 weeks of a single or two ovarian corpora lutea may provide
20 mm = mean for 8+5 weeks
an insight into the zygosity of the pregnancy. Table 2.3
depicts the ultrasound findings expected accord-
30 mm = mean for 10+0 weeks
ing to gestational age in a normally developing twin
40 mm = mean for 10+6 weeks 13
pregnancy.
Variants of Normal
The following ultrasound features are less commonly
seen variants of the normal intrauterine pregnancy
(IUP), and if they have not been seen previously by
the operator can lead to diagnostic confusion and
uncertainty.
(a) Chorionic bumps (Figure 2.4)
○ Appear as cystic areas within chorion
○ Evolve to become echogenic
○ Usually resolve spontaneously
○ Cause gestational sac to appear irregular
○ May be associated with an increased risk of
miscarriage
Figure 2.2 Trichorionic triplet pregnancy.
200
180
160
Fetal HR (bpm)
140
120
100
80
Figure 2.3 Monochorionic diamniotic pregnancy.

60
(b) Umbillical cord cysts (Figure 2.5)

40 45 50 55 60 65 70 75
○ Overall incidence in first trimester of 3–4
Gestation (days)
per cent
Figure 2.1 Relationship between embryonic heart rate and
gestational age; median, 95th and 5th centiles [3]. (Relevant
○ Incidence may be as high as 25 per cent at
permissions obtained from copyright holder.) eight to nine weeks
Table 2.3 Schematic depicting the ultrasound diagnosis of chorionicity and amnionicity in early twin pregnancy (ᴑ = chorionic cavity;
Ⴠ= amniotic cavity; Ⴠ= embryo)
Multiple pregnancy diagnosis
Gestation Dichorionic diamniotic Monochorionic diamniotic Monochorionic monoamniotic
5+0 to 5+6
6+0 to 6+6
7+0 to 7+6
14
15
Figure 2.6 Echogenic coelomic fluid seen throughout the

Figure 2.4 Chorionic bump producing an irregularly shaped gestation and amniotic sacs.
gestation sac contour.
Figure 2.7 Fluid collection in endometrial cavity, surrounding

Figure 2.5 Cross section of umbilical cord (left) containing cystic an IUP.
structure within.
○ Unlikely to be clinically significant unless Learning Points

large and multiple or if they persist into the • The landmarks for diagnosis of normal early
second trimester and are associated with other pregnancy must be learned prior to performing
structural abnormalities first-trimester ultrasound scans, so that the
(c) Echogenic coelomic fluid (Figure 2.6) ultrasound findings may be explained.
○ Fluid within the gestation and amniotic sacs • A systematic approach to the ultrasound
appears echogenic as opposed to anechoic evaluation and measurement of an early
○ Underlying process unknown but may be due intrauterine pregnancy will ensure a correct
to preceding haemorrhage assessment and conclusion.
○ Not known to be associated with an increased • Accurate diagnosis of multiple pregnancy
risk of miscarriage may require repeated scans, depending on the
gestation at initial presentation.
(d) Fluid in endometrial cavity (Figure 2.7)
○ This may be a ‘subchorionic haematoma’ Further Reading
in women who have experienced vaginal
1. Verhaegen J, Gallos ID, van Mello NM, Abdel-Aziz M,
bleeding, but may be seen in women with no
Takwoingi Y, Harb H et al. (2012). Accuracy of single
bleeding, probably due to secretions within progesterone test to predict early pregnancy outcome
the endometrial cavity in women with pain or bleeding: meta-analysis of
○ Can be variable in position and amount cohort studies. BMJ 345: e6077
○ Not thought to have an effect on outcome of 2. Jurkovic D, Gruboeck K, Campbell S (1995).
pregnancy Ultrasound features of normal early pregnancy
15
development. Curr Opin Obstet Gynecol Dec;7(6): 4. Arleo EK, Dunning A, Troiano RN (2015). Chorionic
493–504. bump in pregnant patients and associated live birth
3. Papaioannou G, Syngelaki A, Poon L, Ross A, rate: a systematic review and meta-analysis.
Nicolaides K (2010). Normal ranges of embryonic J Ultrasound Med Apr;34(4): 553–557.
length, embryonic heart rate, gestational sac diameter 5. Ross JA, Jurkovic D, Nicolaides K (1997).
and yolk sac diameter at 6–10 weeks. Fetal Diagn Ther Coelocentesis: a study of short-term safety. Prenat
28: 207–219. Diagn Oct;17(10): 913–917.
16
17
Chapter
Diagnosis of Miscarriage
3 Nicola Mitchell-Jones and Cecilia Bottomley
Miscarriage is the most common complication of early confusing for patients. Preferred terms are described
pregnancy. Ultrasound is now pivotal in modern- in Table 3.1, and Figure 3.1 shows the types of
day practice for its diagnosis and management of miscarriage.
miscarriage.
Aetiology
Terminology The prevalence of miscarriage is commonly quoted
When diagnosing miscarriage or possible miscarriage as one in five pregnancies, with higher rates of preg-
in patients following ultrasound assessment, it must nancy loss if ‘biochemical pregnancies’ are included
be remembered that the diagnosis is highly emotive (where miscarriage occurs before a pregnancy is vis-
and has wide-reaching psychological consequences. ible on scan). Around 70 per cent of miscarriages
The terminology used to describe miscarriage can be are attributed to chromosomal abnormalities (most
Table 3.1 Terminology used in early pregnancy assessment
Term Definition Notes

Miscarriage Pregnancy loss at < 24 weeks’ gestation ‘Spontaneous miscarriage’ is used where the pregnancy has
been expelled from the uterus.
‘Delayed’ or ‘missed’ miscarriage is used where the
pregnancy has ceased to develop but a spontaneous
miscarriage is yet to occur.
Late miscarriage Pregnancy loss between 12 and 24 weeks Used where fetal demise occurs in the second trimester.
gestation Pregnancy loss < 24 weeks where signs of life are noted at
delivery is termed a neonatal death.
Live intrauterine Intrauterine pregnancy with visible embryo May also be referred to as a ‘viable’ pregnancy.
pregnancy and heart pulsations or fetal heartbeat (FH)
Intrauterine pregnancy Intrauterine pregnancy where viability is yet May represent a normal early pregnancy of 5–6 weeks’
of uncertain viability to be determined (FH not seen on gestation or a failed pregnancy with arrested growth.
(IPUV) initial scan)
Inevitable miscarriage A pregnancy destined to end in miscarriage; An active miscarriage is in progress, products of conception
the cervix is open, but the pregnancy has are seen within the cervix on ultrasound and/or clinical
yet to be expelled examination.
Incomplete miscarriage/ RPOC (well-defined mixed echoes) within The presence of vascularity within this tissue helps confirm
retained products of the uterine cavity with no identifiable the diagnosis and differentiate from intrauterine blood clot
conception (RPOC) gestation sac (although RPOC may be avascular). If uncertainty and an
intrauterine pregnancy has not previously been seen, the
findings are classified as ‘pregnancy of unknown location’.
Complete miscarriage Ultrasound finding of empty uterus with If an intrauterine pregnancy has not previously been seen,
no retained tissue identified, where an this term cannot be applied, and the findings are classified
intrauterine pregnancy has previously been as ‘pregnancy of unknown location’.
visualized 17
Chapter 3: Diagnosis of Miscarriage
(a) (b) (c)
(d) (e)
Figure 3.1 Types of miscarriage. A and B: Delayed miscarriage. Embryo with CRL of 19 mm. Fetal heart pulsations are absent, as
demonstrated with colour doppler (image A). Empty gestation sac with a mean sac diametre of 37 mm (image B). C: Incomplete miscarriage.
Heterogeneous material of mixed echoes within the uterine cavity in keeping with retained products of conception. Some vascularity is
seen within this tissue helping to differentiate between this and a blood clot within the cavity. D: Inevitable miscarriage. Gestation sac within
the cervix (cervical ectopic pregnancy must be excluded). E: Complete miscarriage. The endometrial cavity is empty. This term may only be
applied where an intrauterine pregnancy has been confirmed previously (otherwise, use ‘pregnancy of unknown location’).
Bleeding Score: please circle as appropriate

0 – no bleeding 1 – minimal bleeding 2 – moderate bleeding 3 – soaked sanitary towel 4 – passing clots or flooding
Passing clots or
flooding
Figure 3.2 Pictorial blood loss assessment chart. Taken from Higham J, O’Brien P, Shaw R (1990). Assessment of menstrual blood loss using a
pictorial chart. BJOG 97(8): 734–739.
commonly trisomy). The risk of miscarriage increases More rarely, a clinical diagnosis of miscarriage may be
more significantly after the age of 35 due to a higher made where the cervical os is open and products of
frequency of chromosomal abnormalities. Other aeti- conception have been passed or are seen within the
ological factors include thrombophilias, maternal sys- cervix.
temic disease or its treatment, uterine anomalies, and
endometrial environmental factors. Ultrasound Diagnosis
The diagnosis of miscarriage may in some cir-
Presentation cumstances be made at the initial ultrasound scan
Vaginal bleeding is the most common symptom pre- (Table 3.2). These ultrasound criteria have been deter-
ceding a diagnosis of miscarriage. This can be objec- mined such that both the specificity and positive pre-
tively assessed using a pictorial blood loss assessment dictive value are 100 per cent and there is allowance
chart (Figure 3.2). Many women, however, have no for interobserver variability in measurements. A mis-
symptoms at the time of diagnosis. Ultrasound is the carriage must not be diagnosed where there is any
18 primary diagnostic tool for a diagnosis of miscarriage. perceived possibility that the pregnancy is ongoing,
19
Table 3.2 Ultrasound criteria for diagnosis of miscarriage (where these criteria are not fulfilled, a repeat scan is indicated, as in Figure 3.3.
MSD: mean gestation sac diameter (mean of three orthogonal measurements)
Diagnostic criteria Gestation by Last Explanation

Menstrual Period (LMP)
Visible embryo with CRL ≥ 7 mm without At any gestation Colour Doppler may be applied to confirm the absence
fetal heart pulsations of heart pulsations.
Gestation sac with MSD ≥ 25 mm At any gestation Previously referred to as an ‘anembryonic pregnancy’ or
without visible yolk sac (YS) or embryo ‘blighted ovum’.
This pregnancy has stopped developing in the early
stages before the embryo is visible (or the embryo
has become nonvisible following demise) and may be
described as an ‘empty sac’.
Embryo with absent fetal heart pulsations, At any gestation Applies for any CRL (though caution if CRL is small,
where previous scan demonstrated heart where a repeat scan may be considered to confirm the
pulsations diagnosis).
Visible embryo with CRL ≥ 3 mm without At ≥ 70 days gestation Diagnostic for miscarriage only if dates known for
fetal heart pulsations certain (usually reserved for women following assisted
OR reproduction treatment).
Gestation sac with MSD ≥ 18 mm
without visible embryo
Action and
Initial Scan Repeat Action and
Rescan Diagnosis
Finding Scan Finding Rescan Interval
Interval
Embryo < 7 mm
No FH Rescan ≥7 days
FH present Live IUP
FH absent Miscarriage
GS +/– YS but no
embryo
Rescan ≥7 days
MSD ≥12mm
Embryo and FH present Live IUP
FH present
GS +/– YS but no
embryo Rescan ≥14 days GS ≥ doubled in size but
Rescan in 1 week
no FH
MSD <12mm FH absent
GS < doubled and no FH Miscarriage
Figure 3.3 Flow chart for management of intrauterine pregnancy of uncertain viability. Chart demonstrates action in cases of intrauterine
pregnancy of uncertain viability (where initial scan does not demonstrate a embryo with heart pulsations). A second scan is required at an
interval determined by the initial scan findings. In some cases, a third interval scan is required.
as this could result in the termination of a potentially then an interval scan is required to assess ongoing preg-
viable pregnancy. nancy development. The timing of the repeat scan (7 or
If a live pregnancy (fetal heart pulsations present) 14 days) is dependent on the initial findings (Figure 3.3).
or a failed pregnancy fulfilling the diagnostic criteria If a woman has fetal cardiac activity noted on an
of miscarriage (Table 3.2) is not found on initial scan, initial scan and re-presents, then the absence of cardiac 19
(a) (b) Figure 3.4 Diagnosing miscarriage.

A & B: This patient was initially seen
at 10 weeks’ gestation by menstrual
dates with a complaint of light vaginal
bleeding; initial scan (A) demonstrated
a live IUP of eight weeks gestation by
CRL measurement. Further bleeding
prompted a second scan (B), at which
fetal heart pulsations were no longer
present. C & D: This patient underwent
initial scan at nine weeks gestation by
menstrual dates due to moderate vaginal
bleeding; on the first occasion (C), a
gestation sac with a 3 mm embryo was
(c) (d) seen, and no fetal heart pulsations were
present. Repeat scan seven days later
(D) demonstrates no significant change
in measurements, and again no fetal
heart pulsations were present. E & F: This
patient underwent viability assessment
due to a history of recurrent miscarriage.
The initial scan (E) was performed at six
weeks’ gestation by menstrual dates;
an intrauterine gestation sac with an
MSD of 12 mm was seen. A repeat scan
(F) was performed 14 days later; the MSD
was 19 mm, and a yolk sac was visible;
however, no embryo was identified.
(e) (f)
activity on repeat assessment is diagnostic of miscar- an increased chance of miscarriage. Other factors
riage without the need to fulfil measurement criteria. associated with increased risk of miscarriage are dis-
To minimise the risk of termination of an ongo- cordance between embryo size and menstrual dates,
ing pregnancy, the diagnosis of miscarriage should be moderate or heavy vaginal bleeding and increasing
confirmed by two operators or on two separate occa- maternal age (a woman aged 40 has up to a 45 per cent
sions. Figure 3.4 shows some scan images in patients chance of miscarriage).
who were diagnosed with a miscarriage.
Caution
Soft Markers and Prediction of As detailed, the diagnosis of miscarriage may often
need to be deferred for up to three weeks, where repeat
Miscarriage scan is necessary. Strict adherence to the guidelines is
Where fetal heart pulsations are not seen on initial essential to avoid termination of a potentially viable
scan (IPUV), clinicians may use ultrasound find- pregnancy. However, careful counselling of women in
ings and clinical information to help counsel women such a situation is important to manage expectations
regarding the likely pregnancy outcome. Soft mark- and prepare them for possible bleeding or spontane-
20 ers (Table 3.3) are not diagnostic but suggestive of ous miscarriage in the meantime.
21
Table 3.3 Soft markers of miscarriage: ultrasound findings that are not diagnostic of miscarriage but may present an increased risk of
miscarriage; in all cases, a repeat scan in 7–14 days is recommended to assess ongoing viability
Soft marker Image Description

Empty amnion The presence of an amniotic sac without visible
embryo seen within. Referred to as the ‘empty
amnion sign’ and usually associated with a nonviable
pregnancy.
Subchorionic haematoma Hypoechoic, crescent-shaped area separating the

uterine wall and chorion. Frequently associated with
vaginal bleeding. Also associated with adverse perinatal
outcome.
Chorionic bumps Irregular, hyperechogenic bulge from the

choriodecidual surface into the gestation sac.
Associated with first- and second-trimester miscarriage.
Large yolk sac YS diameter of ≥ 5 mm is commonly a pathological

sign.
Early embryonic growth Significant discrepancy between the expected size of the embryo (from LMP dates) and the observed
restriction sized on scan (in women with certain menstrual dates).
Bradycardic fetal heart Fetal heart pulsations < 100 bpm are predictive of miscarriage (except in very small embryos (2–5 mm),
pulsations which are expected to have a fetal heart rate of < 100 bpm).
21
measurements: a multicentre observational study.

Learning Points Ultrasound Obst Gynecol 38: 497–502.
• Ultrasound diagnosis of miscarriage is made 2. Bottomley C, Bourne T (2009). Diagnosing
using objective measurements and pathways. miscarriage. Best Practice & Research Clinical Obstetrics
• Frequently an interval scan is required. and Gynaecology 23: 463–477.
• The diagnostic criteria are altered after 70 days 3. Doubilet P, Benson C, Bourne T, Blaivas M (2013).
(10 weeks) of gestation where gestational age Diagnostic criteria for nonviable pregnancy early in
of the pregnancy is certain (usually only in the first trimester. N Eng J Med 369: 1443–1451.
pregnancies conceived via in vitro fertilization. 4. National Institute for Health and Care Excellence
• The diagnosis of miscarriage should be confirmed (NICE) (2012). Ectopic pregnancy and
by two practitioners or on two separate occasions. miscarriage: diagnosis and initial management in
early pregnancy of ectopic pregnancy and miscarriage.
• Several ultrasound ‘soft markers’ are associated
NICE Clinical Guideline 154.
with an increased risk of a failing pregnancy,
but these are not diagnostic of miscarriage and 5. Jeve Y, Rhana R, Bhide A, Thangaratinam (2011).
Accuracy of first-trimester ultrasound in the diagnosis
should be used only to inform that a repeat scan of early embryonic demise: a systematic review.
is required and for counselling. Ultrasound Obstet Gynecol 38: 489–496.
• The likelihood of impending miscarriage 6. Newbatt E, Beckles Z, Ullman R, Lumsden MA, on
diagnosis may be predicted using a combination behalf of the Guideline Development Group (2012).
of maternal history, the presence of symptoms, Ectopic pregnancy and miscarriage: summary of NICE
bleeding score, and ultrasound findings. guidance. BMJ 345: e8136.
7. Preisler J, Kopeika J, Ismail L, Vathanan V, Farren
Further Reading J, Abdallah, Y, Battacharjee P, Van Holsbeke C,
Bottomley C, Gould D, Johnson S, Stalder C, Van
1. Abdallah Y, Daemen A, Kirk E, Pexsters A, Naji Calster B, Hamilton J, Timmerman D, Bourne T
O, Stalder C, Gould D, Ahmed S, Guha S, Syed S, (2015). Defining safe criteria to diagnose miscarriage:
Bottomley C, Timmerman D, Bourne T (2011). prospective observational multicentre study. BMJ 351:
Limitations of current definitions of miscarriage using h4579.
mean gestational sac diameter and crown–rump length
22
23
Chapter
Gestational Trophoblastic Disease
4 Anna Graham and Jemma Johns
Gestational trophoblastic disease (GTD) is the collec- produce a diploid zygote (46XX or 46XY). This then
tive term for a number of conditions, including hyda- undergoes mitosis and develops into a normal fetus
tidiform mole (HM) (complete and partial), invasive and placenta. HMs are genetically abnormal preg-
mole, choriocarcinoma, and placental site trophoblas- nancies and are categorised by their genetic and his-
tic tumour (PSTT) (Table 4.1). GTD is characterised topathological features into CHMs and PHMs. These
by abnormal proliferation of the trophoblast layer genetics are summarised in Figure 4.1.
of the placenta; if there is any evidence of persistent Rarely, a CHM and twin pregnancy coexist
elevation of beta human chorionic gonadotrophin (approximately 1/20,000–100,000 pregnancies). They
(hCG), the condition is referred to as gestational tro- occur when two oocytes are fertilised: one abnormally
phoblastic neoplasia (GTN). (from an empty oocyte), as shown in Figure 4.1, pro-
ducing a CHM; and one normally, producing a nor-
Epidemiology mal pregnancy.
The United Kingdom has a national register for HM
pregnancies, and all cases are managed from two cen-
tres: the Sheffield Trophoblastic Disease Centre and Histopathology
the Charing Cross Hospital Trophoblastic Disease HMs arise from abnormal trophoblast hyperpla-
Service. This ensures that central histopathological sia (Figure 4.2). The trophoblast is the outer layer of
review occurs and hCG surveillance is consistent. cells of the blastocyst. In a normal pregnancy, the
The reported incidence in the United Kingdom for trophoblast will develop into the placenta. The tro-
CHM is 1 per 1,000 pregnancies and 3 per 1,000 for phoblast has two layers: the inner cellular layer is the
PHM (Table 4.2). Most other countries have less rig- cytotrophoblast, and the outer layer is the syncitiotro-
orous reporting systems, but rates have historically phoblast. In HMs, both of these layers develop with
been reported as higher in Asian countries, with GTD abnormal proliferation and vesicular swelling of pla-
occurring in 2 per 1,000 pregnancies. cental villi. CHMs show diffuse trophoblastic hyper-
Maternal age is a risk factor for a HM, with women plasia and swelling of the villi, whereas PHMs tend to
over 35 years having an elevated relative risk of 1.9 for have focal areas of abnormal change. A histopatholog-
a CHM compared to under 35 year olds; this rises to ical diagnosis is required in all cases of HM, as other
7.5 times higher in the over 40 group. This is consis- methods are unreliable.
tent with the reduced quality of a woman’s ova as she
ages and the subsequent predisposition to abnormal
fertilisation. Additionally, a previous molar pregnancy Human Chorionic Gonadotrophin and
(partial or complete) carries a risk of recurrent molar Hydatidiform Moles
pregnancy of 1–2 per cent. This increases to 15–20 per
hCG is produced by the syntotrophoblast of the
cent after two HMs, and the risk is not decreased by a
placenta. In GTD, there is abnormal trophoblastic
change in partner.
hyperplasia, and therefore significantly more hCG is
produced than in a normal pregnancy. Approximately
Genetics 50 per cent of CHMs will have preevacuation levels of
In a normal pregnancy, a spermatozoon with 23 chro- hCG > 100,000 mIU/mL, in comparison to less than
mosomes fertilises an oocyte with 23 chromosomes to 10 per cent of PHMs. 23
Chapter 4: Gestational Trophoblastic Disease
Table 4.1 Comparison of the main features of GTD
GTD Overview
Complete Genetically abnormal pregnancy – 46XX/XY
Hydatidiform Mole No fetus
(CHM) Vaginal bleeding in 1st or 2nd trimester; medical complications common
15% progress to GTN
Partial Hydatidiform Genetically abnormal pregnancy – 69XXX/XXY/XYY
Mole (PHM) Abnormal fetus
Missed miscarriage, vaginal bleeding, medical complications rare
0.5% progress to GTN
Invasive mole Benign tumor
Derived from myometrial invasion of HM
15% metastasise to lungs or vagina
Persistently elevated hCG following HM
Choriocarcinoma Malignant disease
Occurs following any pregnancy: 25% post miscarriage or ectopic, 25% post normal pregnancy, 50% post HM
Metastasise to lungs, brain, liver, pelvis, vagina, kidney, intestines, and spleen
Placental Site Malignant disease
Trophoblastic Tunour Very rare – arises from the placental implantation site
(PSTT) Occurs following nonmolar pregnancies more commonly than HM
Lymphatic metastasis
Table 4.2 Epidemiology of GTD
Gestational trophoblastic disease

Incidence in U.K. per Risk factors for GTD Risk of developing Risk of repeat HM (%)
1,000 pregnancies to GTN (%)
CHM 1 • Increased maternal age 15 1–2
• Previous HM
• Asian
PHM 3 • Increased maternal age 0.5 1–2
• Previous HM
• Asian
Clinical Presentation an early pregnancy ultrasound scan and diagnosis of a

nonviable pregnancy; see Table 4.3.
HMs were historically diagnosed in the mid trimester;
however, with the introduction of nuchal scanning at
11–14 weeks’ gestation and widespread access to early Clinical Presentation – CHMs
pregnancy units with scanning facilities, this is now Eighty to ninety per cent of CHMs present with vag-
rarely the case. The average gestational age at evacua- inal bleeding between 6 and 16 weeks’ gestation. The
tion in the United Kingdom is now less than 10 weeks, other classic signs and symptoms are less common,
and the classic symptoms described in textbooks – such as uterine enlargement greater than expected
including hypertension, hyperthyroidism, the pass- for gestational dates, which occurs in 25 per cent of
ing of grapelike products and abdominal distention cases; hyperemesis, which appears in 10 per cent;
secondary to bilateral multiple ovarian theca lutein and pregnancy-related hypertension in the first
cysts – are now rare. The most common presenting or second trimester, which occurs in around 1 per
symptom in both CHMs and PHMs is vaginal bleed- cent (Table 4.3). There remain rarer presentations,
24 ing in early pregnancy, which in most cases leads to such as hyperthyroidism, early onset preeclampsia,
25
spermatozoon with
(a)
23 Chromosomes
Diploid
46XX, 46XY
zygote
2 sets of
Y Sperm fertilises chromosomes
Oocyte
Y23 + X23 Mitosis 1 paternal set
Normal 1 maternal set
X 46XY
Pregnancy Viable fetus
Normal
trophoblastic tissue
Oocyte with 23
Chromosomes
Paternal
(b) Diploid
Karyotype
X
X23 duplicates
80% Empty
46XX
CHM Oocyte
46XX–75–80%
46XY–20–25%
2 sets of Paternally
Complete Derived
Hydatidform Chromosomes
Mole
Mitosis Absent Fetus or Fetal
Blood Cells
Paternal Diffuse Trophoblastic
Diploid Hyperplasia
X Karyotype Diffuse swelling of
Y Villi
X23 + Y23 fuse
Empty
46XY
20% Oocyte
CHM
(c)
Triploid
X Karyotype
90% 69XXX, XXY, XYY
Y 2 sperm X23 +
Y23 fertilise 2 sets of paternal
OoycteX23 Mitosis chromosomes
90% X 69XXY 1 set of maternal
PHM
chromosomes
Fetus or fetal blood
cells present
Partial Focal trophoblastic
Hydatidiform hyperplasia
Mole Focal swelling of villi
Diploid
Karyotype
X Sperm X23 10% Tetraploid
fertilises
Ooycte X23 Mitosis failure
92XXXY or Mosaic
X 46XX conceptions
10% Similar presentation
PHM to above
Figure 4.1 Genetic development in (a) a normal pregnancy; (b) a complete hydatiform mole; and (c) a partial hydatiform mole.
25
(a) (c)
Complete Partial hydatidiform

hydatidiform mole shows mixed
mole shows dilated, oedematous
enlarged and and sclerosed
bulbous villi with irregular villi with
branching and occasional
budding, cistern trophoblast
(b) formation and, (d) hyperplasia.
focally,
circumferential
trophoblastic
hyperplasia.
Figure 4.2 Gestational trophoblastic disease: (a) complete hydatidiform mole; (b) partial hydatidiform mole. Images courtesy of Dr Abdel-
Ghani Selim, MBBCh, MSc, PhD, FRCPath Consultant Histopathologist and Cytopathologist, King’s College Hospital, National Health Service
Foundation Trust.
abdominal distention due to theca lutein cysts, as well findings are supported by two other smaller studies,
as acute respiratory failure or neurological symptoms which found overall ultrasound detection rates of 56
such as seizures (secondary to metastatic disease), all per cent and 44 per cent respectively. As with all USS
of which warrant exclusion of HM. diagnoses, the accuracy of results is user dependent,
and operator experience contributes to detection
Clinical Presentation – PHMs rates. Therefore, although USS assists in the diagno-
PHMs tend to present later than CHMs but also pre- sis of HMs, the products obtained from all medical or
sent with vaginal bleeding (75 per cent) or incomplete surgical miscarriages of all failed pregnancies should
or missed miscarriage (90 per cent). Other symptoms undergo histological assessment to exclude tropho-
are rarer, which reflects the pathology of PHM com- blastic neoplasia.
pared to CHM; focal trophoblastic hyperplasia rather
than diffuse produces excessive uterine enlargement Ultrasound Features – CHMs
in only around 10 per cent of cases; hCG is raised only From the late first trimester onwards, CHMs have
marginally compared to normal pregnancies, leading classic ultrasound scan findings, including an
to hyperemesis, hyperthyroidism, and theca lutein enlarged uterine cavity filled with a heterogeneous
cysts very rarely (Table 4.3). mass containing multiple cystic areas and referred to
as a ‘snowstorm’ appearance (Table 4.4a); a lack of evi-
Ultrasound Diagnosis of HMs dence of fetal development; and bilateral theca lutein
A U.K. study of over 1,000 cases at a regional refer- cysts in 15 per cent of cases (Table 4.4). The differen-
ral centre found that 79 per cent of complete moles tial diagnosis on USS is of retained placental tissue
and 29 per cent of partial moles were suspected on that has undergone hydropic degeneration (Table 4.5).
ultrasound examination prior to histological diagno- The history from the patient may help to distinguish
sis. The overall rate of detection was 44 per cent. In between the two; the CHM will have had minimal
addition to this, 10 per cent of cases that were thought bleeding, whereas the hydropic retained products of
to be molar on USS were diagnosed as nonmolar conception (RPOC) are likely to describe an incom-
26 hydropic abortions on histological review. These plete miscarriage with heavier bleeding.
27
Table 4.3 A comparison of clinical presentation and USS findings of CHM and PHM
1st trimester, 2nd trimester USS findings and hCG levels USS diagnosis
CHM 80–90% vaginal bleeding 6–16 weeks • Heterogenous Mass – ‘snowstorm’ 79%
40% asymptomatic • Multiple cystic spaces
25% uterine enlargement • No fetus
10% hyperemesis • 15% theca lutein cysts
5% anaemia • 50% hCG > 100,000 mIU/ml
1–2% preeclampsia
Rare passing of ‘grapelike’ products
Rare hyperthyroidism
PHM 75% vaginal bleeding • Echogenic placental tissue 29%
Missed/incomplete miscarriage • Multiple cystic areas
10% uterine enlargement • Fetus present
2.5% preeclampsia • Rarely theca lutein cysts
• Increase in transverse diametre of GS
• 10% hCG > 100,000 mIU/ml
Table 4.4 (a) CHM at 12 weeks; and (b) theca lutein cysts
History and clinical USS USS features

presentation
CHM 33 yo • Diffuse heterogeneous mass
P2 + 1 (termination) • Uterus enlarged to 18 weeks’ size
12 + 2/40 • Multiple cysts within the mass
Brown PV discharge • No fetus
Attended for nuchal scan
Dx: CHM or hydropic RPOC
CHM 32 yo • Enlarged ovaries bilaterally

P1 • Multiple follicles
Bilateral multifollicular cysts in
13/40 CHM
hCG: 905193
Dx: Theca lutein cysts or
hyperstimulated ovaries
USS features are less apparent earlier than this, and Ultrasound Features – PHMs
although the scan may be suspicious of a HM, the dif-
PHMs have less distinctive features on USS in either
ferential diagnosis is often an early intrauterine preg-
the first and second trimester compared to CHMs;
nancy (IUP) or a pregnancy of unknown location
however, USS remains helpful in facilitating their
(PUL) (Table 4.6). A CHM twin pregnancy will be more
diagnosis. There is likely to be a gestational sac, but
difficult to diagnose. There will be a heterogenous mass
there may also be a thickened trophoblastic layer con-
with cystic areas; however, there will also be a fetus with
taining multiple avascular cystic spaces (Table 4.8).
or without fetal heart pulsations (Tables 4.7 and 4.8).
PHMs often present as an incomplete or missed mis-
The RCOG recommends that prenatal invasive test-
carriage, and the findings on USS may be just this,
ing for fetal karyotype should be considered where it is
with no evidence of HM on the scan (Table 4.8). The
unclear whether the pregnancy is a complete mole with
differential diagnosis is a CHM and coexistent twin
a coexisting normal twin or a partial mole. 27
(Table 4.7).
Table 4.5 Hydropic retained products of conception

presentation
Hydropic RPOC 39 yo • Diffuse heterogeneous mass
P1 • Multiple cysts within the mass
7 + 2/40 • No fetus
Pelvic pain
No PV bleeding
Dx: CHM or hydropic RPOC
Table 4.6 (a) Pregnancy of unknown location (PUL); (b) rescanned a week later with a molar pregnancy suspected

presentation
CHM 23 yo • Heterogeneous mass
P1 + 1 (termination) • Small cystic area within
6 + 4/40 the mass
PVB 2/7 • No fetus
Classified as a PUL
hCG and progesterone requested
Dx: PUL
CHM Pt above rescanned at 7 + 4/40 • Diffuse heterogeneous mass

hCG: 49061 • Few cysts within the mass
Dx: CHM or hydropic RPOC • No fetus
Table 4.7 CHM and coexistent twin pregnancy

presentation
CHM + Twin 32 yo • Diffuse heterogenous mass
P2 + 3 miscarriages • Multiple cysts within the mass
12 + 1/40 • Live fetus with fetal heart
Asymptomatic pulsations
Attended nuchal scan
Dx: CHM + twin or PHM
28
29
Table 4.8 (a) PHM at 13 weeks; (b) PHM at 16 weeks with no evidence of HM on USS

presentation
PHM 27 yo • GS present
P0 • Embryo present (not visible in this image)
13 + 3/40 • No FH
Asymptomatic • Thickened placental tissue
Attended nuchal scan • Cystic areas within placenta
Dx: Early embryonic demise
or PHM
PHM 35 yo • Thickened placental tissue

P2 + 1 (miscarriage) • Nonviable fetus present
16 + 2 • No evidence on USS of HM
Asymptomatic
Routine scan
Dx: Early embryonic demise
Management of HMs advise that an intrauterine pregnancy should be visu-

alised on USS prior to a TOP. This is likely to identify
It is essential that when a nonviable pregnancy is diag-
or raise suspicions of a CHM, which would then war-
nosed and molar pregnancy is suspected (clinically,
with USS and hCG) that surgical management is rec- rant a referral. The rate of progression to GTN follow-
ommended and the products of conception are sent ing a TOP has been estimated to be 1/20,000, but due
for histological analysis (Figure 4.3). This is to ensure to late diagnosis, this leads to poor prognosis. It is rec-
that the correct diagnosis is established and the patient ommended that women undergoing a TOP are coun-
can be monitored for subsequent progression to GTN. selled to be assessed for ongoing pregnancy symptoms
It is widely accepted that surgical management should and to perform a urine pregnancy test at three to four
be performed via suction aspiration rather than sharp weeks postprocedure if in any doubt.
curette to reduce the risk of perforation. Ultrasound The CHM twin pregnancy poses a management
examination throughout this procedure also aids in dilemma, because if the CHM is treated surgically this
reducing the risk of perforation and ensuring that the will inevitably end the healthy pregnancy; however, if
uterine cavity is completely evacuated. the pregnancy is allowed to continue then the woman
The overall preevacuation rate of HM diagnosis is at risk of both the previously discussed complica-
on USS is under 50 per cent, and given that the great tions as well as malignant disease. The RCOG Green-
majority of PHM are not even suspected, it is essential Top Guideline quotes live birth rates of around 25 per
that products from all miscarriages are sent for histo- cent, but Sebire et al. showed healthy birth rates to be
logical diagnosis to exclude molar pregnancy. This around 40 per cent in a case series of 77 pregnancies.
does not exclude expectant or medical management This study also showed that there was no increase in
of miscarriage but does imply the need for collection the risk of developing GTN despite continuing with
of products by the patient to be sent for histology. In the pregnancy until term. Women should be coun-
reality, this rarely occurs. selled about the risks, including the increased risk of
It could also be argued that all specimens removed early fetal loss (40 per cent), premature delivery (36
at a termination of pregnancy (TOP) should also be per cent), and preeclampsia (4–20 per cent); however,
analysed for HM, but given the large numbers being ultimately the clinician should support the woman’s
performed in the United Kingdom, around 200,000 choice as this is likely to vary significantly due to her
per year, this would be unfeasible. The RCOG does personal history, age, fertility potential, and other
not recommend screening for GTD; however, it does children. 29
Miscarriage Suspected Molar Pregnancy
Expectant Management Medical Management Surgical Management
Normal
Histology
Products of Conception
Hydatidiform Molar Discharge

Pregnancy
Refer to National Centre
Serum and urine hCG

every 2 weeks
hCG rising or
Contraception Advised
hCG reducing
plateauing = GTN
Complete Partial
Further management:
Mole Mole
chemotherapy
hCG remains raised hCG returns to hCG levels every 2

at 56 days normal in 56 days weeks until normal
hCG monthly levels hCG monthly levels repeat hCG level 4

for 6 months post for 6 months post- weeks after normal
a normal hCG evacuation result
Discharge
Additional pregnancy
Re-refer
Figure 4.3 Management of molar pregnancies (Flow chart developed from Royal College of Obstetricians and Gynaecologists
(February 2010). The management of gestational trophoblastic disease. Green-Top Guideline 38).
30
31
Monitoring Post-HM Evacuation • The risk of progression to gestational

trophoblastic neoplasia is 15 per cent for
All patients with identified HM should be referred to
complete hydatidiform moles and 0.5 per cent for
one of the U.K. centres for histopathological review and
partial hydatidiform moles.
placed on the national registry for hCG follow-up. An
overview of hCG follow-up is given in Figure 4.3. During • Hydatidiform moles rarely present with the
the hCG follow-up period, women are advised to use classical symptoms described in textbooks
reliable contraception. Traditionally barrier methods and are far more likely to present with vaginal
were recommended, but now in the United Kingdom bleeding or missed or incomplete miscarriage in
the national centres advise that oral contraceptives after the first trimester.
molar evacuation, before hCG returns to normal, can • The majority of complete hydatidiform moles will
be used safely. Studies have shown no increase in devel- be suspected on ultrasound prior to histological
opment of invasive mole or choriocarcinoma in women diagnosis. Ultrasound has a lower sensitivity for
taking oestrogen and or progestogens during this time. the diagnosis of partial molar pregnancies, and
Following a diagnosis of GTD, even when the hCG has they are often diagnosed as missed miscarriages.
normalised, if the patient becomes pregnant again, she • Suspected molar pregnancies should be
is once again at risk of developing GTN. Therefore, managed surgically with suction aspiration,
hCG levels should be checked after every pregnancy to and all miscarriage products should be sent
ensure no reactivation of previous HM. for histological diagnosis to exclude molar
pregnancy.
• Upon diagnosis, all HMs should be referred to
Gestational Trophoblastic Neoplasia the national centre for central histopathological
Molar pregnancies are followed up so closely due to review and hCG follow-up.
the risk of development to GTN, which can be fatal if • In the United Kingdom, if gestational
left untreated. The rate of development from a com- trophoblastic neoplasia develops, 95 per cent will
plete molar pregnancy is around 15 per cent and from be low risk and have close to 100 per cent cure
a partial hydatidiform mole 0.5 per cent. The diagnosis rates, and 5 per cent will be high risk and have 84
of GTN is made on the basis of an elevated hCG pla- per cent cure rates.
teau or rising hCG titres over a period of several weeks.
GTN is scored and staged using the International
Federation of Gynaecology and Obstetrics (FIGO) Further Reading
(2000) scoring system for GTN. Approximately 95 1. Royal College of Obstetricians and Gynaecologists
per cent of patients will have low-risk, low-resistant (February 2010). The management of gestational
disease and will be treated with monotherapy che- trophoblastic disease. Green-Top Guideline 38.
motherapy (methotrexate); if this fails, a second line 2. Seckl MJ, Sebire NJ, Berkowitz RS (2010).Gestational
chemotherapy can be used (actinomycin D or EMA/ trophoblastic disease. Lancet 376: 717–729.
CO [etoposide, methotrexate, actinomycin D, cyclo- 3. Ngan H, Kohorn E, Cole L, Kurman R, Kim S, Lurain
phosphamide, vincristine]). This group has an overall J, Seckl M, Sasaki S, Soper J (2012). Figo Cancer
survival rate of nearly 100 per cent. Report. Trophoblastic disease. International Journal of
High-risk disease occurs in only 5 per cent of cases Gynecology and Obstetrics: S130–S136.
and usually presents with many metastases months or 4. Lurain J (2010). Gestational trophoblastic disease I:
years after the causative pregnancy. They are at a high epidemiology, pathology, clinical presentation and
risk of developing resistant disease and therefore require diagnosis of gestational trophoblastic disease, and
treatment with multi-agent chemotherapy. Even in this management of hydatidiform mole. AJOG. Dec:
high-risk group there is a cure rate of around 84 per cent. 531–539.
5. Parazzini F, LaVecchia C, Pampallona S (1986).
Parental age and risk of complete and partial
Learning Points hydatidiform mole. Br J Obstet Gynecol 93: 582–585.
• Molar pregnancies have an incidence of 1 in 1,000 6. Sebire NJ, Foskett M, Fisher RA, et al. (2002). Risk of
pregnancies for complete hydatidiform moles and partial and complete molar pregnancy in relation to
3 in 1,000 for partial hydatidiform moles. maternal age. Br J Obstet Gynecol 109: 99–102. 31
7. Sebire NJ, Fisher RA, Foskett M, Rees H, Seckl MJ, pregnancies in missed miscarriages. Ultrasound Obstet
Newlands ES (2003). Risk of recurrent hydatidiform Gynecol 25: 493–497.
mole and subsequent pregnancy outcome following 11. Kirk E, Papageorghiou AT, Condous G, Bottomley
complete or partial hydatidiform molar pregnancy. C, Bourne T (2007). The accuracy of first trimester
BJOG 110: 22–26. ultrasound in the diagnosis of hydatidiform mole.
8. Sebire NJ, Jauniaux E (2012). Gestational trophoblastic Ultrasound Obstet Gyecol 29: 70–75.
disease: the role of ultrasound imaging. Ultrasound 12. Royal College of Obstetricians and Gynaecologists
Clin 7: 33–45. (2011). The Care of Women Requesting Induced
9. Fowler D, Lindsay I, Seckl M, Sebire N (2006). Routine Abortion. Evidence-based Clinical Guidance No 7.
pre-evacuation ultrasound diagnosis of hydatidiform London: RCOG.
mole: experience of more than 1000 cases from a 13. Sebire NJ, Foskett M, Paradinas FJ, et al. (2002).
regional referral centre. Ultrasound Obstet Gynecol Outcome of twin pregnancies with complete
27(1): 56–60. hydatidiform mole and healthy co-twin. Lancet
10. Johns J, Greenwold S, Buckley S, Jauniaux E (2005). 359: 2165–2166.
A prospective study of ultrasound screening for molar
32
33
Chapter
Pregnancy of Unknown Location
5 Shabnam Bodiwala and Tom Bourne
The term pregnancy of unknown location (PUL) is < 15 per cent each time. This is likely to be
describes the clinical scenario that arises when a an ectopic pregnancy that is never visualised
woman has a positive urinary pregnancy test, but on TVS.
a pregnancy cannot be visualised on a transvaginal
The PUL rate can vary significantly depending on
ultrasound scan (TVS).
the unit in question and has been reported to be any-
where between 5 and 42 per cent. This rate is largely
Clinical Outcomes dependent upon the quality of ultrasound scanning
It is important to emphasise that the term PUL is not a within a unit. The more ectopic and intrauterine preg-
diagnosis and that all women need follow-up to deter- nancies that are definitively visualised on TVS, the
mine a final clinical outcome. The final outcome in lower the PUL rate. A designated early pregnancy unit
women classified as having a PUL is either intrauter- equipped with specialists adequately trained in TVS
ine pregnancy, failed PUL, ectopic pregnancy, or persis- should aim for a rate of < 15 per cent, as suggested by
tent PUL: the International Society of Ultrasound in Obstetrics
• Intrauterine pregnancy (IUP): This includes and Gynaecology.
women with a very early IUP, where an embryo The current management of PUL is based on strat-
or yolk sac is not visible on an initial scan and so ifying women as being either at ‘low risk’ (IUP and
was classified as a PUL. Between 30–40 per cent FPUL) or ‘high risk’ of complications (EP or PPUL).
of women with a PUL are usually subsequently See Figure 5.1. Women with low-risk PUL (IUP and
diagnosed with an IUP. FPUL) generally need minimal follow-up, whilst high-
• Failed PUL (FPUL): This includes all women risk PUL (EP and PPUL) will need repeat hCG levels
initially classified as a PUL with a probable measured and further ultrasound scans until the final
complete miscarriage where an IUP had not been location and outcome of the pregnancy is known.
previously visualised using ultrasound or a failing
pregnancy undergoing spontaneous resolution Presentation
(this may be intrauterine or ectopic). In the Women usually present for assessment in early preg-
region of 50–70 per cent of women with a PUL nancy with vaginal bleeding and/or pelvic pain. Other
will be a failing PUL. reasons include previous poor outcome (ectopic preg-
• Ectopic pregnancy (EP): This category includes nancy/miscarriage/molar pregnancy), maternal anx-
all women initially classified as a PUL where iety, and hyperemesis gravidarum. It is important to
the ectopic pregnancy was not visualised on note that with the advent of earlier scans being offered
the initial TVS. Evidence suggests that 6–20 and women expecting their pregnancy to be visualised
per cent of women classified as having a PUL at earlier gestations, PUL is to an extent an iatrogenic
will subsequently be diagnosed with an ectopic phenomenon. The trade-off when performing ultra-
pregnancy. sonography at earlier gestations lies between increas-
• Persistent PUL (PPUL): This is a PUL that is ing the PUL rate, with the result that women undergo
followed with serial serum hCG levels, but a unnecessary blood tests and follow-up, and missing
pregnancy is not visualised on TVS and does not the opportunity to manage ectopic pregnancies more
resolve spontaneously. Often, the hCG change conservatively because they were examined too late.
over three consecutive tests (each 48 hours apart) There is evidence to suggest that, in asymptomatic 33
Chapter 5: Pregnancy of Unknown Location
Pregnancy of
Unknown Location
‘triage’
LOW risk (60–90%) HIGH risk (10–40%)
Intrauterine Ectopic
Failed PUL PPUL
Figure 5.3 Transvaginal ultrasound image of a more thickened
and heterogeneous endometrium.
Figure 5.1 Low-versus high-risk triage of women with a PUL.
Figure 5.4 Transvaginal ultrasound image of a fluid in the

endometrial cavity – often called a pseudosac. Note the presence
Figure 5.2 Transvaginal ultrasound image of a thin endometrium. of a previous Caesarean section scar that is also visible on
The calipers are measuring the endometrial thickness. this image.
women, the best time to perform a TVS whilst mini- The term pseudosac is an outdated term refer-
mising the chances of morbidity and mortality asso- ring to a collection of fluid in the endometrial cavity
ciated with a ruptured ectopic pregnancy is at seven (Figure 5.4). It tends to have a central location within
weeks (49 days). the endometrial cavity (whereas an intrauterine ges-
tation sac (IUGS) tends to be eccentrically placed).
Ultrasound Findings A pseudosac has also been described as having a
TVS remains the gold standard investigation in early ‘pointy edge’. It does not have the usual hyperechoic
pregnancy. By definition, an intrauterine gestation sac decidual reaction around it, as seen with an IUGS
cannot be visualised if the pregnancy has been classi- (Figure 5.5). It may also be transient and change shape
fied as a PUL. There may be a thin endometrium sim- during scanning and/or when pressure is exerted.
ilar to that seen in the nonpregnant state (Figure 5.2) Note that an early intrauterine gestational sac may
or a more thickened and heterogenous appearance be easily confused with a pseudosac, and the pres-
(Figure 5.3). However, endometrial thickness has not ence of a hypoechoic area in the endometrial cavity
been found to be a useful predictor of PUL outcome is more likely to be an early intrauterine gestational
when used in isolation, and it is contentious as to sac rather than a marker of an ectopic pregancy. In
whether it has real clinical utility when used in logis- fact, in the absence of an adnexal mass, a fluid-filled
34 tic regression models with other variables. structure within the uterus has a ‘0.02% probability of
35
Figure 5.5 Transvaginal ultrasound image of an early intrauterine Figure 5.6 Blood in the pelvis. Note the blood that can be seen in
gestation sac. Note the hyperechogenic ring, and that neither a the utero-vesical pouch, as well as the Pouch of Douglas.
yolk sac or fetal pole is visible.
ectopic pregnancy’ (and 99.98 per cent probability of Serum Progesterone

IUP) according to a study by Benson et al. This must A serum progesterone levels has been shown to be
be remembered in order to avoid unnecessary interven- a good predictor of pregnancy viability. Some units
tion with methotrexate and inadvertent termination of use a serum progesterone level as a single-visit strat-
an intrauterine pregnancy. egy. One such recognised protocol involves dis-
Even when the pregnancy cannot be visualised, charging women if their initial progesterone level is
there may be other ultrasound findings that influence ≤ 10 nmol/l, with a urine pregnancy test in two weeks
management. This includes the presence of blood in to confirm a negative result. In a study by Cordina
the pelvis, which may represent a ruptured ectopic et al., using this strategy allowed 37 per cent of PUL
pregnancy. There is no consensus on what is ‘signifi- to be discharged with minimal follow-up. Of course,
cant’ blood on ultrasound, but it can be defined as a drawback of such a study will be that some ectopic
when blood in the Pouch of Douglas (a potential space pregnancies are misclassified, and in this study five
between the posterior part of the uterus and the rec- ectopic pregnancies (two needing surgical interven-
tum) tracks posteriorly all the way to the fundus of the tion) were inadvertently classified as low risk and
uterus and/or blood is seen in the utero-vesical pouch. discharged.
If blood is seen in Morison’s pouch (a potential space
separating the liver from the right kidney that is not Serum hCG
filled with any fluid in normal conditions) on trans- Single measurements of serum hCG perform poorly as
abdominal ultrasound, this also indicates a worry- a predictor of PUL outcome, and management should
ing amount of blood loss. Blood usually has a typical be based on serial hCG measurements. The concept of
‘ground glass’ appearance, whilst clear fluid will have the ‘discriminatory zone’ (that the PUL is less likely to
an anechoic (black) appearance. Note that the gain on be an ectopic pregnancy if the hCG is < 1,000 IU/L)
the ultrasound machine must be adjusted appropri- is an outdated one and should not be relied upon
ately to make this distinction. Figure 5.6 demonstrates in clinical practice. This is because the majority of
the preceding findings. ectopic pregnancies diagnosed in developed coun-
tries have serum hCG levels below 1,000 IU/L. Where
Management single levels may be helpful is to flag cases that need
Clinical information has not been found to be diagnos- senior review. If a woman is classified as a PUL with
tically useful for predicting the final outcome of PUL, an initial hCG of over 1,000 IU/L, it is sensible to have
and diagnosis is largely based on serum biochemistry the ultrasound findings checked, as most intrauterine
results. Measuring serum hCG and/or serum proges- pregnancies will be visualised at hCG values above
terone is the current mainstay of managing women this level, and so the possibility of an ectopic preg-
with a PUL. nancy that has been missed should be considered. 35
hCG Ratio PUL. The M4 model utilises the patients’ initial hCG

and the hCG ratio to assign risk (where high risk of
The hCG ratio (hCG at 48 hours/hCG at 0 hours) is a
an ectopic pregnancy is defined as being ≥ 5 per cent).
commonly used algorithm to manage PUL. If the hCG
It has been demonstrated to perform better than a
ratio is < 0.87, the final outcome is likely to be a failing
single-visit strategy using serum progesterone levels
PUL (low risk); if it is > 1.66, the final outcome is likely
and the hCG ratio.
to be an ongoing IUP (low risk), and if the hCG ratio
A newer risk prediction model (the M6 model)
is ≥ 0.87 – ≤ 1.66, the final outcome is likely to be an
utilises initial progesterone as well as the initial hCG
ectopic pregnancy (high risk). See Figure 5.7.
and hCG ratio and has been developed on a much
larger cohort of PUL. It has been found to be superior
Risk Prediction Models in performance to the M4 model and works as a two-
The use of risk prediction models to help manage PUL step process; see Box 5.1.
was first described in 2004 by Condous et al., who It is important to state that the use of a model
developed the M4 model. The model was then vali- does not replace careful clinical assessment, and if
dated on nearly 2,000 prospectively collected cases of there is any concern about the patient clinically, then
management should be altered as deemed appropri-
ate. Neither a normally rising or falling serum hCG
Likely failing Likely Likely ongoing excludes an ectopic pregnancy, and the patient must
PUL ectopic IUP be counselled to seek medical advice if she experi-
ences abdominal pain until an intrauterine pregnancy
has been demonstrated on an ultrasound scan or the
hCG ratio
hCG ratio
hCG ratio
patient has a negative pregnancy test.
≥0.87
<0.87 >1.66
and ≤1.66
Persistent PUL
This is defined as a PUL that is followed with three
Figure 5.7 hCG ratio cutoff values and the likely final outcomes successive 48-hour serum hCG levels that vary less
with a PUL. than 15 per cent and where a pregnancy is never
Box 5.1: M6 Model to Predict PUL Outcome

Step 1: if the initial serum progesterone is ≤ 2 (irrespective of the initial hCG), a 48-hour blood test is not performed,
as the final outcome is highly likely to be a failed PUL. The patient is advised to perform a urine pregnancy test in
two weeks to confirm a negative result. If the result is positive, then the patient is asked to attend a follow-up serum
hCG +/– transvaginal ultrasound.
Step 2: For all women with an initial progesterone of > 2, a 48-hour serum hCG level is performed, and the model
assigns risk depending on the result. Two submodels have been created, as although step 1 can be used in women
using progesterone supplementation, the initial progesterone level is likely to be artificially raised in this group of
patients and would skew the results of a model that includes the serum progesterone level.
The two submodels use the following variables:
M6P model: uses the initial progesterone, initial hCG and the hCG ratio (for women not using progesterone
supplementation).
M6NP model (NP = no progesterone): uses the initial hCG and the hCG ratio (for women using progesterone
supplementation).
If the PUL is assigned as ‘high risk’, a repeat ultrasound scan and serum hCG level is recommended in 48 hours.
If the risk prediction is ‘low risk, likely failing PUL’, a urine pregnancy test in two weeks is recommended, and if the
prediction is ‘low risk, likely intrauterine pregnancy’, a repeat scan in one week is recommended. See Figure 5.8. The
management of PUL can often be haphazard and prolonged; this model allows significant streamlining and rational-
ising of the care for women in this situation. To facilitate its use, the M6 model is available for clinical use at no charge
at www.earlypregnancycare.org. It can also be downloaded as an app for smartphones (search ‘early pregnancy
Leuven’).
36
37
STEP 2:
STEP 1:
Perform 48 hr HCG
Go to STEP 2
Progesterone ≤ 2?
Put data into the M6 model

NO
YES
Risk EP < 5% Risk EP < 5%
Risk EP ≥ 5%
Risk FPUL > Risk IUP Risk IUP > Risk FPUL
Likely outcome =
FPUL
HIGH RISK LOW RISK LOW RISK
likely EP likely FPUL likely IUP
DO NOT perform
48 hr HCG
& hCG + REPEAT UPT in US in
UPT in 2 weeks SCAN in 48 hrs 2 weeks 1 week
Figure 5.8 Management algorithm for the M6 risk prediction model.
visualised on TVS. This may represent a failed intra- • The concept of a ‘discriminatory zone’ may be
uterine pregnancy or an ectopic pregnancy that has useful in highlighting cases that require senior
not been visualised. There is no data to support any review but should not be used as cutoffs to rule
one management option. This may involve expectant in or out either an ectopic or an intrauterine
management, medical treatment with methotrex- pregnancy.
ate or surgical management via uterine curettage/ • The management of PUL can often be haphazard
hysteroscopy. and lack an evidence base. There is therefore
In an international consensus document, Barnhart a clinical need to rationalise the management
et al. described four possible outcomes in a patient of PUL.
with a persistent PUL: • Management is dictated by triaging women
• Nonvisualised EP (defined as a rising serum hCG into either a low-risk or high-risk of
level after uterine evacuation). complications group.
• Treated persistent PUL (defined as those who are • Various management protocols exist to triage
treated medically [with methotrexate] without PUL, including the following:
confirmation of the location of the gestation by – Initial progesterone levels and a single-visit
TVS, laparoscopy, or uterine evacuation). strategy for those with a progesterone of ≤
• Resolved persistent PUL (defined as resolution of 10 nmol/l
serum hCG levels after expectant management or – hCG ratio (hCG at 48 hours/hCG at 0 hours)
after uterine evacuation [without medical therapy]
without evidence of chorionic villi on pathology). – Risk prediction models utilising hCG +/–
progesterone levels
• Histological IUP (defined as identification of
chorionic villi in the contents of the uterine
evacuation). Further Reading
1. Barnhart K, van Mello NM, Bourne T, Kirk E,
Summary and Learning Points Van Calster B, Bottomley C, Chung K, Condous
G, Goldstein S, Hajenius PJ, Mol BW, Molinaro T,
• The term PUL is an intermediate classification KL O’Flynn O’Brien KL, Husicka R, Sammel M,
and not a final diagnosis. Timmerman D (2011). Pregnancy of unknown 37
location: a consensus statement of nomenclature, Hajenius PJ (2012). Diagnostic value of serum hCG on
definitions, and outcome. Fertil Steril. 95(3): 857–866. the outcome of pregnancy of unknown location: a
2. Kirk E, Bottomley C, Bourne T (2014). Diagnosing systematic review and meta-analysis. Hum Reprod
ectopic pregnancy and current concepts in the Update 18: 603–617.
management of pregnancy of unknown location. Hum 10. Condous G, Kirk E, Lu C, Van Huffel S, Gevaert O,
Reprod Update 20(2): 250–261. De Moor B, De Smet F, Timmerman D, Bourne T
3. Condous G, Timmerman D, Goldstein S, Valentin L, (2005). Diagnostic accuracy of varying discriminatory
Jurkovic D, Bourne T (2006). Pregnancies of unknown zones for the prediction of ectopic pregnancy in
location: consensus statement. Ultrasound Obstet women with a pregnancy of unknown location.
Gynecol 28: 121–122. Ultrasound Obstet Gynecol 26: 770–775.
4. Bottomley C, Van Belle V, Mukri F, Kirk E, Van Huffel 11. Condous G, Okaro E, Khalid A, Timmerman D,
S, Timmerman D, Bourne T (2009). The optimal Lu C, Zhou Y, Van Huffel S, Bourne T (2004). The use
timing of an ultrasound scan to assess the location of a new logistic regression model for predicting the
and viability of an early pregnancy. Hum Reprod outcome of pregnancies of unknown location. Hum
24(8): 1811–1817. Reprod. 19(8): 1900–1910.
5. Ellaithy M, Abdelaziz A, Hassan MF (2013). Outcome 12. Van Calster B, Abdallah Y, Guha S, Kirk E, Van
prediction in pregnancies of unknown location Hoorde K, Condous G, Preisler J, Hoo W, Stalder
using endometrial thickness measurement: is this of C, Bottomley C, Timmerman D, Bourne T (2013).
real clinical value? Eur J Obstet Gynecol Reprod Biol. Rationalizing the management of pregnancies of
168(1): 68–74. unknown location: temporal and external validation
6. Benson CB, Doubilet PM, Peters HE, Frates MC of a risk prediction model on 1962 pregnancies. Hum
(2013). Intrauterine fluid with ectopic pregnancy: a Reprod. 28(3): 609–616.
reappraisal. Ultrasound Med 32: 389–393. 13. Guha S, Ayim F, Ludlow J, Sayasneh A, Condous G,
7. Condous G, Van Calster B, Kirk E, Haider Z, Kirk E, Stalder C, Timmerman D, Bourne T, Van
Timmerman D, Van Huffel S, Bourne T (2007). Calster B (2014). Triaging pregnancies of unknown
Clinical information does not improve the location: the performance of protocols based on single
performance of mathematical models in predicting the serum progesterone or repeated serum hCG levels.
outcome of pregnancies of unknown location. Fertil Hum Reprod. 29(5): 938–945.
Steril. 88: 572–580.
14. Van Calster B, Bobdiwala S, Guha S, Van Hoorde K,
8. Cordina M, Schramm-Gajraj K, Ross JA, Lautman Al-Memar M, Harvey R, Farren J, Kirk E, Condous
K, Jurkovic D (2011). Introduction of a single visit G, Sur S, Stalder C, Timmerman D, Bourne T (2016).
protocol in the management of selected patients with Managing pregnancy of unknown location based
pregnancy of unknown location: a prospective study. on initial serum progesterone and serial serum
BJOG 118(6): 693–697. hCG: development and validation of a two-step triage
9. Van Mello N, Mol F, Opmeer BC, Ankum WM, protocol. Ultrasound Obstet Gynecol [Epub ahead of
Barnhart K, Coomarasamy A, Mol BW, van der Veen F, print].
38
39
Chapter
Tubal Ectopic Pregnancy
6 Emma Kirk
An ectopic pregnancy is any pregnancy implanted other gynaecological, gastrointestinal, or urological

outside of the endometrial cavity. The most common disorders, including urinary tract infection, appen-
site is the Fallopian tube. However, other sites include dicitis, gastroenteritis, miscarriage, and ovarian cyst
the cervix, ovary, Caesarean section scar, and abdo- accident.
men (see Figure 6.1). A diagnosis of ectopic pregnancy should be con-
The incidence of ectopic pregnancy varies from sidered in all women of reproductive age who pres-
11–20 per 1,000 live births. Around 2–3 per cent of ent with a history of sudden onset abdominal pain or
women attending early pregnancy units will be diag- gastrointestinal symptoms. This is especially the case
nosed with an ectopic pregnancy. if the woman is not aware she has a positive preg-
nancy test when she presents. Abdominal distension,
tenderness, signs of peritonism, and hypovolaemic
Risk Factors shock should raise the suspicion of a ruptured ectopic
The highest risk is associated with tubal damage fol- pregnancy.
lowing surgery or infection (especially Chlamydia tra-
chomatis). Other risk factors include smoking, use of
an intrauterine contraceptive device, in vitro fertilisa- Diagnosis of Ectopic Pregnancy
tion (IVF), and increased maternal age. However, the
majority of women with an ectopic pregnancy have no Ultrasound Diagnosis
identifiable risk factor. Transvaginal ultrasound (TVS) is now accepted as the
diagnostic tool of choice for ectopic pregnancy. The
Aetiology aim of TVS is to positively identify the ectopic preg-
nancy rather than just excluding the presence of an
The exact aetiology remains poorly defined, but with
intrauterine pregnancy.
tubal ectopic pregnancies, it is likely to be a com-
The majority of tubal ectopic pregnancies can be
bination of impaired embryo-tubal transport and
visualised on TVS prior to treatment. In the pub-
alterations in the tubal environment allowing early
lished literature, TVS has reported sensitivities of
implantation.
87.0–99 per cent and specificities of 94.0–99.9 per
cent for the diagnosis of tubal ectopic pregnancy.
Presentation Most should be visualised on the initial TVS exami-
Amenorrhoea, pain, and vaginal bleeding are the clas- nation performed, but the remainder will be initially
sic triad of symptoms reported to occur with an ecto- classified as a pregnancy of unknown location (PUL)
pic pregnancy. There may also be a history of shoulder and diagnosed on subsequent TVS examinations or
tip pain and syncope. However, now, history and at the time of surgery. In one study, almost 75 per
physical examination alone rarely lead to a diagnosis cent of tubal ectopic pregnancies were visualised on
or exclusion of an ectopic pregnancy. the initial TVS performed and the remainder ini-
It has been reported that up to one-third of women tially classified as PULs. Overall, > 90 per cent of the
with an ectopic pregnancy have no clinical signs or tubal ectopic pregnancies were visualised on TVS
symptoms, as they tend to present earlier in the course prior to treatment.
of the disease. The symptoms may also be very non- Sonographic criteria for the diagnosis of ectopic
specific and difficult to differentiate from those of pregnancies have now been described (see Table 6.1). 39
Chapter 6: Tubal Ectopic Pregnancy
Interstitial Isthmic Figure 6.1 Sites for an ectopic

1–6% pregnancy.
Ampullary Tubal
~95%
Abdominal Fimbrial
< 1%
Intramural
< 1% Ovary < 1%
Caesarean
Cervical section scar
< 1% < 1%
Further details of nontubal ectopic pregnancies are ectopic pregnancies (see Figure 6.6). The term ‘viable
given in Chapter 7. ectopic pregnancy’ is applied when fetal heart pulsa-
tions is visualised.
Inhomogeneous Mass There are also a number of nonspecific findings
An inhomogeneous or noncystic adnexal mass that that may be indicative but not diagnostic of an ectopic
moves separate from the ovary is the most common pregnancy; see Table 6.2.
finding in 50–60 per cent of cases of tubal ectopic preg-
nancy (see Figure 6.2). The mass is generally spherical Endometrium
and seen medial to the ovary, although it may have There is no specific endometrial appearance or
a more tubular appearance if bleeding creates a hae- thickness that supports a diagnosis of tubal ectopic
matosalpinx. A consensus on nomenclature proposed pregnancy. Table 6.3 illustrates the variation in the
that these inhomogeneous masses should be termed appearance of the endometrial cavity in women
‘probable ectopic pregnancies’ rather than ‘definite diagnosed with a tubal ectopic pregnancy. In up
ectopic pregnancies’. There is of course the risk that a to 20 per cent of cases, a collection of fluid may be
false positive diagnosis of ectopic pregnancy is made, seen within the endometrial cavity. This is classically
with the mass actually being, for example, a pedun- referred to as a ‘pseudosac’; see Chapter 5, page 33.
culated or broad ligament fibroid or highly exophytic In addition to an ectopic pregnancy, there may be
ovarian cyst. A more conservative approach is linked a coexistent IUP. This is referred to as a heterotopic
to the need for a very high level of diagnostic certainty pregnancy. A heterotopic pregnancy should be con-
in the event that medical management is being considered in all women presenting after IVF when more
sidered. Administration of methotrexate to a false than one embryo has been transferred. It should also
positive diagnosis of ectopic pregnancy could poten- be considered in those women with an IUP who have
tially lead to inadvertent termination of an undetected persistent pain and in those with a persistently raised
intrauterine pregnancy (IUP) or severe abnormality hCG after a miscarriage or termination of pregnancy.
in any surviving pregnancy. The incidence of heterotopic pregnancy in natural
conceptions was originally estimated on a theoretical
Empty Gestational Sac or Gestational basis to be 1 in 30,000 pregnancies but in real life is
likely to be more like 1 in 7,500.
Sac with or without Yolk Sac or
Fetal Pole Free Pelvic Fluid
An empty gestational sac in the adnexal region will A small amount of anechoic free pelvic fluid can be
be visualised in around 20–40 per cent of cases of found in both intrauterine and extrauterine pregnan-
tubal ectopic pregnancy (see Figures 6.3, 6.4, 6.5). In cies and is often of no significance. The presence of
another 15–20 per cent, this sac will contain either echogenic fluid has been reported in up to about one-
a yolk sac or fetal pole. There are reported cases of half of all tubal ectopic pregnancies and often signifies
40 molar ectopic pregnancies and multiple gestation haemoperitoneum. Although this may be due to tubal
41
Table 6.1 Sonographic criteria for the diagnosis of ectopic pregnancies
Type of ectopic USS image Diagram Sonographic criteria Additional information

pregnancy
Tubal
Inhomogeneous mass 1. Empty uterine cavity The most common finding in
2. An inhomogeneous adnexal mass 50–60% of cases.
Ovary
seen separate to the ovary
Ectopic
Empty gestational sac 1. Empty uterine cavity Present in around 20–40%

2. An empty extrauterine gestation sac of cases of tubal ectopic
seen separate from the ovary pregnancy.
Ectopic Ovary
Sac
Sac with yolk sac/fetal 1. Empty uterine cavity Seen in 15–20% of cases. The
pole Uterus 2. A yolk sac or fetal pole ± cardiac term ‘viable ectopic’ is often
Ectopic activity in an extrauterine sac. applied when fetal heart
Yolk sac
pulsations are visualised.
Endometrium CRL
Interstitial 1. Empty uterine cavity Use of 3D ultrasound to obtain

2. Products of conception/gestation a coronal view of the uterus can
Uterus sac located in the interstitial be useful. The added information
(intramyometrial) portion of the tube given with this view means
surrounded by a continuous rim of that a connection may be seen
Endometrium myometrium between the endometrial cavity
Ectopic 3. Interstitial line sign (thin echogenic line and interstitial portion of the
extending from central uterine cavity Fallopian tube.
echo to periphery of interstitial sac)
(continued)
41
42

pregnancy
Cornual 1. A single interstitial portion of Fallopian Interstitial pregnancies are
tube in the main uterine body often referred to as cornual
Ectopic
Uterus 2. Products of conception/gestation sac pregnancies. However, a true
mobile and separate from the uterus cornual pregnancy occurs
surrounded by myometrium when implantation occurs in
3. No communication between the the noncommunicating horn
gestation sac and the unicornuate associated with a unicornuate
uterus cavity uterus.
4. Vascular pedicle joining the gestational
sac to the unicornuate uterus.
Cervical 1. Empty uterine cavity The exact aetiology is unknown.
2. Barrel-shaped cervix One theory is that there is rapid
3. Products of conception/gestation transport of the fertilised ovum
Cervix
Uterus sac below the level of the internal to the cervical canal before it is
Ectopic
cervical os capable of nidation. Recognised
4. Negative sliding organ sign predisposing factors include
trauma to the cervical canal
caused by previous surgical
instrumentation, anatomical
anomalies, IVF, and use of an
intrauterine contraceptive
device.
Caesarean section 1. Empty uterine cavity Results from implantation of a
scar Cervix 2. Products of conception/gestation sac pregnancy within a lower uterine
LSCS Scar
located anteriorly at the level of the segment Caesarean section scar.
internal os covering the presumed They have been reported to occur
Ectopic site of the previous lower segment in 1 in 1800–2200 pregnancies of
Caesarean section scar all pregnancies and to comprise
3. Negative sliding organ sign 6% of ectopic pregnancies in
4. Evidence of peritrophoblastic flow on women with a previous Caesarean
Endometrium colour Doppler examination section. The obvious risk factor is
a previous history of Caesarean
section, but why implantation
in the scar occurs in some
women is poorly understood.
Myomectomy, uterine curettage,
manual removal of placenta, IVF,
and adenomyosis have been
identified as other possible risk
factors.
43
Ovarian 1. Empty uterine cavity Ovarian ectopic pregnancies

2. Cystic structure with a wide echogenic occur when the pregnancy
ring on or within the ovary, generally implants within or on the surface
seen surrounded by ovarian cortex of the ovary and account for up
Ectopic and separate from the corpus luteum to 3% of ectopic pregnancies.
Ovary
Intramural 1. Products of conception/gestational They occur when the

sac above the internal os. pregnancy implants within
2. Evidence of trophoblast breaching the myometrium separate to
Uterus
the endometrium–myometrium the endometrial cavity and
junction or completely confined to the the Fallopian tubes. The exact
Endometrium
myometrium aetiology and pathogenesis
Ectopic
3. Lack of decidual reaction in the vicinity is unclear. Theories include
of the trophoblast implantation in a focus of
4. Evidence of increased adenomyosis, invasion of
peritrophoblastic blood flow on colour the myometrium through
Doppler examination microscopic tracts due to
uterine trauma from surgical
instrumentation or following
difficult IVF transfers and
external migration and
implantation on the serosal
surface of the uterus.
Abdominal 1. Empty uterine cavity An abdominal pregnancy
Ovary 2. No evidence of a dilated Fallopian results from implantation in the
tube or complex adnexal mass peritoneal cavity, outside the
3. Gestation sac surrounded by loops of uterus, ovaries, and Fallopian
bowel and separated by peritoneum tubes. In a primary abdominal
4. Wide mobility similar to fluctuation of pregnancy, the original
Ectopic implantation site is the
the sac
peritoneal cavity. Secondary
abdominal pregnancies
are more common and are
the result of tubal abortion
and reimplantation into the
abdominal cavity. The most
common site of implantation for
an abdominal pregnancy is the
broad ligament.
(continued)
44

pregnancy
Heterotopic 1. Intrauterine pregnancy and A heterotopic pregnancy
Tubal Ectopic
Uterus 2. Any of the previously mentioned occurs when any of the
ectopic pregnancies previously mentioned forms
Intrauterine of ectopic pregnancy is
Pregnancy
found simultaneously with
an intrauterine pregnancy.
The incidence of heterotopic
pregnancy in natural
conceptions was originally
estimated on a theoretical
basis to be 1 in 30,000
pregnancies but in real life is
likely to be more like 1 in 7,500.
The incidence is thought to
be 1 to 3 in 100 pregnancies if
conception is due to assisted
reproductive techniques The
risk increases in proportion
to the number of embryos
transferred with IVF.
45
Figure 6.5 Image of a tubal ectopic Doppler sharing fetal heart

pulsations
Figure 6.2 Image of a tubal ectopic pregnancy showing an
inhomogeneous mass.
Figure 6.3 Image of a tubal ectopic pregnancy showing an empty

Figure 6.6 Image of a tubal ectopic pregnancy showing a
gestational sac in the adnexa.
gestational sac with two fetal poles (monochorionic diamniotic
twin ectopic).
rupture, it may be more commonly due to leakage of

blood from the fimbrial end of the tube. The amount
of fluid is thought to be significant if it reaches above
the fundus of the uterus or is visualised in Morison’s
Pouch. This is the space between the kidney and the
liver in the right-upper quadrant of the abdomen.
This simple examination performed using an abdom-
inal probe forms part of the Focussed Assessment by
Sonography for Trauma (FAST) scan used in emer-
gency departments.
Figure 6.4 Image of a tubal ectopic pregnancy sharing an embryo Biochemical Investigations
generated sac.
No biochemical investigations by themselves should
be used to make a diagnosis of tubal ectopic pregnancy. 45
Table 6.2 Nonspecific findings that may be indicative of an ectopic pregnancy
USS finding USS images Description Additional

information
Echogenic free fluid • Echogenic fluid may signify Other nonectopic
haemoperitoneum secondary to tubal causes of
rupture or tubal miscarriage. haemoperitoneum
• The amount is thought to be significant if it include a ruptured
reaches above the level of the fundus of the haemorrhagic ovarian
uterus or if it is present in Morison’s Pouch. cyst.
Fluid within the • This is a collection of fluid within the This is often referred to
endometrial cavity endometrial cavity. as a ‘pseudosac’.
• It is usually possible to distinguish if from an It has been reported
early intrauterine gestational sac, which is to be present in up to
seen as an eccentrically placed hyperechoic 20% of cases of ectopic
ring within the endometrial cavity. pregnancy.
The presence of a
collection of fluid within
the endometrial cavity
alone, however, should
not be used solely to
diagnose an ectopic
pregnancy.
Table 6.3 Endometrial appearances in women with a tubal ectopic pregnancy (all images taken from
real cases where a tubal ectopic pregnancy was also visualised on the same TVS examination)
Appearance Description
Triple line.
Periovulatory appearance.
Thickened endometrium.
46
47
Appearance Description
Thin endometrium.
Disrupted endometrium.
Collection of fluid in the

endometrial cavity.
Coexistent intrauterine pregnancy.
Intrauterine contraceptive
device (IUCD) in place within the
endometrial cavity.
47
Table 6.4 Factors helping decide on most appropriate management of a tubal ectopic pregnancy
Expectant management Medical management Surgical management

Patient • Haemodynamically stable • Haemodynamically stable • Haemodynamicallly unstable
• Pain-free • Pain-free • Pain
• Willingness to attend for • Willingness to attend for follow-up
follow-up • No contraindication to methotrexate
Ultrasound Findings • No fetal cardiac activity • No fetal cardiac activity • Haemoperitoneum
• Certainty that there is no intrauterine • Fetal cardiac activity
pregnancy • Large ectopic mass (> 3.5 cm)
Serum Biochemistry • hCG ideally < 1,500 IU/L • hCG ideally < 1,500 IU/L but up to • hCG > 5,000 IU/L
• Decreasing hCG levels 5,000 IU/L • Rising hCG levels
• Rising hCG levels
However, as discussed in Chapter 5, serum hCG and • Diagnosis should be based on positive
progesterone levels can be used to help predict ectopic visualisation of an ectopic pregnancy rather
pregnancy in women classified with a pregnancy of than the inability to visualise an intrauterine
unknown location (PUL). pregnancy.
A serum hCG level is useful in planning the man- • Specific sonographic criteria now exist for all
agement of an ultrasound visualised tubal ectopic types of ectopic pregnancies.
pregnancy. An hCG level of > 3,000–5,000 IU/L is usu-
ally an indication for surgical management. At lower
levels of hCG, expectant or medical management may
Further Reading
be appropriate. However, the hCG level alone cannot 1. Elson CJ, Salim R, Potdar N, Chetty M, Ross JA, Kirk
be used to plan the most suitable treatment; the ultra- EJ on behalf of the Royal College of Obstetricians and
Gynaecologists (2016). Diagnosis and management of
sound appearance of the ectopic pregnancy should
ectopic pregnancy. BJOG 123: e15–e55.
also be taken into consideration (see Table 6.4).
2. Bouyer J, Coste J, Shojaei T, Pouly JL, Fernandez H,
Gerbaud L, Job-Spira N (2003). Risk factors for ectopic
Surgical Diagnosis pregnancy: a comprehensive analysis based on a large
Laparoscopy with histological confirmation was case-control, population-based study in France. Am J
Epidemiol. 157: 185–194.
previously regarded as the gold standard for diagnosis
of tubal ectopic pregnancy. Most surgical procedures 3. NICE (December 2012). Ectopic pregnancy and
miscarriage: diagnosis and initial management in
now for tubal ectopic pregnancies are carried out as a
therapeutic procedure after the ectopic pregnancy has NICE Clinical Guideline 154.
been diagnosed on TVS. Diagnostic surgery is gener-
4. Kirk E, Bottomley C, Bourne T (2014). Diagnosing
ally reserved for women presenting with signs of an
ectopic pregnancy and current concepts in the
acute abdomen and hypovolaemic shock. A surgical management of pregnancy of unknown location. Hum
diagnosis may also be made in women with a PUL Reprod Update 20(2): 250–261.
who become symptomatic. 5. Confidential Enquiry into Maternal Deaths in the
Laparoscopy has been quoted has having a ~ 5 per United Kingdom (CMACE) (2011). The Eighth Report
cent false negative and ~ 5 per cent false positive rate. of the Confidential Enquiries into Maternal Deaths in
Given this, the high positive predictive values for TVS the United Kingdom. CMACE 118.
and the now widespread use of conservative manage- 6. Benson CB, Doubilet PM, Peters HE, Frates MC
ment strategies for tubal ectopic pregnancies, laparos- (2013). Intrauterine fluid with ectopic pregnancy:
copy is now no longer considered the gold standard. a reappraisal. J Ultrasound Med. 32: 389–393.
7. Condous G, Okaro E, Khalid A, Lu C, Van Huffel
S, Timmerman D, Bourne T (2005). The accuracy
Learning Points of transvaginal sonography for the diagnosis of
• The majority of ectopic pregnancies should be ectopic pregnancy prior to surgery. Hum Reprod
48 visualised on TVS prior to treatment. 20: 1404–1409.
49
8. Kirk E, Papageorghiou AT, Condous G, Tan L, the initial transvaginal ultrasound examination?
Bora S, Bourne T (2007). The diagnostic Acta Obstet Gynecol Scand. 87: 1150–1154.
effectiveness of an initial transvaginal scan in
11. Elson J, Tailor A, Banerjee S, Salim R, Hillaby K,
detecting ectopic pregnancy. Hum Reprod
Jurkovic D (2004). Expectant management of tubal
22: 2824–2828.
ectopic pregnancy: prediction of successful outcome
9. Brown DL, Doubilet PM (1994). Transvaginal using decision tree analysis. Ultrasound Obstet Gynecol
sonography for diagnosing ectopic 23: 552–556.
pregnancy: positivity criteria and performance
12. Lipscomb GH, Mc Cord ML, Stovall TG, Huff G,
characteristics. J Ultrasound Med 13:
Portera SG, Ling F (1999). Predictors of success
259–266.
of methotrexate treatment in women with ectopic
10. Kirk E, Daemen A, Papageorghiou AT, Bottomley C, pregnancies. N Engl J Med 341: 1974–1978.
Condous G, De Moor B, Timmerman D, Bourne T
13. RCOG (2016). Diagnosis and management of ectopic
(2008). Why are some ectopic pregnancies
pregnancy. Green-Top Guideline No. 21.
characterized as pregnancies of unknown location at
49
Chapter
Nontubal Ectopic Pregnancy
7 Dimitrios Mavrelos and Davor Jurkovic
Nontubal ectopic pregnancies are relatively rare and to differentiate this from a tubal pregnancy. The term
account for less than 5 per cent of the total number of ‘cornual pregnancy’ should be restricted for preg-
pregnancies, which are partially or completely located nancy in a functional rudimentary cornu of a unicor-
outside the uterine cavity (see Figure 6.1). They are nuate uterus to avoid errors in communication.
often difficult to differentiate from pregnancies that
are located normally within the uterine cavity. Their Diagnosis of Interstitial Ectopic Pregnancy
rarity and variable location add further to diagnostic The ultrasound diagnostic criteria for an interstitial
difficulties. ectopic pregnancy (Figure 6.2) are the following:
Nontubal ectopic pregnancies can be divided 1. Empty uterine cavity
into two broad categories: those that are partially
2. Gestational sac in the lateral aspect of the uterine
or completely confined to the uterus, which include
fundus surrounded by myometrium
interstitial, cervical, Caesarean scar and intramural
3. A thin interstitial line adjoining the gestational sac
pregnancies; and those that are located within the
and the endometrial cavity
peritoneal cavity, which include ovarian and abdomi-
nal pregnancies. The main differential diagnoses of an interstitial
ectopic pregnancy include an intrauterine pregnancy
(IUP) implanted high and lateral in the endometrial
Intersitial, Cornual, Cervical, cavity (previously known as ‘angular pregnancy’),
Caesarean Scar, and Intramural an IUP in a uterus with a congenital uterine anom-
aly such as a bicornuate or septate uterus or a prox-
Pregnancies imal tubal ectopic pregnancy located in the isthmic
part of the tube. The first step in making the diag-
Interstitial Ectopic nosis is identification of an empty uterus. The uterus
Interstitial pregnancy represents a subset of tubal should be scanned in the transverse plane in order to
ectopic pregnancies where implantation has occurred follow the endometrium up to the uppermost lateral
in the proximal part of the Fallopian tube as it travels aspect to the internal tubal ostia (Figure 7.1). If an
through the myometrium. As a consequence of their interstitial pregnancy exists, following the interstitial
location, interstitial ectopics are associated with rel- portion of the tube in this way will lead to visuali-
atively high mortality since the myometrial mantle sation of a gestational sac, which will be covered by
supports more advanced development of the preg- myometrium and is connected to endometrial cavity
nancy before rupture occurs and rupture is associated by a thin echogenic line, the ‘interstitial line’ (Figure
with more rapid blood loss. Risk factors for interstitial 7.2). Visualisation of the ‘interstitial line’ connecting
pregnancy include ipsilateral salpingectomy, previous the pregnancy with the endometrial cavity excludes
ectopic pregnancy, and in vitro fertilisation (IVF). The an IUP in a congenitally anomalous uterus or a preg-
surgical management of an interstitial ectopic pregnancy implanted high and laterally but still in the
nancy is different from that of a more distal Fallopian endometrial cavity. In both of these instances, the
tube ectopic and may require more advanced lapa- connection between pregnancy and endometrial cav-
roscopic skill. It is thus critical that practitioners of ity will be much wider than the ‘interstitial line’. If a
early pregnancy ultrasound are aware of the diag- three-dimensional (3D) ultrasound is available, a cor-
50 nostic criteria for an interstitial ectopic and are able onal plane view of the uterus can increase diagnostic
51
Chapter 7: Nontubal Ectopic Pregnancy
(a) (b)
Uterus
Figure 7.1 Interstitial portion of tube in transverse plane.
(a) (b)
Uterus
Endometrium
Ectopic
Figure 7.2 Interstitial ectopic demonstrating two-dimensional (2D) interstitial line.
(b)
Uterus
(a)
Ectopic
Rudimentary horn
Endometrium
Figure 7.3 Cornual pregnancy surrounded by myometrium.
confidence (Figure 7.3). Once the diagnosis is made, will require more dissection to remove the pregnancy
it is useful, from a surgical perspective, to describe and suturing of the myometrial incision in a fashion
the relative proximity of the gestational sac to the similar to a myomectomy. As the tube is effectively
endometrial cavity; the more distal the pregnancy, occluded by the sutures, we advocate removal of the
the likelier it is that a loop can be passed around it distal part of the Fallopian tube as well to prevent
and excision performed. More proximal pregnancies ipsilateral tubal ectopics in the future. 51
Cornual Pregnancy viable IUP. The differential centres on the connection

between gestational sac. As outlined in the preced-
A cornual pregnancy is a pregnancy in the non-
ing, an interstitial pregnancy will have a thin, nar-
communicating functional rudimentary horn of a
row, echogenic line connecting the gestational sac
unicornuate uterus. A unicornuate uterus with a non-
with the endometrial cavity, representing the proxi-
communicating rudimentary horn represents around
mal Fallopian tube (Figure 7.2). In contrast, a cornual
4 per cent of anomalous uteri. A functional noncom-
pregnancy will be completely surrounded by myo-
municating horn contains endometrium and has an
metrium (Figure 7.3), while an IUP in an anomalous
attached Fallopian tube. Over half of the women with
uterus will have a wide connection between gesta-
this anomaly present with severe dysmenorrhea due
tional sac and endometrial cavity.
to retrograde menstruation from the blind ending
horn. The rest, however, remain asymptomatic and
may present with a pregnancy in the noncommuni- Cervical Pregnancy
cating horn, a cornual pregnancy. Undiagnosed cor- The cervix contains relatively little contractile tissue
nual pregnancies can advance well into the second compared to the myometrium, so implantation here
trimester and present with abdominal pain on average can have serious consequences when a pregnancy is
at 21 weeks. Rupture at such advanced gestation can terminated and the cervix is unable to stem bleeding.
be catastrophic, with severe intra-abdominal bleed- Early diagnosis of a cervical pregnancy allows early
ing. The majority of cornual pregnancies are currently and effective treatment as opposed to later diagnosis,
diagnosed at rupture even though diagnostic criteria when a hysterectomy may become necessary due to
to make this diagnosis early in the first trimester have intractable haemorrhage. The internal cervical os is
been formulated. identified by TVS as the point of insertion of the uter-
ine arteries. To find this level when scanning, the cervi-
Diagnosis of Cornual Pregnancy
cal canal is visualised in the transverse plane and then
The uterus is scanned in the transverse plane to iden- scanned slowly cranially. The uterine arteries are seen
tify both the interstitial portions of the Fallopian as prominent vessels in the lateral aspect of the uterus
tubes, as outlined in the preceding. The first clue for entering the myometrium. Doppler examination can
the diagnosis of a unicornuate uterus is the finding of a help to identify this vascularity clearly. Implantation
single interstitial portion of Fallopian tube. Suspicious of a pregnancy below this level represents a cervical
practitioners will then examine the adnexae to iden- pregnancy. A cervical pregnancy becomes likelier if
tify a rudimentary horn. This is often found lateral to there has been previous instrumentation of the cer-
the unicornuate uterus but medial to the ovary and vix, a previous Caesarean section or the pregnancy is
has the echotexture similar to myometrium. Once achieved following in vitro fertilisation and embryo
the rudimentary horn is found, it can be established transfer.
whether it contains a functional cavity with endome-
trium and thus whether a cornual pregnancy is pre- Diagnosis of Cervical Pregnancy
sent. The diagnostic criteria are as follows:
The diagnosis of cervical pregnancy centres on dem-
1. Unicornuate uterus with a single interstitial onstrating a gestational sac or trophoblastic tissue in
portion of Fallopian tube the cervical canal and differentiating between ongo-
2. A gestational sac surrounded by a myometrial ing pregnancy and the cervical phase of a miscarriage.
mantle There are important differences that can help practi-
3. No communication between the gestational sac tioners make the correct diagnosis; in a miscarriage,
and the unicornuate uterus cavity the internal cervical os is open, the gestational sac has
4. A vascular pedicle feeding into the become irregular and there is no heartbeat. In con-
noncommunicating functional rudimentary horn trast, a spherical gestational sac in the cervical canal
The main differential diagnoses are an interstitial with a closed internal cervical os is strongly sugges-
pregnancy and an IUP in an anomalous uterus, such tive of a cervical pregnancy, and if a viable embryo
as a bicornuate uterus. It is of course critical that the is seen within the sac, the diagnosis is confirmed
differentiation is made, as the first requires a differ- (Figure 7.4). It may be, however, that the pregnancy
52 ent surgical approach and the second is potentially is too early to contain an embryo, while the internal
53
cervical os can only be established by approximation expands and the internal cervical os remains closed,
as described previously. To improve diagnostic con- giving an hourglass appearance that is typical of a
fidence, patience and the ‘sliding organ sign’ can be cervical ectopic pregnancy. Later in pregnancy, the
employed. A pregnancy that has reached the cervi- uterine fundus is pushed superiorly and thus harder
cal stage of a miscarriage will have become detached to identify by TVS. In these circumstances, a trans-
from its original implantation point in contrast to an abdominal scan can be performed to gain additional
ongoing cervical pregnancy. Thus patient observation more information.
of the gestational sac or trophoblast under examina-
tion will reveal whether the tissue is moving within Caesarean Scar
the canal, in which case a miscarriage is more likely. A lower segment Caesarean section involves a trans-
Moreover, gentle palpation with the probe in a mis- verse incision on the uterus posterior to the bladder
carriage will demonstrate sliding of the sac on the cer- usually just above the level of the internal cervical
vical canal surface, the ‘sliding organ sign’. In contrast, os. In some women, particularly those with a retro-
a cervical pregnancy remains implanted and thus will verted uterus, the Caesarean scan can become defi-
not slide but move in concert with surrounding cervi- cient, which is visualised on TVS as a hypoechoic
cal tissue. In an ongoing cervical pregnancy, Doppler discontinuity of the anterior uterine wall and cervix
examination can be used to demonstrate vessels cross- bulging towards the bladder (Figure 7.5). It is possi-
ing from the cervix into the trophoblastic tissue of the ble for a pregnancy to implant within the scar, which
gestational sac, which will be absent in a miscarriage. if undiagnosed or untreated may then develop later
In a more advanced pregnancy, the cervical canal in pregnancy into a morbidly adherent placenta with
(a) (b) Figure 7.4 Interstitial ectopic in a coronal

plane 3D image.
Ectopic
Endometrium
Uterus
(a) (b)
Uterus
Endometrium
Cervix
Ectopic
Figure 7.5 Cervical pregnancy with spherical gestational sac below the internal cervical os. 53
attendant risks to mother and baby. As expected, mul- Figure 7.7 shows a USS image of a pregnancy implanted
tiple previous Caesarean sections increase the likeli- in a Caesarean section scar. Once the diagnosis is
hood of a deficient scar, which in turn increases the made, operators should try to establish the relation-
likelihood of a Caesarean scar pregnancy and abnor- ship between gestational sac and the bladder as well
mal implantation. as herniation into the broad ligament, as this infor-
mation can inform subsequent surgical management.
Diagnosis of Caesarean Scar Ectopic Pregnancy
The diagnosis of Caesarean scar ectopic pregnancy Intramural Pregnancy
shares some features with cervical ectopic pregnancy
Only a few case reports exist in the literature of
previously described. Again, the main differential is
intramural pregnancy. This is a pregnancy that has
the cervical phase of a miscarriage. On TVS, the aim
become enveloped by the myometrium beneath the
is to demonstrate a pregnancy implanted at the level
endometrial–myometrial junction. Previous uterine
of the internal cervical os covering the Caesarean
surgery such as myomectomy or adenomyosis may
section scar. Similar to when suspecting a cervical
predispose to this abnormal implantation by creat-
ectopic, gentle pressure can be applied with the probe
ing access to the myometrium and an environment
to explore whether the pregnancy slides over the sur-
that allows myometrial implantation and pregnancy
face of the Caesarean section scar or whether it moves
growth.
in concert with surrounding tissues, the ‘sliding organ
sign’. Doppler examination can be used to identify Diagnosis
peritrophoblastic blood vessels crossing into the preg-
Recently the ultrasound diagnostic criteria for the
nancy from the scar, which will be absent in a detached
diagnosis of intramural pregnancy have been formu-
sac in the process of miscarrying (Figure 7.6). Jurkovic
lated, as follows (see Figure 7.8):
et al. suggested the following criteria for the diagnosis
of Caesarean section scar ectopic: 1. Gestational sac/products of conception above the
internal os
1. Empty uterine cavity
2. Evidence of trophoblast breaching the
2. Gestational sac located at the level of the internal
endometrium–myometrium junction or
os covering the visible or presumed site of the
completely confined to the myometrium
previous lower uterine segment Caesarean section
3. Lack of decidual reaction in the vicinity of the
scar
trophoblast
3. Evidence of functional trophoblastic/placental
4. Evidence of increased peritrophoblastic blood
circulation on Doppler examination
flow on colour Doppler examination
4. Negative sliding organs sign, that is, inability to
displace the gestational sac from its position with The differential diagnosis includes invasive gesta-
gentle pressure by the transvaginal probe tional trophoblastic disease, which can also present
with foci of trophoblastic tissue invading deep into
(a) (b) Figure 7.6 Deficient Caesarean scar on

2D transvaginal ultrasound.
Uterus
Endometrium
Deficient
scar
54
55
(a) (b)
(c)
Uterus
Endometrium
Ectopic
Figure 7.7 Pregnancy implanted into deficient Caesarean section scar with Doppler.
(a) (b) Figure 7.8 Myometrial pregnancy.
Endometrium
Ectopic
Uterus
55
the myometrium. This is clinically important, as the can also result after rupture of a tubal ectopic preg-
trophoblastic disease requires referral to a dedicated nancy and subsequent reimplantation. The common-
oncology unit. est sites for abdominal ectopic pregnancy implantation
are the pouches around the uterus (Pouch of Douglas/
Ovarian and Abdominal Pregnancies uterovesical pouch), broad ligament, and the sero-
sal surfaces of the uterus and tubes. More advanced
Ovarian Ectopic pregnancies can involve the omentum and bowel. An
It is possible for a pregnancy to implant on the sur- abdominal pregnancy is the rarest form of nontubal
face of the ovary, giving rise to the rare diagnosis of ectopic pregnancy, and as a consequence most practi-
ovarian ectopic. Pregnancy after assisted conception tioners may not come across this diagnosis more than
or conception with a contraceptive coil in situ make a few times in their career. Nevertheless, it is impor-
this type of ectopic pregnancy more likely. tant to be aware of this entity, as it carries significant
mortality.
Diagnosis of Ovarian Ectopic Pregnancy
Diagnosis of Abdominal Pregnancy
The ultrasound appearance of an ovarian ectopic is
an echogenic ring in the ovarian cortex that may have Achieving the diagnosis of abdominal pregnancy
circumferential blood flow on Doppler examination in early gestation is often difficult. An empty uterus
(Figure 7.9). As such, it is not easy to differentiate an will give rise to suspicion of ectopic pregnancy, and
ovarian ectopic pregnancy from a corpus luteum, if a gestational sac is then seen in an unusual location
although the visualisation of two structures with such as the Pouch of Douglas or vesicouterine pouch,
appearances similar to a cystic corpus luteum within the with intact Fallopian tubes and ovaries, then the diag-
ovary should always give rise to suspicion of an ovarian nosis can be made (Figure 7.10). In one published case
ectopic. It has been suggested that corpus luteum is less of an abdominal pregnancy diagnosed at eight weeks’
echogenic than the trophoblastic tissue of a gestational gestation, the authors were able to differentiate it from
sac. If the gestational sac contains a yolk sac or even an a tubal ectopic by identifying that the gestational sac
embryo, then the diagnosis is more straightforward. was in the Pouch of Douglas and surrounded by bowel
The main differential diagnosis of an ovarian ectopic is a loops. Doppler examination can be used to demon-
tubal ectopic pregnancy that is fixed to the ovary by pel- strate the trophoblast induced vascularisation from
vic adhesions. The sliding organ sign can be employed to the peritoneal surface. In more advanced abdomi-
attempt to make this differentiation; an ovarian ectopic nal pregnancy (> 20 weeks’ gestation), the diagnosis
will move in concert with the ovary on pressure with the centres on identification of an empty uterus, abnor-
ultrasound probe, while a tubal ectopic can be shown to mal fetal lie, oligohydramnios, and poor placental
slide on the ovary on pressure. definition.
Abdominal Ectopic Pregnancy Learning Points

A pregnancy can implant directly on the surfaces and • Nontubal ectopic pregnancies are rare and
organs in the abdominal cavity. Abdominal pregnancy represent < 5 per cent of all ectopic pregnancies.
(a) (b)
Ovary
Ectopic
Endometrium Corpus luteum
Uterus
56 Figure 7.9 Ovarian ectopic pregnancy.
57
(a) (b) Uterus
Endometrium
Ovary
Ectopic
Figure 7.10 Abdominal pregnancy in the Pouch of Douglas.
Table 7.1 Summary table of ultrasonic criteria for the diagnosis of nontubal ectopic pregnancy
Empty endometrial Myometrial Connection with Internal

cavity mantle endometrial cavity cervical os
Uterine
Interstitial √ √ Thin N/A
Cornual √ √ None N/A
Cervical √ √ None below
Intramural √ √ None above
Caesarean scar √ √ Cervical canal at level of
Nonuterine
Ovarian √ X X N/A
Abdominal √ X X N/A
• The first step in achieving the diagnosis a unicornuate uterus (cornual pregnancy). Ultrasound
is common in all ectopic pregnancies: the Obstet Gynecol 30(5): 765–770.
identification of an empty uterus. 2. Sagiv R, Debby A, Keidar R, Kerner R, Golan A (2013).
• Examiners must then carefully examine all Interstitial pregnancy management and subsequent
pregnancy outcome. Acta Obstet Gynecol Scand
potential sites of ectopic pregnancy, including
92(11): 1327–1330.
the entire Fallopian tube from interstitium to
fimbriae, the ovaries, the uterus, cervix and 3. Jurkovic D, Mavrelos D (2007). Catch me if you
scan: ultrasound diagnosis of ectopic pregnancy.
Caesarean scar as well as the Pouch of Douglas Ultrasound in Obstetrics & Gynecology: The Official
and vesicouterine pouch. Journal of the International Society of Ultrasound in
• There are now recognised sonographic criteria Obstetrics and Gynecology 30(1): 1–7.
for all nontubal ectopic pregnancies; see 4. Ackerman TE, Levi CS, Dashefsky SM, Holt SC,
Table 7.1. Lindsay DJ (1993). Interstitial line: sonographic
finding in interstitial (cornual) ectopic pregnancy.
Radiology 189(1): 83–87.
Further Reading 5. Stiller RJ, de Regt RH (1991). Prenatal diagnosis of
1. Mavrelos D, Sawyer E, Helmy S, Holland TK, Ben- angular pregnancy. JCU 19(6): 374–376.
Nagi J, Jurkovic D (2007). Ultrasound diagnosis of 6. Mavrelos D, Sawyer E, Helmy S, Holland TK, Ben-
ectopic pregnancy in the non-communicating horn of Nagi J, Jurkovic D (2007). Ultrasound diagnosis of 57
ectopic pregnancy in the non-communicating horn of 12. Grimes HG, Nosal RA, Gallagher JC (1983). Ovarian
a unicornuate uterus (cornual pregnancy). Ultrasound pregnancy: a series of 24 cases. Obstetrics and
Obstet Gynecol 30(5): 765–770. Gynecology 61(2): 174–180.
7. Jurkovic D, Hacket E, Campbell S (1996). Diagnosis 13. Joseph RJ, Irvine LM (2012). Ovarian ectopic
and treatment of early cervical pregnancy: a review pregnancy: Aetiology, diagnosis, and challenges
and a report of two cases treated conservatively. in surgical management. Journal of Obstetrics &
Ultrasound Obstet Gynecol 8(6): 373–380. Gynaecology 32(5): 472–474.
8. Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, 14. Comstock C, Huston K, Lee W (2005). The
Pineda G, Arslan AA (2012). The diagnosis, treatment, ultrasonographic appearance of ovarian ectopic
and follow-up of cesarean scar pregnancy. Am J Obstet pregnancies. Obstetrics and Gynecology 105(1):
Gynecol 207(1): 44 e41–13. 42–45.
9. Timor-Tritsch IE, Monteagudo A, Cali G, Palacios- 15. Poole A, Haas D, Magann EF (2012). Early abdominal
Jaraquemada JM, Maymon R, Arslan AA, Patil ectopic pregnancies: a systematic review of the
N, Popiolek D, Mittal KR (2014). Cesarean scar literature. Gynecol Obstet Invest 74(4): 249–260.
pregnancy and early placenta accreta share common 16. Sandro G, Dario R, Gabriela B, Graziano C, Vittorio
histology. Ultrasound Obstet Gynecol 43(4): 383–395. U, Gian Carlo Di R (2004). Early ultrasonographic
10. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim diagnosis and laparoscopic treatment of abdominal
R, Elson CJ (2003). First-trimester diagnosis and pregnancy. European Journal of Obstetrics &
management of pregnancies implanted into the lower Gynecology and Reproductive Biology 113(1):
uterine segment Cesarean section scar. Ultrasound in 103–105.
Obstet Gynecol 21(3): 220–227. 17. Varma R, Mascarenhas L, James D (2003). Successful
11. Memtsa M, Jamil A, Sebire N, Jauniaux E, Jurkovic outcome of advanced abdominal pregnancy with
D (2013). Diagnosis and management of intramural exclusive omental insertion. Ultrasound in Obstet
ectopic pregnancy. Ultrasound in Obstet Gynecol Gynecol 21(2): 192–194.
42(3): 359–362.
58
59
Chapter
The Adnexa and Other Pathology
8 Wouter Froyman and Dirk Timmerman
With the introduction of routine obstetric ultrasound pregnancy) must always be ruled out (see Chapters 6
examination, adnexal masses are increasingly being and 7).
incidentally detected during pregnancy. The incidence
of adnexal pathology diagnosed in the first trimester Benign Adnexal Lesions
varies from 0.2 to 6 per cent. The overall incidence
of malignancy in adnexal masses identified in preg- Non-neoplastic Ovarian Lesions
nancy ranges from 1 to 8 per cent. In general, adnexal As described previously, functional ovarian cysts rep-
tumours can be accurately classified using transvagi- resent the largest group of lesions detected during
nal ultrasound (TVS). Different algorithms exist to pregnancy.
differentiate between benign and malignant tumours Follicular cysts/simple cysts have their origin in
or to stratify the risk of malignancy, using elements anovulatory follicles (Figure 8.1). They are unilocular
such as the tumour size, morphology, and the pres- and thin-walled with anechoic contents. They rarely
ence of colour Doppler flow. exceed 8–10 cm in diameter and typically resolve
As the majority of cysts (up to 72 per cent) detected spontaneously within six weeks.
at the time of a first-trimester ultrasound examination Corpus luteum cysts are formed following ovu-
spontaneously resolve and therefore are considered to lation (Figure 8.2). They are thick-and hyperechoic-
be physiological in nature, expectant management is walled cysts that often show circumferential blood
advocated. Characteristics favourable for spontaneous flow, sometimes described as the ‘ring of fire’. The
regression include simple morphology on ultrasound, cyst contents typically have a spider-web-like appear-
size less than 5–6 cm in diameter and diagnosis before ance due to internal haemorrhage, but may frequently
16 weeks of gestation. Larger masses or those with a show different features including blood clots within
more complex morphology are less likely to resolve the cyst, resembling solid components. In these cases,
spontaneously and may represent a neoplastic process. Doppler examination (a clot will have no blood flow)
The risk of ovarian torsion decreases as the ges- and ‘pushing’ the lesion with the probe (a clot will
tational age increases. In the literature, rates of 1–3 have typical jellylike movement) can be used to help in
per cent are reported. When they are symptomatic, differentiating between clots and solid parts. During
simple cysts diagnosed during pregnancy can be suc- pregnancy, these cysts usually resolve after the first
cessfully and safely treated with ultrasound-guided 14–16 weeks of gestation.
cyst aspiration. However, in the few cases where the Luteomas are rare solid ovarian tumours that
nature of the cyst is uncertain, the risks to the preg- occur exclusively in pregnancy (Figure 8.3). They are
nancy from surgical intervention must be weighed generally asymptomatic and are often found inciden-
against the risk of malignancy. tally. Maternal hirsutism or virilisation has been seen
During pregnancy, the same ovarian masses can be in approximately 30–35 per cent of reported cases
found as in the nonpregnant population. Additionally, of pregnancy luteoma. Approximately 75 per cent of
a number of pregnancy-associated masses may occur female infants born to virilised mothers with luteo-
(see the section ‘Nonneoplastic Ovarian Lesions’ later mas are virilised, whereas in the absence of maternal
in this chapter). When a patient presents with a symp- virilisation, fetuses are not virilised. On ultrasound
tomatic adnexal mass in early pregnancy, first an ecto- examination, luteomas appear as unilateral or bilat-
pic pregnancy (and the rarely occurring heterotopic eral (almost half of cases) heterogeneous solid masses,
59
Chapter 8: The Adnexa and Other Pathology
Figure 8.3 Luteoma of pregnancy. Heterogeneous solid mass,

often highly vascularised.
Figure 8.1 Simple cyst. Unilocular and thin-walled appearance,
anechoic content. Image is courtesy of Professor Lil Valentin.
Figure 8.4 Theca-lutein cyst. Left: Thin-walled multilocular

cyst with anechoic content (‘spoke wheel’ appearance).
Right: Intrauterine pregnancy.
Figure 8.2 Corpus luteum gravidarum. Thick- and hyperechoic- Image originally published in Van Holsbeke C, Amant F, Veldman
walled cyst, circumferential blood flow (‘ring of fire’). J, De Boodt A, Moerman P, Timmerman D (2009). Hyperreactio
luteinalis in a spontaneously conceived singleton pregnancy.
Ultrasound Obstet Gynecol 33: 371–373.
Reproduced with permission from John Wiley and Sons
predominantly hypoechoic compared with the sur-
rounding normal ovarian tissue. They are often
highly vascularised, mimicking ovarian neoplasms. bilateral thin-walled multilocular cysts with anechoic
However, they spontaneously regress when the preg- content (‘spoke wheel’ appearance). Ascites may be
nancy has ended. present. Most theca-lutein cysts spontaneously regress
Theca-lutein cysts (Figure 8.4) are seen in cases of later in pregnancy or after delivery.
hyperreactio luteinalis (due to very high endogenous
or exogenous β-hCG stimulation, as in multiple preg- Benign Ovarian Neoplasms
nancies, gestational trophoblastic disease and fertil- Mature teratomas/dermoid cysts are the most com-
ity treatment). Depending on the size of the masses, mon nonfunctional ovarian masses in premenopausal
patients are either asymptomatic or they present with women (Figure 8.5). They mostly have a unilocular
pain due to intra-abdominal pressure, torsion or cystic appearance with mixed echogenicity, due to dif-
intracystic haemorrhage. Virilisation due to hyper- ferent tissue components such as fat, bone, hair and
androgenism can occur in as many as 25 per cent fluid. Acoustic shadowing is typical and often prevents
60 of affected patients. These lesions usually present as the cyst from being completely visualised (‘tip of the
61
Figure 8.5 Dermoid. Unilocular cystic appearance with mixed

echogenicity, hyperechoic tissues packed together into a
Rokitansky nodule. Minimal vascularisation.
Figure 8.7 Decidualisation. Appearance of rounded vascularised
papillary projections with smooth contours.
Figure 8.6 Endometrioma. Unilocular tumour, low-level

echogenic content (‘ground glass’) and limited vascularity.
Figure 8.8 Serous cystadenoma. Smooth, thin walled,

iceberg’ phenomenon). Different hyperechoic tissues anechoic cyst.
often pack together into a Rokitansky nodule, and the
presence of hair, is often seen as multiple stripy hyper- these features can raise the suspicion of malignancy.
echoic interfaces (‘dermoid mesh’). In general, vascu- However, as seen in follow-up scans after pregnancy,
larity is minimal. these features resolve spontaneously. When the diag-
Endometriomas are typically unilocular tumours nosis remains uncertain, further investigation is
with a low-level echogenic content representing old advised to rule out a malignant neoplasm. Patients
blood (‘ground glass’ appearance) and limited vascu- with endometriomas are mostly asymptomatic during
larity (Figure 8.6). However, atypical features may be pregnancy.
present. Debris within the cyst may give the impres- Cystadenomas count for half of all benign adnexal
sion of solid components. epithelial neoplasms.
Due to high progesterone levels, these lesions Serous cystadenomas appear as smooth, thin-
may undergo decidualisation during pregnancy walled, anechoic cysts (Figure 8.8). They are bilateral
(Figure 8.7). The appearance of vascularised papil- in 15 per cent of cases, and their mean size is limited
lary projections with smooth contours is common. to 5–8 cm. They may be unilocular or multilocular
When no preexisting scan of the ovary is documented, with thin septa. 61
Figure 8.9 Mucinous cystadenoma. Large, thin-walled cysts,

multilocular with low-level echogenic fluid.
Figure 8.11 Fibroma. Round solid tumors with regular lining.

Stripy or fan-shaped acoustic shadows.
presence of subtle acoustic shadows behind the papil-

lary projections. Vascularity is low to moderate.
Ovarian fibromas and fibrothecomas are rare and
present as round or oval solid tumours, with regular lin-
ing (Figure 8.11). Vascularity is peripheral and limited.
Stripy or fan-shaped acoustic shadows may be seen.
Benign Nonovarian Lesions

Normal Fallopian tubes are rarely visible during an
ultrasound examination. A hydrosalpinx (chronic sal-
pingitis) appears as a tubular thin-walled mass, with
anechoic content, incomplete septae, and typical
‘beads-on-a-string’ sign, due to 2–3-mm-sized hyper-
Figure 8.10 Serous cystadenofibroma. Unilocular-solid cyst
with thin walls and anechoic content. Presence of subtle acoustic echoic structures on the tubal wall (seen on a trans-
shadows behind the papillary projections. Low vascularity. verse section) (Figure 8.12). They generally do not
change in size or appearance throughout pregnancy
Mucinous cystadenomas are classically thin-walled, and seldom cause symptoms. Acute pelvic inflamma-
large, and unilateral (Figure 8.9). Typically they con- tory disease is not often seen during pregnancy.
sist of several up to innumerable internal locules filled Paraovarian cysts originate in the broad ligament
with low-level echogenic fluid. between the ovary and the Fallopian tube and appear
Cystadenomas are not hormonally sensitive and as thin-walled unilocular anechoic cysts close to, but
usually contain limited vascularisation. separable from, the ovary (Figure 8.13). Their mean
Cystadenofibromas are relatively rare and may be diameter is usually < 5 cm and they show minimal
serous or mucinous (Figure 8.10). They appear as vascularity. They have no clinical significance.
unilocular-solid or, less frequently, as multilocular-
solid masses with thin walls and anechoic or low- Malignant Adnexal Masses
level echogenic content. The solid component is often Malignant neoplasms during pregnancy are uncom-
62 a papillary projection. A typical characteristic is the mon but they do occur.
63
Figure 8.12 Hydrosalpinx. Tubular thin-walled mass, anechoic

content, incomplete septa.
Figure 8.14 Serous borderline tumour. Unilocular-solid tumour
with papillary projection and high vascularisation.
Figure 8.13 Paraovarian cyst. Thin-walled unilocular anechoic cyst

(right) close to but separable from the ovary (left).
Figure 8.15 Primary invasive ovarian cancer. Irregular
multilocular-solid tumour with moderate vascularisation.
Most frequently reported are the nonepithelial
tumours (germ cell and sex cord-stromal tumours)
followed by ovarian tumours of low malignant poten-
tial (LMP, e.g., borderline tumours) and epithelial
ovarian cancers. The presence of more complex mor-
phology (multilocularity, wall irregularities, papillary
projections, and other solid components) and high
vascularisation on Doppler ultrasound are features
suspicious for malignancy. The presence of ascites,
peritoneal implants, or an omental cake indicates
advanced-stage disease. Of all malignant tumours
of the ovary, 10 per cent are metastases from other
organs, mainly gastrointestinal or breast tumours.
These are usually solid and bilateral. Figures 8.14
through 8.16 show examples of these malignant Figure 8.16 Metastatic ovarian cancer. Solid tumour with
neoplasms. moderate vascularisation. 63
Other Pelvic Pathology in Pregnancy in 1.4–2 per cent of pregnancies. They appear as
round masses (whorled) with variable echogenicity
Peritoneal Pseudocysts (isoechoic or hypoechoic) and peripheral vasculari-
sation. Although it is often easy to recognise that
Peritoneal pseudocysts are collections of peritoneal
there are fibroids present, it is their location that is
fluid surrounded by adhesions. They usually appear
the most important in determining the clinical sig-
as multilocular cysts, with multiple complete and thin
nificance. It is important to state whether a fibroid is
septa, which generally move upon pushing (‘flapping
within the myometrium or wall of the uterus (intra-
sail sign’). They have sharp angles and their contour
mural), on the outside surface of the uterus (sub-
follows the lining of the pelvic wall or adjacent organs.
serosal) or projecting into the cavity of the uterus
The majority of cases are asymptomatic.
(submucosal); see Table 8.1. The presence of acous-
tic shadowing is common, which is more prominent
Fibroids in cases of calcifications. These lesions can enlarge
Fibroids or leiomyomas are the most common solid during pregnancy and cause focal pain. When the
masses in pregnancy. They are seen on ultrasound fibroid outgrows its blood supply, it may undergo
Table 8.1 Classification of uterine fibroids
Type Example USS image Schematic diagram Details

example
Subserous These project from the outside surface
(serosa) of the uterus. They only usually
Endometrium
cause a problem if extremely large. Some
Fibroid may be on a thin stalk and are entirely
extrauterine. These are classified as
pedunculated and are at risk of torsion.
Uterus
Sometimes they may be mistaken for an
ovarian mass or an ectopic pregnancy.
Intramural These are predominantly within the wall of

the uterus or myometrium. They rarely cause
Endometrium a significant problem unless > 5 cm.
Fibroid
Uterus
Submucosal These are within the cavity of the uterus.

They protrude into the endometrial cavity to
varying degrees.
Type 0 These project entirely within the cavity like

a polyp.
Endometrium
Fibroid
Uterus
64
65
Type Example USS image Schematic diagram Details

example
Type 1 The majority is within the cavity, with < 50%
in the myometrium.
Endometrium
Fibroid
Uterus
Type 2 > 50% is within the surrounding

myometrium.
Endometrium
Fibroid
Uterus
‘red degeneration’, which results in a complex mor-

phology with cystic areas.
Appendicitis
Appendicitis is the most common cause of right iliac
fossa pain and the most common cause of nonobstet-
ric surgery during pregnancy, accounting for 25 per
cent of cases. The incidence of appendicitis is similar in
pregnancy compared to the nonpregnant population,
ranging between 1 in 1,400 and 1 in 1,500 births. The
clinical presentation can be misleading, for instance if
the appendix is at an unusual site, such as retro-caecal
(15 per cent of cases) or behind a gravid uterus.
With TVS, graded pressure can be applied with the
probe to move normal loops of bowel out of the way.
An inflamed appendix is identifiable as a noncom-
pressible tubular, blind-ending structure with an indi-
vidual wall thickness of greater than 3 mm or greater
than 6 mm if its two walls are measured together with Figure 8.17 Appendicitis. Transvaginal visualisation of
appendicitis. In a transverse section, the inflamed appendix appears
an empty lumen. In a transverse section, the inflamed as a double concentric ring, called the ‘target sign’.
appendix appears as a double concentric ring, called Image is courtesy of Professor Lil Valentin.
the ‘target sign’ (Figure 8.17).
ascending to its mature location (in the retroperito-
Pelvic Kidney neum just caudal to the diaphragm). It has an esti-
A pelvic kidney (congenital pelvic renal ectopia) mated incidence of 1:900. Though often clinically
occurs when the metanephros (embryonic secretory asymptomatic, it is an important differential diag-
organ) retains its original pelvic position rather than nosis in the aetiology of pelvic masses and pain, as 65
Figure 8.18 Pelvic kidney. Transvaginal visualisation of pelvic

kidney. Rounded or elliptical shape with the characteristic central
echogenic interface of the renal pelvis. Figure 8.19 Pregnancy with IUD. Full arrow marks the presence
of an intrauterine gestational sac, and the dashed arrow marks the
presence of IUD.
like horseshoe kidneys, pelvic kidneys are associated
with malrotation and predisposed to dilatation and
stasis (which may lead to calculus formation and
infection) as well as traumatic injury. An attempt pregnancy rates range from 0.02–0.2 in LNG IUD
should be made to look for other congenital uro- users and from 0.1–0.8 in copper IUD users.
genital anomalies. Kidneys may also be encountered In the unlikely event that pregnancy occurs, it
in a pelvic position after renal transplantation. On is more common to occur within the first year after
ultrasound, a pelvic kidney can often be seen as a the placement of the IUD, presumably secondary
rounded or elliptical shape with the characteris- to the higher incidence of displacement or expulsion
tic central echogenic interface of the renal pelvis of the IUD during that time period (Figure 8.19).
(Figure 8.18). More than half of IUDs identified in early pregnancy
are malpositioned.
Intrauterine pregnancies with an IUD in situ are at
Intrauterine Contraceptive Devices increased risk for first- and second-trimester miscar-
(IUDs) and Nonsurgical Sterilisation riage, including septic abortion and preterm delivery
if the IUD is left in place. Miscarriage rates up to 50 per
Devices cent are observed if the IUD is left in situ. Removing
Levenorgestrel (LNG)-Releasing IUD and the IUD reduces these risks without completely neu-
tralising them, as the miscarriage rate after the IUD
Copper IUD extraction is quoted to be approximately 25 per cent.
IUDs are gaining popularity as a reversible form of The World Health Organisation and U.S. Food and
contraception. Using two-dimensional ultrasound, Drug Administration recommend that if the IUD is
the stem of the IUD is easily identified as a linear echo- seen and the strings are visible or can be retrieved
genic structure. While the arms of the copper IUD are from the cervical os with the diagnosis of an intra-
also fully echogenic, the arms of the LNG IUD are uterine pregnancy, then the IUD should be removed
only echogenic at the proximal and distal ends, with by gently pulling on the strings.
characteristic central posterior acoustic shadowing on While some studies report on fetal malformations,
transverse images. data are insufficient to draw conclusions on any asso-
Although the IUD is a highly effective form of ciation between conceiving with an IUD in situ and
birth control, complications, including pregnancy, do risk of malformations.
occur. The strong local effect of the IUD on the endo- In conclusion, timely evaluation of the pregnant
metrium accounts for its good contraceptive efficacy woman with an IUD is important to exclude the
against intrauterine pregnancies. Therefore, in the presence of an ectopic pregnancy and to reduce sub-
rare cases of a pregnancy during the use of an IUD, sequent complications if the woman chooses to con-
66 it is very likely to be ectopic. The respective ectopic tinue her pregnancy.
67
• Features favourable for regression include size

< 5–6 cm, a simple appearance, and diagnosis
before 16 weeks of gestation.
• Up to 2 per cent of pregnant women will have
uterine fibroids.
Further Reading
1. Hoover K, Jenkins TR (2011). Evaluation and
management of adnexal mass in pregnancy. Am J
Obstet Gynecol 205: 97–102.
2. Kaijser J, Bourne T, Valentin L, Sayasneh A, Van
Holsbeke C, Vergote I, et al. (2013). Improving
strategies for diagnosing ovarian cancer: a summary
of the International Ovarian Tumor Analysis (IOTA)
studies. Ultrasound Obstet Gynecol 41: 9–20.
3. Condous G, Khalid A, Okaro E, Bourne T (2004).
Should we be examining ovaries during pregnancy?
Figure 8.20 Three-dimensional view of Essure device in the Prevalence and natural history of adnexal pathology
right tube with intrauterine, intramural, and proximal isthmic tubal detected at first trimester sonography. Ultrasound
portion. Deficient positioning in the left tube. Obstet Gynecol 24: 62–66.
4. Sayasneh A, Ekechi C, Ferrara L, Kaijser J, Stalder C,
Sur S et al. (2015). The characteristic ultrasound
Hysteroscopic Sterilisation Devices features of specific types of ovarian pathology (review).
Hysteroscopic tubal sterilisation is a well-tolerated Int J Oncol 46(2): 445–458.
ambulatory procedure that can avoid the risks of gen- 5. Chiang G, Levine D (2004). Imaging of adnexal masses
eral anaesthesia and is less invasive than laparoscopic in pregnancy. J Ultrasound Med 23: 805–819.
sterilisation. Hysteroscopic sterilisation devices such 6. Van Holsbeke C, Amant F, Veldman J, De Boodt A,
as the Essure System (Bayer) are placed transcervically, Moerman P, Timmerman D (2009). Hyperreactio
with hysteroscopic guidance, into the proximal por- luteinalis in a spontaneously conceived singleton
tion of each Fallopian tube across the uterotubal junc- pregnancy. Ultrasound Obstet Gynecol 33: 371–373.
tion, where they induce fibrosis and tubal occlusion. 7. Mascilini F, Moruzzi C, Giansiracusa C, Guastafierro F,
Two-dimensional and three-dimensional ultra- Savelli L, De Meis L et al. (2014). Imaging of
sound allows visualisation of the micro-insert, as a gynecological disease: clinical and ultrasound
coil with an intrauterine, intramural, and proximal characteristics of decidualized endometriomas
surgically removed during pregnancy. Ultrasound
isthmic tubal portion in case of optimal placement Obstet Gynecol 44: 354–360.
(Figure 8.20). Some studies have shown very good
8. Paladini D, Testa A, Van Holsbeke C, Mancari R,
effectiveness, including a five-year follow-up study
Timmerman D, Valentin L (2009). Imaging in
that showed no pregnancies among 449 women with gynecological disease (5): clinical and ultrasound
bilateral placement who relied on the Essure inserts characteristics in fibroma and fibrothecoma of the
for contraception. However, these trials are challenged ovary. Ultrasound Obstet Gynecol 34: 188–195.
because of concerns about incomplete follow-up and 9. De Haan J, Verheecke M, Amant F (2015).
biased results. There are no data available about preg- Management of ovarian cysts and cancer in pregnancy.
nancy outcome after hysteroscopic sterilisation. Facts Views Vis Obgyn 7(1): 25–31.
10. Testa A, Ferrandina G, Timmerman D, Savelli L,
Learning Points Ludovisi M, Van Holsbeke C et al. (2007). Imaging
in gynecological disease (1): ultrasound features of
• About 0.2–6 per cent of women will have some metastases in the ovaries differ depending on the
sort of adnexal pathology diagnosed in early origin of the primary tumor. Ultrasound Obstet Gynecol
pregnancy. 29: 505–511.
• The majority of ovarian cysts diagnosed are 11. Abbasi N, Patanaude V, Abenhaim HA (2014).
functional and will spontaneously resolve. Management and outcomes of acute appendicitis in 67
pregnancy-population-based study of over 7000 cases. 15. Moschos E, Twickler DM (2011). Intrauterine
BJOG 121(12): 1509–1514. devices in early pregnancy: findings on ultrasound
12. Haider Z, Condous G, Ahmed S, Kirk E, Bourne T and clinical outcomes. Am J Obstet Gynecol
(2006). Transvaginal sonographic diagnosis of 204: 427.e1–6.
appendicitis in acute pelvic pain. J Ultrasound Med 16. Brahmi D, Steenland MW, Renner R-M, Gaffield ME,
25: 1243–1244. Curtis KM (2012). Pregnancy outcomes with an
13. Singer A, Simmons MZ, Maldjian PD (2008). IUD in situ: a systematic review. Contraception
Spectrum of congenital renal anomalies presenting in 85: 131–139.
adulthood. Clin Imaging 32(3): 183–191. 17. Legendre G, Levaillant JM, Faivre E, Deffieux X,
14. Nowitzki KM, Hoimes ML, Chen B, Zheng LZ, Kim YH Gervaise A, Fernandez H (2011). 3D ultrasound to
(2015). Ultrasonography of intrauterine devices. assess the position of tubal sterilization microinserts.
Ultrasonography 34(3): 183–194. Hum Reprod 26: 2683–2689.
68
69
Chapter
Uterine Anomalies and Early Pregnancy
9 Matthew Prior and Nick Raine-Fenning
Congenital uterine anomalies arise from an abnor- due to different populations being studied, diagnostic
mality in the embryological development process. tests and classification systems used, the true preva-
This is due to defects of unification (failure of struc- lence remains uncertain.
tures to come together or fuse), canalisation (failure
of a canal to develop within a structure), or complete Effect on Pregnancy
agenesis (complete failure of development). Women with uterine anomalies are at higher risk of
Failure of normal development results in a spec- infertility, early and second-trimester miscarriage,
trum of anomalies from a mild convex indentation of preterm birth, and malpresentation at delivery.
the uterine fundus (arcuate uterus) to a complete fail- Given the inconsistency in the diagnosis and cat-
ure of development or fusion resulting in a unicornu- egorisation of uterine anomalies, the precise impact of
ate uterus or uterus didelphys. specific anomalies is uncertain. Nonetheless, a recent
systematic review showed a reduced conception rate for
Types of Anomaly all anomalies except the arcuate uterus. Many previously
Multiple systems have been proposed to classify uter- believed an arcuate uterus was benign and could even
ine anomalies, the most widely adopted of these is the be considered a normal variant. However, it has been
American Fertility Society classification, shown in shown that women with an arcuate uterus are more
Figure 9.1. than twice as likely (RR 2.39) to miscarry in the second
This simple system aids clinicians when discussing trimester compared with women with a normal uterus.
uterine anomalies. Nonetheless, there are several criti- The presence of a uterine septum is most associ-
cisms: it cannot categorise multiple anomalies (e.g., a ated with increased rates of first-trimester miscarriage
bicornuate septate uterus); and there is no morpho- (RR 2.89). It appears that unicornuate and bicornuate
metric diagnostic criteria, therefore it is possible for unification defects are associated with first-trimester
clinicians to assign the same anomaly to a different cat- loss, but uterus didelphys does not increase the risk of
egory. Newer systems have been proposed to address first- or second-trimester miscarriage.
these limitations, including adding morphometric cri- However, uterine anomalies are most strongly
teria, or the entirely new European Society of Human associated with obstetric complications. The rate of
Reproduction and Embryology (ESHRE)–European preterm birth is increased by both canalisation defects
Society for Gynaecological Endoscopy (ESGE) clas- (RR 2.14) and unification defects (RR 2.97); and mal-
sification system. However, the use of these classifica- presentation at delivery is also increased by canalisa-
tions is not yet widespread due to their complexity. An tion defects (RR 6.24) and unification defects (3.87).
ideal system would be simple, have good inter-rater The cause of preterm birth is unknown, but theories
reliability, and provide prognostic value, but this is yet include a reduced maximum uterine capacity or asso-
to be developed. Table 9.1 summarises the most com- ciated cervical incompetence.
mon types of uterine anomalies.
Screening and Diagnosis
Prevalence When scanning women in early pregnancy, it is
Uterine anomalies are more common in women who always worthwhile suspecting an anomaly given the
experience miscarriage compared with the general increased prevalence of uterine anomalies in women
population (13 per cent versus 5 per cent). However, who miscarry. 69
Chapter 9: Uterine Anomalies and Early Pregnancy
I Hypoplasia/agenesis II Unicornuate III Didelphus
(a) (b) Non

(a) Vaginal (b) Cervical
Communicating Communicating IV Bicornuate
(c) Fundal (d) Tubal (e) Combined

(c) No cavity (d) No horn (a) Complete (b) Partial
V Septate VI Arcuate VII DES drug-related
(a) Complete (b) Partial

Figure 9.1 American Fertility Society classification system for uterine anomalies.
Traditional two-dimensional ultrasound can often of the probe results in the rotation of the ultrasound
raise the suspicion of a uterine anomaly. This is also beam to acquire a series of 2D images at predetermined
the case with hysterosalpingography, hysteroscopy, and intervals. A slow acquisition maximises the number
laparoscopy. Nonetheless, to accurately make a diagno- of two-dimensional images in the data set, resulting
sis, it is necessary to simultaneously view the external in a higher-resolution 3D volume. However, this vol-
contour of the uterus and the fundal aspect of the endo- ume is more likely to suffer from artefact due to move-
metrial cavity in the coronal plane. This can only be ment of the patient, although this is less problematic
achieved using three-dimensional ultrasound or mag- in gynaecological imaging because the pelvic organs
netic resonance imaging (MRI) (see Tables 9.2 and 9.3). are stationary, unlike the blood vessels and some other
organs. The volume can then be analysed in real time
3D Ultrasound or saved for offline analysis later on.
Three-dimensional (3D) ultrasound provides the cli-
nician with a precise view of the uterus in the coro- Image Manipulation
nal plane with the added benefit of being low cost and The acquired scan volume can be displayed in a num-
having high patient tolerability ber of different formats depending in the tissue type
A 3D volume is most commonly acquired using an and area of interest. In gynaecology, this is usually the
automated technique after performing a two-dimen- multiplanar view, which shows three perpendicular
sional scan. The three-dimensional transvaginal probe images: the sagittal and reconstructed transverse and
is positioned at the midline of the area of interest in coronal views. The operator can then manipulate each
the sagittal plane. The operator then preselects a region plane individually to reveal an unlimited number of
of interest; in the case of uterine morphology, this is views, all of which retain a perpendicular relationship
the entire uterus and cervix. Next the angle of acqui- with one another. Using the acquisition technique
sition is selected to ensure that both lateral aspects of previously described, it is almost always possible to
the uterus are included in the acquisition. The oper- obtain the coronal view of the uterus, which is usu-
ator can then determine the speed of acquisition that ally lying perpendicular to the ultrasound beam. The
70 subsequently defines the image quality. The activation uterus is visualised in the coronal plane using the
71
Table 9.1 Diagnostic tests
Image Pros Cons

Optimal
MRI Precise high-resolution coronal Expensive
view image Time consuming
Images can be reviewed at a later
date
3D ultrasound Coronal image 3D facility on scan

Low cost machine required
High patient tolerability
Widely available
Volume can be reviewed at a
later date
Combined hysteroscopy Simultaneous view the external No coronal image

and laparoscopy contour of the uterus and the Invasive
fundal aspect of the endometrial Unable to measure
cavity septal length
Suboptimal
Hysterosalpingogram Excellent view of Use of contrast
(HSG) endometrial cavity
Low cost
Hysteroscopy Can be performed as outpatient External contour not

visible
Invasive
Unable to measure
septal length
71
(continued)
Image Pros Cons

Laparoscopy Direct visualisation Endometrial cavity not
visible
Invasive
Cannot measure fundal
indent
2D ultrasound Low cost No coronal image

High patient tolerability Dynamic test
Widely available
Table 9.2 Types of anomaly
Anomaly 3D-scan image Prevalence Prevalence Effect on early Treatments

General Miscarriage pregnancy
population population
Arcuate 3.9 2.9 Increase in second- None
trimester miscarriage
Septum 2.3 5.3 Increase in first- and Hysteroscopic

second-trimester septal resection
miscarriage
Bicornuate 0.4 2.1 Increase in first- and None

second-trimester
miscarriage
72
73
Anomaly 3D-scan image Prevalence Prevalence Effect on early Treatments

General Miscarriage pregnancy
population population
Unicornuate 0.1 0.5 Increase in first- None
trimester miscarriage
Didelphys 0.3 0.6 No change None
Table 9.3 USS diagnosis of an arcuate uterus
Image Details
2D longitudinal view It is difficult to show in a 2D longitudinal
image that there is the suspicion of an uterine
anomaly. Only when panning from side to
side in real time will the sonographer gain
information.
2D transverse view In transverse section, it can be appreciated that

there is a uterine anomaly, although it is often
difficult to differentiate between an arcuate,
septate, and bicornuate uterus.
3D image The uterine anomaly is clearly seen on a 3D USS

examination.
73
interstitial portions of the Fallopian tubes as reference • Optimal tests to diagnose uterine anomalies are
points, and a diagnosis can be made. 3D ultrasound and MRI.
• A randomised controlled trial of hysteroscopic
Treatment septal resection is required to demonstrate its
The options for women with uterine anomalies and a safety and efficacy in women with a history of
history of miscarriage are limited. There are no medi- infertility, miscarriage, or preterm birth.
cal treatments, and only the septate uterus is amenable
to surgery. Hysteroscopic septal resection is commonly Further Reading
performed for women with a septum and a history of
1. Buttram Jr VC, Siegler A, DeCherney A, Gibbons
recurrent miscarriage, despite no understanding of W, March C (1988). The American Fertility Society
what makes a septum pathological and the potential classifications of adnexal adhesions, distal tubal
risks of surgery. The evidence for this operation is also occlusion, tubal occlusion secondary to tubal
limited to case control studies limited by using differ- ligation, tubal pregnancies, mullerian anomalies
ent populations, surgical technique and variable length and intrauterine adhesions. Fertility and Sterility
of follow-up. There are no completed randomised 49(6): 944–955.
controlled trials (RCT), although two are ongoing, 2. Grimbizis GF, Di Spiezio Sardo A, Saravelos SH, et al.
the U.K. SEPTUM trial and the Dutch TRUST study. (2016). The Thessaloniki ESHRE/ESGE consensus on
Results of these RCTs are urgently needed to demon- diagnosis of female genital anomalies. Gynecol Surg
strate the safety and efficacy of hysteroscopic septal 13: 1–16.
resection. In the meantime, the National Institute for 3. Chan YY, Jayaprakasan K, Tan A, Thornton JG,
Health and Care Excellence (NICE) suggests current Coomarasamy A, Raine-Fenning NJ (2011).
evidence on efficacy is adequate to support the use of Reproductive outcomes in women with congenital
this procedure provided that normal arrangements are uterine anomalies: a systematic review. Ultrasound
in place for clinical governance, consent and audit. Obstet Gynecol 38(4): 371–382.
4. Chan YY, Jayaprakasan K, Zamora J, Thornton
Learning Points JG, Raine-Fenning N, Coomarasamy A (2011).
The prevalence of congenital uterine anomalies in
• Uterine anomalies are common, although the true unselected and high-risk populations: a systematic
prevalence is not known. review. Hum Reprod Update 17(6): 761–771.
• There is no agreed classification system to
5. Kowalik CR, Goddijn M, Emanuel MH, Bongers MY,
categorise uterine anomalies.
Spinder T, de Kruif JH, et al. (2011). Metroplasty
• Suspect uterine anomalies when performing 2D versus expectant management for women with
ultrasound, but be aware that it is suboptimal to recurrent miscarriage and a septate uterus. Cochrane
diagnose specific anomalies. Database Syst Rev. (6): CD008576.
74
75
Chapter
The Use of 3D Ultrasound and Colour
10 Doppler in Early Pregnancy

Venetia Goodhart and Davor Jurkovic
Both three-dimensional (3D) and colour Doppler of uncertainty where its use is necessary to provide
(CD) are relatively novel techniques that are used as essential diagnostic information. The use of pulsed
part of ultrasound examination to complement stan- Doppler should be avoided before 12 weeks’ gestation
dard B-mode images and provide additional diag- (the first trimester).
nostic information. CD ultrasound has been used in
routine practice for more than 30 years, and its major Clinical Applications of Colour
application has been the assessment of blood flow in
pelvic tumours. Three-dimensional ultrasound is a Doppler in Early Pregnancy
more recent development that has been extensively CD is used in early pregnancy to identify the site and
used in obstetrics for the diagnosis of complex fetal number of corpora lutea. It also helps in the diagno-
anomalies. In gynaecology, the most important indi- sis of tubal ectopic pregnancy by demonstrating blood
cation for 3D ultrasound is the diagnosis of congenital supply to the ectopic gestational sac. In cervical and
and acquired uterine abnormalities. Caesarean scar ectopic pregnancies, CD facilitates
differential diagnosis between intrauterine (intra-
cavitary) and ectopic pregnancies. The assessment
Safety of blood supply in Caesarean scar or cervical preg-
The intensity of ultrasound in 3D scanning is compa- nancies is helpful in planning the management and
rable to standard two-dimensional B-mode imaging. assessing the risk of intraoperative haemorrhage.
In view of that, the same safety measures should be Differential diagnoses for miscarriage include
employed, and ultrasound should only be performed common uterine cavity anomalies such as endome-
by trained individuals where there is a clinical need; trial polyps or submucous fibroids. On CD examina-
see Chapter 1. tion, a polyp will have a single feeder vessel, whereas a
Exposure to colour and pulsed Doppler may nega- submucous fibroid will display a circular blood supply
tively impact embryological development in an ongo- around the lesion. Retained products of conception
ing pregnancy. It has been established that colour typically have a scattered blood supply and increased
and in particular pulsed Doppler use higher inten- vascularity.
sities than standard B-mode imaging. Increasing the
baseline temperature of tissues in animal studies has
been shown to interfere with proliferative activity Identifying the Corpus Luteum
and cause cell death and vascular damage. Potential Identification of the corpus luteum is a routine part of
damage is caused to the human embryo if the tem- early pregnancy assessment. The corpus luteum can
perature is elevated by 4°C for more than five min- appear as solid, haemorrhagic, or cystic. Although the
utes. Nonthermal damage such as cavitation has also corpus luteum can usually be identified on B-mode
been noted in the lung and intestine of animal tissues. imaging, it can sometimes be poorly defined and hard
As described in Chapter 1, the TI and MI should be to visualise against the normal ovarian tissue. CD
monitored. is also useful in identifying more than one corpus.
The MI should be kept below 0.7 and the expo- Regardless of its appearance, the corpus luteum typi-
sure to ultrasound should be as low as reasonably cally exhibits the characteristic ‘ring of fire’ under col-
achievable (ALARA). CD should be avoided in nor- our Doppler examination. This is due to the increased
mal ongoing pregnancies, apart from in situations vascularity of the active corpus (Figure 10.1). 75
Chapter 10: The Use of 3D Ultrasound and Colour Doppler in Early Pregnancy
Figure 10.1 Characteristic ‘ring of fire’ exhibited by the corpus

luteum (CL). Figure 10.2 Intrauterine gestation sac (GS) with evidence of
functional peritrophoblastic circulation compared to a pseudosac
(P) with absent flow.
While multiple corpora lutea are a common find-

ing in patients who have undergone assisted repro-
duction with ovarian stimulation, more than one
corpus should raise clinical suspicion of multiple
pregnancy. Ectopic pregnancy must be considered
even in the presence of an intrauterine gestation sac.
Although the incidence of heterotopic pregnancy is
relatively infrequent in spontaneous conception, it is
common following assisted conception (1 per cent)
and therefore must be excluded. The majority of tubal
ectopic pregnancies are ipsilateral (approximately
70 per cent), and the location of the corpus luteum Figure 10.3 Cervical phase of an ongoing miscarriage showing
facilitates identification of the ectopic pregnancy. In implantation within the uterine cavity (UC) despite presence of the
all women with ectopic pregnancies, the blood supply gestation sac overlying the Caesarean scar (CS).
to trophoblast is seen as a separate area of increased
vascularity from the corpus luteum, which increases It also serves a role in characterising a cervical
the certainty of the ultrasound diagnosis of ectopic ectopic from a Caesarean scar ectopic pregnancy or the
pregnancy. cervical stage of an inevitable miscarriage so that the
correct management can be employed (Figure 10.3).
Implantation Site CD can help to confirm whether a Caesarean scar
Colour Doppler examination is well suited to iden- or intramural pregnancy breeches the endometrial
tify the placental implantation site given the charac- myometrial junction. In these scenarios, the pres-
teristic low-impedance turbulent flow exhibited by ence of peripheral vasodilatation is more significant
the transformed spiral arteries within the forming when there is an accompanying myometrial weak-
placenta. High vascularity identified with CD is an ness caused by uterine scarring. The vascularity here
indicator of functional peritrophoblastic or placental is important, as the absence of the normal architec-
circulation. ture compromises the myometrial function so that it
The importance of identifying the site of implanta- does not contract as expected, potentially resulting in
tion lies in distinguishing between intrauterine preg- haemorrhage. Increased vascularity in a normal myo-
nancies (IUPs), where the implantation is confined metrium does not have an associated risk of bleeding.
within the uterine cavity, and ectopic pregnancies. However, when diagnosing Caesarean scar ectopics,
A cystic endometrium can be differentiated from a an increased blood supply gives an indication of the
gestational sac not only by the presence of the tropho- risk of massive haemorrhage (Figure 10.4).
blastic reaction but also by this characteristic vascu- The ability to appreciate the vascularity of an
76 larity (Figure 10.2). ectopic pregnancy can be useful when planning best
77
Figure 10.4 Caesarean scar ectopic pregnancy (GS) with high

vascularity anterior to the gestation sac and implanted outside Figure 10.5 Evidence of early embryonic demise (embryo – E)
the UC. confirmed by the lack of cardiac activity (absence of colour over the
embryo but presence noted elsewhere).
management. With highly vascular ectopic pregnan-

cies, clinicians may favour surgical management in indicators for the diagnosis of RPOC. Even a very
view of the heightened risk of rupture and maternal small amount of RPOC tends to exhibit high blood
haemorrhage. This is especially the case in Caesarean supply. One of the main roles of CD in early pregnancy
scar pregnancies, when vascularity is proportional to has been to facilitate detection of RPOC and increase
blood loss. the sensitivity of ultrasound diagnosis of incomplete
Uterine ectopic pregnancies cannot be expelled by miscarriage (Figure 10.6). CD can also be used to dis-
contraction. Initially, they induce extreme vasodilata- tinguish between RPOC and organised blood clot,
tion of the uterine vessels in the vicinity of retained which can have a similar appearance on ultrasound.
trophoblast, which can be easily depicted on CD. This When used in conjunction with clinical symptoms,
facilitates resorption of pregnancy into the mater- best management decisions can be achieved, that
nal circulation. As the amount of volume of retained is, whether cases can be managed conservatively or
trophoblast decreases, the blood supply also tends to require surgical intervention. Identifying vascular
diminish. RPOC (measured as maximum peak systolic velocity)
can prepare the clinician for potential complications
Assessing Viability at surgical evacuation such as maternal haemorrhage.
When there is uncertainty regarding the viability of a
pregnancy, CD can be used to aid detection of embry- Uterine ‘Arteriovenous Malformation’
onic cardiac activity, or indeed prove its absence in the It has been suggested that increased blood flow to an
case of miscarriage (Figure 10.5). Abnormal pregnan- otherwise uncomplicated intrauterine pregnancy may
cies will often demonstrate highly vascular tropho- represent an arteriovenous malformation (AVM).
blast on CD, which sometimes helps to confirm the RPOC are usually expelled by uterine contrac-
diagnosis of miscarriage. tions. If this process is not effective, the only other
physiological method for removal is through the
Retained Products of Conception peritrophoblastic circulation and reabsorption. In
Surgical evacuation for incomplete miscarriage is one some women, RPOC will be accompanied by extreme
of the major indications for emergency gynaecological vasodilatation, which some refer to as AVM. As these
surgery. Diagnosing a small amount of retained prod- changes typically regress after spontaneous or surgical
ucts of conception (RPOC) can be difficult, as they removal of the pregnancy, we prefer to use the term
are not clearly visible on B-mode scan. Endometrial pseudo arteriovenous malformation.
thickness measurements are routinely taken as part of Pseudo AVM is a common physiological finding
transvaginal ultrasound, and traditionally have been in women in whom products of conception have been
used in conjunction with the appearance of the mid- retained over a prolonged period. Some have expressed
line echo to identify RPOC. However, endometrial concerns that extreme vasodilatation increases the
thickness measurements have been shown to be poor risk of severe haemorrhage with an associated risk 77
(a) (b)
Figure 10.6 (a) The retained products of pregnancy are not clearly visualised on B-mode imaging. (b) When CD is applied, the vascularity
assists the identification of the RPOC.
(a) (b)
Figure 10.7 (a) Pseudo AV malformation is highly vascular initially. (b) However, after surgical evacuation it regresses spontaneously and the
uterine appearances normalise.
of hysterectomy. However, recent studies have shown

that this risk is low. Whilst high blood flow is a con-
cern in some forms of ectopic pregnancies, such as
intramural and cervical pregnancies, it bears no sig-
nificance with regards to miscarriage of normally
implanted intrauterine pregnancies (Figure 10.7).
In contrast, true AVMs are a permanent feature,
present in nonpregnant women. They feature mas-
sive vasodilatation of the uterine vessels, including
the radial arteries, and are associated with heavy men-
strual periods. AVM can appear as ‘areas of strong Figure 10.8 An invasive molar pregnancy exhibiting a vascular
appearance within the myometrium (transverse view).
hypervascularity and strong turbulence in comparison
with the normal surrounding myometrial perfusion’.
can be explained by the tendency of molar tissue to
Gestational Trophoblastic Disease invade the myometrium or to be retained for a long
The villi in gestational trophoblastic disease are time, thus giving the vascular appearance shown in
avascular and will demonstrate absent flow on col- Figure 10.8.
our Doppler examination. Despite this, the litera- The uterus reacts to vasodilatation in gestational
ture often refers to increased vascularity as being a trophoblastic disease using the same mechanism
78 useful diagnostic indicator of molar pregnancy. This observed in uncomplicated miscarriage. Therefore,
79
there can be diagnostic difficulty on ultrasound when

it comes to differentiating between RPOC and gesta-
tional trophoblastic disease.
The Use of 3D Ultrasound in Early

Pregnancy
The development of 3D imaging as part of transvagi-
nal ultrasound has allowed clarification in diagnosing
complications of early pregnancy and assisted in for-
mulating management decisions. Three-dimensional
imaging allows clinicians to obtain coronal views
of the uterus, which is difficult using conventional
two-dimensional imaging. It is an integrated part
of the transvaginal scan (providing the ultrasound
machine has a 3D function), which is routinely used
in the assessment of early pregnancy, without add-
ing significant time to the scan. The images are self-
explanatory and can be stored permanently and
assessed independently. Figure 10.9 Normal intrauterine pregnancy on 3D.
Location of the Pregnancy

One of the benefits of 3D imaging is that it very clearly
demonstrates the endometrial myometrial junction.
This is particularly useful in early pregnancy as it
allows the clinician to establish the exact location of
the pregnancy in relation to the uterine cavity and
assess for invasion beyond said junction, thereby
assisting the diagnosis of intramural, interstitial, cer-
vical, or Caesarean scar ectopic pregnancies.
A normal IUP is a pregnancy located within
the uterine cavity with trophoblastic invasion that
does not breach the endometrial myometrial junc-
tion (Figure 10.9). The uterine cavity is defined as
the virtual space between the uterine ostia of the
Fallopian tubes and the internal cervical os, lined with
endometrium.
Interstitial Pregnancy
The visualisation of the interstitium is facilitated by the
use of 3D ultrasound and the ability to see the proxi- Figure 10.10 Three-dimensional image of an interstitial
pregnancy showing a gestational sac in the lateral aspect of the
mal part of the tube is the most difficult part of diag- uterus, which is adjoined to the uterine cavity by thin, hyperechoic
nosing an interstitial pregnancy. Three-dimensional line representing the proximal section of the interstitial tube.
imaging can better assess interstitial pregnancies as it
provides improved views of the interstitial portion of
the tube and allows the clinician to better assess the Intramural Pregnancy
position of pregnancy in relation to the uterine cav- These pregnancies can either be partial (the tro-
ity to rule out uterine anomalies and aid management phoblast breaches the endometrial myometrial
decisions (Figure 10.10). junction) or complete (the trophoblast lies entirely 79
Figure 10.11 Three-dimensional image of the uterus showing

the UC and a GS, which is located in the posterior wall of the uterus.
These findings were typical of an intramural pregnancy.
Figure 10.12 Caesarean scar ectopic pregnancy showing
evidence of anterior herniation (UC = uterine cavity;
within the myometrium). The pregnancy is located GS = gestational sac).
above the internal os and medial to the interstitial
tube (Figure 10.11). Given the site of implantation,
there is a lack of decidual reaction in the surround- Uterine Anomalies
ing tissue. Uterine anomalies can be an incidental finding during
the ultrasound assessment of early pregnancy. It can
at times be difficult to differentiate between an intra-
Cornual Pregnancy uterine pregnancy and interstitial or cornual ectopic
Diagnosis of a cornual pregnancy is based on a single pregnancies in the presence of an underlying anom-
interstitial portion of the Fallopian tube within the aly. Although diagnosis of a uterine anomaly can be
main uterine body. The gestation sac can be seen compromised in pregnancy due to dilation of the uter-
mobile and separate from the uterus and is sur- ine cavity by the presence of the pregnancy, 3D ultra-
rounded by myometrium. A vascular pedicle can sound can undoubtedly aid diagnosis and especially
be seen joining the gestation sac to the unicornuate help to rule out ectopic pregnancy by examining the
uterus. relationship between the uterine septum and the preg-
nancy (Figure 10.13).
Caesarean Scar Pregnancy
Caesarean scar pregnancies extend outside the uter- Learning Points
ine cavity and exhibit myometrial involvement. There • B-mode ultrasound is sufficient in providing
is partial or complete absence of a decidual reaction diagnostic information in most women
and there must be evidence of functional peritropho- presenting with simple early pregnancy
blastic flow. Three-dimensional ultrasound helps to complications.
assess the exact location of the Caesarean scar ectopic • Three-dimensional ultrasound and colour
and whether there is any evidence of herniation, in Doppler may help in the more complex and
order to establish the feasibility of surgical evacuation difficult cases, particularly in women with
80 (Figure 10.12).
81
Further Reading
1. The British Medical Ultrasound Society. Statement
on the safe use, and potential hazards of diagnostic
ultrasound. www.bmus.org
2. The British Medical Ultrasound Society. Guidelines
for the safe use of diagnostic ultrasound equipment.
www.bmus.org
3. Morin L et al. (2005). Ultrasound evaluation of first
trimester pregnancy complications. J Obstet Gynaecol
Canada Jun;27(6): 581–591.
4. Jurkovic D et al. (1991). Transvaginal colour Doppler
assessment of utero-placental circulation in early
pregnancy. Obstet Gynaecol. 77: 365–369.
5. Jauniaux E et al. (1990). Assessment of placental
development and function. In Kurjak, A. (ed)
Transvaginal Colour Doppler, pp. 53–65 (Carnforth,
UK: Parthenon Publishing).
6. Jurkovic et al. (2016). Surgical treatment of Cesarean
scar ectopic pregnancy: efficacy and safety of
ultrasound-guided suction curettage. Ultrasound
Obstet Gynecol. Apr;47(4): 511–517. doi:
Figure 10.13 Intrauterine pregnancy in a right cornu of a 10.1002/uog.15857
bicornuate uterus. 7. Sawyer et al. (2007). The value of measuring
endometrial thickness and volume on transvaginal
ultrasound scan for the diagnosis of incomplete
incomplete miscarriage and those with uterine miscarriage. Ultrasound Obstet Gynaecol. Feb;29(2):
anomalies and ectopic pregnancies. 205–209.
• Colour Doppler should be available on all 8. Van den Bosch et al. (2015). Maximum peak systolic
modern machines used for early pregnancy velocity and management of highly vascularized
diagnostics. retained products of conception. J Ultrasound Med.
• In order to ensure safety, key protocols should be Sep;34(9): 1577–1582.
established in every scan department for its use to 9. Timmerman D et al. (2003). Color Doppler imaging
minimise the risk of exposing normal intrauterine is a valuable tool for the diagnosis and management
pregnancy to the potentially harmful effects of of uterine vascular malformations. Ultrasound Obstet
colour Doppler. Gynecol. Jun;21(6): 570–577.
81
Chapter
Ultrasound and the Surgical Management
11 of Early Pregnancy Complications

Tom Holland
The practice of early pregnancy complication manage- is discussed in Chapter 7. Key points when consider-
ment has been transformed over the last 20 years by ing surgery are the size of the trophoblast, size of the
the introduction of high-definition ultrasound into gestational sac and embryo, and the thickness of the
everyday services. This advancement has been in par- overlying myometrium. Previously, wedge resection
allel with progress in minimal access surgery, both in was thought necessary; however, laparoscopic exci-
terms of technique and technology. sion by opening the myometrium, in a similar man-
ner to laparoscopic myomectomy, and removing the
Preoperative Assessment trophoblast is now thought to be sufficient.
A confident, accurate diagnosis helps in the counsel-
ling of patients regarding expectant management of Intraoperative Ultrasound
many conditions that were previously thought of as Before starting any procedure for a pregnancy-related
being surgical problems (such as interstitial preg- problem, where you have not scanned the patient
nancy). However, many complications will necessitate yourself, it is highly recommended that you rescan
surgery, and for these patients an accurate preopera- the patient. Ideally, the scan should be performed pre-
tive diagnosis is essential to ensuring the right oper- operatively as there may be less time pressure; how-
ation by the right surgeon(s) in the right place at the ever, if necessary it can be performed immediately in
right time. theatre once the patient has been anaesthetised. The
benefits of this approach are that you can check the
previous scan findings to make sure you agree and it
Tubal Ectopic Pregnancy also provides immediate direct feedback to improve
The most important aspects to consider prior to com- your scanning experience. It is especially useful with
mencing any laparoscopic surgery are how difficult the ectopic pregnancies, as many doctors in training will
surgery will be and whether the most appropriate sur- have operated on more ectopic pregnancies than they
geon is present. When considering laparoscopic exci- will have diagnosed on ultrasound. It is also an oppor-
sion of a tubal ectopic pregnancy, the main features tunity to assess the level of intra-abdominal bleeding
that will make the surgery difficult will be adhesions. and ectopic location.
Therefore, once the diagnosis of a tubal ectopic preg-
nancy is made, it is essential to assess the ovaries and Miscarriage
other pelvic structures for adhesions. When the tube
Surgical management of miscarriage (SMM) is nor-
is adherent to the ovary, it can be difficult to distin-
mally the first operation that many gynaecology
guish between an ovarian ectopic and a tubal ectopic,
trainees learn. However, the practice of this operation
and these are the sorts of cases that require an experi-
is evolving. Manual vacuum aspiration (MVA) under
enced laparoscopic surgeon.
local anaesthetic is appropriate for many smaller preg-
nancies and has the advantage of avoiding a general
Interstitial Ectopic Pregnancy anaesthetic and the use of an operating theatre. Local
An interstitial pregnancy is a potentially very dan- protocols should be in place, but gestational sac size
gerous due to the abundant vascularity of the myo- is the main criteria used. Other features, which can
metrium and consequent copious haemorrhage if make the procedure more uncomfortable, will be
82 rupture occurs. The diagnosis of interstitial pregnancy pregnancies high in the cavity and retroverted uteri.
83
Chapter 11: Ultrasound and the Surgical Management of Early Pregnancy Complications
Figure 11.1 Transabdominal ultrasound during surgical

management of miscarriage. Figure 11.2 Transrectal scan (using a normal transvaginal probe)
of a Caesarean scar ectopic pregnancy prior to evacuation.
Transabdominal ultrasound is helpful thoughout

both MVA and SMM (Figure 11.1) in order to guide
cervical dilation, reduce the risk of perforation, and
ensure that all the products of conception are removed
without unnecessary damage to the endometrium and
consequent risk of intrauterine adhesions. A partially
full bladder is helpful to improve the picture qual-
ity; however, this can be quite uncomfortable when
the patient is awake. When the patient is asleep, the
bladder can be filled with warm saline via a catheter
to improve the picture quality if necessary. An alter-
native is intraoperative transrectal ultrasound. As
detailed in Chapter 1, this is performed systematically
in the same way as a TVS. The advantage of using this
method intraoperatively is that it allows you to scan
continuously whilst performing the surgical proce- Figure 11.3 During evacuation.
dure transvaginally.
Caesarean Scar Pregnancy

Caesarean scar pregnancy is a rare type of ectopic preg-
nancy, which is implanted into the defect in the myo-
metrium from a poorly healed Caesarean section, as
discussed in Chapter 7. Both ectopic and cervical ectopic
pregnancies of this type are amenable to surgical evacu-
ation. Transrectal ultrasound can be used during evac-
uation of these types of low uterine ectopic pregnancies,
as the visualisation is better than with transabdominal
ultrasound (Figures 11.2, 11.3, and 11.4).
Postoperative
Ultrasound is useful in the assessment of women who
present with possible complications after a surgical Figure 11.4 After evacuation. 83
Chapter 11: Ultrasound and the Surgical Management of Early Pregnancy Complications
Learning Points
• Ultrasound has a role in the pre-, intra-,
and postoperative management of many
gynaecological procedures.
• When making a diagnosis, it is important to also
consider the surgical management and identify
features such as adhesions, which may make the
surgery more difficult.
• Intraoperative ultrasound guidance is helpful to
improve safety and ensure completion of many
evacuation procedures.
Further Reading
1. NICE (December 2012). Ectopic pregnancy and
miscarriage: diagnosis and initial management in
NICE Clinical Guideline 154.
2. Poon LCY, Emmanuel E, Ross, JA, Johns J (2014). How
feasible is expectant management of interstitial ectopic
pregnancy? Ultrasound Obstet Gynecol 43(3): 317–321.
3. Wen J, Cai QY, Deng F, Li YP (2008). Manual versus
electric vacuum aspiration for first‐trimester abortion:
a systematic review. BJOG: An International Journal of
Obstetrics & Gynaecology 115(1): 5–13.
Figure 11.5 Ultrasound images showing a perforation of 4. Vial Y, Petignat P, Hohlfeld P (2000). Pregnancy in a
the uterus sustained at the time of surgical management of cesarean scar. Ultrasound Obstet Gynecol 16: 592–593.
miscarriage, with a small segment of small bowel within the
myometrium: (a) longitudinal view; (b) transverse view. 5. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim
R, Elson CJ (2003). First-trimester diagnosis and
management of pregnancies implanted into the lower
procedure has been performed in early pregnancy. uterine segment Cesarean section scar. Ultrasound
Continuous bleeding or pain after SMM may lead to Obstet Gynecol 21: 220–227.
the suspicion that there are some retained products 6. Jurkovic D, Ben‐Nagi J, Ofilli‐Yebovi D, Sawyer E,
of conception or that a perforation of the uterus has Helmy S, Yazbek J (2007). Efficacy of Shirodkar
occurred (Figure 11.5). Ultrasound examination can cervical suture in securing hemostasis following
also be useful for assessing the presence and extent of surgical evacuation of cesarean scar ectopic pregnancy.
Ultrasound Obstet Gynecol 30(1): 95–100.
pelvic collections, fistulae, and adhesions.
84
85
Index
abdominal ectopic pregnancy, 56–57 early intrauterine pregnancy, implantation site, 76–77

adnexal pathology, 59 4-11 week inhomogeneous mass, 40–45
adnexal pathology, benign adnexal chorionic bumps, 14–15 interstitial ectopic pregnancy, 50, 79
lesions crown rump length (CRL), 11 diagnosis, 50–51
benign ovarian neoplasms, 60–62 diagnosis landmarks, 11–12 intramural pregnancy, 54–56, 79–80
corpus luteum cysts, 59–60 echogenic coelomic fluid, 15 intra-uterine contraceptive devices
cystadenofibromas, 62 fluid in endometrial cavity, 15 (IUDs), 66
decidualisation, 61f8.7 multiple pregnancy diagnosis, 11–14 hysteroscopic sterilisation devices,
endometriomas, 61 ultrasound measurements, mean Essure System (Bayer), 67
follicular/simple cysts, 59–60 CRL, 11–14 pregnancy with IUD, 66
hydrosalpinx, 62–63 umbilical cord cysts, 14–15 intrauterine pregnancy (IUP), 33
luteomas, 59–60 variants of normal, 14–15
mature teratomas, dermoid cysts, early pregnancy ultrasound scan (USS) luteomas, 59–60
60–61, 62–63 provision of care standards, 1–2
mucinous cystadenomas, 62 setting, 1–2 malignant adnexal masses, 62–63
non-neoplastic ovarian use of, aims, 1 mature teratomas, dermoid cysts,
lesions, 59–60 echogenic coelomic fluid, 15 60–61, 62–63
ovarian fibromas, endometriomas, 61 miscarriage diagnosis
fibrothecomas, 60–62 endometrium, 40–46 aetiology, 17–18
paraovarian cysts, 62–63 caution, adherence to guidelines,
serous cystadenomas, 61 failed PUL (FPUL), 33 counselling, 20
theca-lutein cysts, 60 fibroids, 64 presentation, 18
adnexal pathology, malignant adnexal fluid in endometrial cavity, 15 soft markets, prediction of
masses, 62–63 follicular/simple cysts, 59–60 miscarriage, 20
appendicitis, 65 free pelvic fluid, 40–45 terminology, 17–18
auditable standards, 9 ultrasound criteria, diagnosis,
gestational trophoblastic disease 18–19
benign adnexal lesions. See adnexal (GTD), 78–79 mucinous cystadenomas, 62
lesions, benign adnexal lesions epidemiology, 23–24 multiple pregnancy diagnosis, 11–14
benign ovarian neoplasms, 60–62 genetics, 23
histopathology, 23–26 non-neoplastic ovarian lesions, 59–60
caesarean scar pregnancy, 80 main features comparison, 23–24 nontubal ectopic pregnancy. See also
diagnosis, 54–55 gestational trophoblastic neoplasia tubal ectopic pregnancy
cervical pregnancy, 52 (GTN), 31 abdominal ectopic pregnancy, 56–57
diagnosis, 52–53 caesarean scar ectopic
chorionic bumps, 14–15 heterotopic pregnancy, 40 pregnancy, 53
complete hydatidiform moles (CHMs) hGC ratio, 36 caesarean scar ectopic pregnancy,
clinical presentation, 24–26 human chorionic gonadorophin, 23 diagnosis, 54–55
ultrasound features, 26–29 hydatidiform moles (HMs) cervical pregnancy, 52
cornual pregnancy, 52, 80 clinical presentation, 23–27 cervical pregnancy, diagnosis, 52–53
diagnosis, 52 management, 29 cornual pregnancy, 52
corpus luteum (CL) post evacuation monitoring, 31 cornual pregnancy, diagnosis, 52
identification, 75–76 ultrasound diagnosis, 26 interstitial ectopic, 50
corpus luteum cysts, 59–60 hydrosalpinx, 62–63 interstitial ectopic, diagnosis, 50–51
crown rump length (CRL), 11 intramural pregnancy, 54–56
cystadenofibromas, 62 images. See also ultrasound technique, ovarian ectopic pregnancy, 56
image optimisation ultrasonic criteria for diagnosis,
decidualisation, 61f8.7 documentation, storage, 5–9 summary table, 57t7.1
85
Index
ovarian ectopic pregnancy, 56 serum hCG, 35 empty gestational sac, sac with/
ovarian fibromas, serum progesterone, 35 without yolk sac or fetal
fibrothecomas, 60–62 pole, 6
theca-lutein cysts, 60 endometrium, 40–46
paraovarian cysts, 62–63 3-Dimensional (3-D) ultrasound, early free pelvic fluid, 40–45
partial hydatidiform moles (PHMs) pregnancy heterotopic pregnancy, 40
clinical presentation, 27t4.3 caesarean scar pregnancy, 80 inhomogeneous mass, 40–45
ultrasound features, 27 cornual pregnancy, 80 management factors, 48t6.4
pelvic kidney, 65–66 interstitial pregnancy, 79 nonspecific indicative
peritoneal pseudocysts, 64 intramural pregnancy, 79–80 findings, 40–46
persistent PUL (PPUL), 33–34, 36–37 location of pregnancy, 79 presentation, 39
pregnancy of unknown location (PUL) uterine anomalies, 80–81 risk factors, 39
presentation, 33–34 3-Dimensional (3-D) ultrasound and sites, 39
ultrasound findings, 34–35 colour Doppler (CD) surgical diagnosis, 48
pregnancy of unknown location clinical applications, early
(PUL), clinical outcomes pregnancy, 75–79 ultrasound measurements, mean
ectopic pregnancy (EP), 33 corpus luteum (CL) CRL, 11–14
failed PUL (FPUL), 33 identification, 75–76 ultrasound technique, image
intrauterine pregnancy (IUP), 33 gestational trophoblastic optimisation
persistent PUL (PPUL), 33–34, disease, 78–79 depth, 3
36–37 implantation site, 76–77 focus, 3
pregnancy of unknown location retained products of conception frequency, 4
(PUL), management (RPOC), 77–78 gain, 3
hCG ratio, 36 safety, 75 image orientation, 3
M6 model, 36–37 uterine arteriovenous malformation magnification, 3
risk prediction models, 36–37 (AVM), 77–78 umbilical cord cysts, 14–15
serum hCG, 35 viability assessment, 77 uterine anomalies, 80–81
serum progesterone, 35 transabdominal scan (TAS) uterine anomalies, early
procedure, methodology, 5 pregnancy
retained products of conception transvaginal scan (TVS) vs., 3 anomaly types, screening,
(RPOC), 77–78 transvaginal scan (TVS) diagnosis, 69–70
procedure, methodology, 4 effect on pregnancy, 69
safety, 1 transabdominal scan (TAS) vs., 3 image manipulation, 70–74
indices, 1–2 tubal ectopic pregnancy (EP), 33 prevalence, 69
mechanical index (MI), thermal aetiology, 39 3D ultrasound, 70
index (TI), 3f1.1 biochemical investigations, 45–48 treatment, 74
scanning modes, 1 diagnosis. sonographic uterine arteriovenous malformation
serous cystadenomas, 61 criteria, 39–40 (AVM), 77–78
86

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Early Pregnancy Ultrasound

Early Pregnancy Ultrasound

Cambridge University Press is part of the University of Cambridge.

1 Introduction to Early Pregnancy 8 The Adnexa and Other Pathology 59

Table 1.1 Standards for provision of care in early pregnancy units

Table 1.2 Ultrasound safety indices

Explanation Recommended levels *

Chapter 1: Introduction to Early Pregnancy Ultrasound

Similarly, when examining in the longitudinal plane,

Figure 1.1 Image showing on-screen display of mechanical index

5. Frequency front of the patient, before the procedure. The probe

Chapter 1: Introduction to Early Pregnancy Ultrasound

Table 1.4 Image orientation

Transabdominal Scan Transvaginal Scan Transvaginal Scan

The right ovary will be on the left

The fundus of the uterus

Transabdominal Scan (TAS) Documentation and Storage of Images

Table 1.5 Systematic approach to the TVS

Ultrasound image Schematic drawing Details

7. Assessment of the • Both adnexa should be fully examined for masses.

9. Other sites • In a woman with a previous caesarean section it will be

Table 1.6 Suggested information to be included in the structured ultrasound report

Chapter 1: Introduction to Early Pregnancy Ultrasound

Table 1.6 (continued)

important to document all findings and to label all Learning Points

Gestation Ultrasound findings Ultrasound image Diagram

5+1 to 5+5 The GS should be visible by 5+2. The yolk sac

5+6 to 6+0 The embryonic pole is visible as a straight line,

6+1 to 6+6 The embryo appears kidney bean-shaped. It is

7+0 to 7+6 The CRL measures 11–16 mm. The

Chapter 2: The Normal Early Intrauterine Pregnancy 4–11 Weeks

Table 2.1 (continued)

Gestation Ultrasound findings Ultrasound image Diagram

8+0 to 8+6 The CRL measures 17–23 mm. The

9+0 to 10+0 The CRL measures 23–32 mm. The limbs

Table 2.2 Mean CRL in relation to gestational age

Figure 2.3 Monochorionic diamniotic pregnancy.

(b) Umbillical cord cysts (Figure 2.5)

Multiple pregnancy diagnosis

Gestation Dichorionic diamniotic Monochorionic diamniotic Monochorionic monoamniotic

Chapter 2: The Normal Early Intrauterine Pregnancy 4–11 Weeks

Figure 2.6 Echogenic coelomic ﬂuid seen throughout the

Figure 2.7 Fluid collection in endometrial cavity, surrounding

○ Unlikely to be clinically significant unless Learning Points

3 Nicola Mitchell-Jones and Cecilia Bottomley

Table 3.1 Terminology used in early pregnancy assessment

Term Definition Notes

(a) (b) (c)

Bleeding Score: please circle as appropriate

Chapter 3: Diagnosis of Miscarriage

Diagnostic criteria Gestation by Last Explanation

GS < doubled and no FH Miscarriage

(a) (b) Figure 3.4 Diagnosing miscarriage.

Chapter 3: Diagnosis of Miscarriage

Soft marker Image Description

Subchorionic haematoma Hypoechoic, crescent-shaped area separating the

Chorionic bumps Irregular, hyperechogenic bulge from the