Ultrasound Evaluation

Transvaginal sonography is more sensitive and specific than transabdominal sonography in evaluating first-trimester pregnancies. Transvaginal sonography can differentiate between intrauterine pregnancy (IUP) and EP in 75 percent of pregnant women who present with pain or bleeding. Transvaginal sonography has 69 percent sensitivity and 99 percent specificity for diagnosing EP.9 If a definite IUP or EP is seen, the workup is complete. The finding of an IUP rules out the diagnosis of EP as long as there is a single gestation. Patients on fertility drugs may have multiple gestations. The presence of a yolk sac, fetal pole, or cardiac activity within an intrauterine gestational sac confirms the presence of an IUP. Visualization of a gestational sac alone should not be relied upon to make the diagnosis of an early IUP unless a double decidual sign is clearly seen. The presence of an EP is immediately established in about 15 percent, by either visualization of cardiac activity or an obvious gestational sac, yolk sac, and fetal pole outside of the uterus. The finding of a tubal ring in the adnexa is highly suggestive of an EP and may be frequently found in those with EP (Fig 109-10). An EP is strongly suspected when pelvic free fluid and/or a complex adnexal mass is seen. 10H and I2 Consider ordering a "formal"

pelvic ultrasound when no IUP is seen on bedside sonography, since the ancillary findings of EP may be subtle.

FIG. 109-10. Tubal ring. This represents hypertrophy of the left fallopian tube in a patient with an ectopic pregnancy.

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