Terminology for describing normally sited and ectopic pregnancies on ultrasound: ESHRE recommendations for good practice

Abstract

Study question: What recommendations can be provided to improve terminology for normal and ectopic pregnancy description on ultrasound?

Summary answer: The present ESHRE document provides 17 consensus recommendations on how to describe normally sited and different types of ectopic pregnancies on ultrasound.

What is known already: Current diagnostic criteria stipulate that each type of ectopic pregnancy can be defined by clear anatomical landmarks which facilitates reaching a correct diagnosis. However, a clear definition of normally sited pregnancies and a comprehensive classification of ectopic pregnancies are still lacking.

Study design size duration: A working group of members of the ESHRE Special Interest Group in Implantation and Early Pregnancy (SIG-IEP) and selected experts in ultrasound was formed in order to write recommendations on the classification of ectopic pregnancies.

Participants/materials setting methods: The working group included nine members of different nationalities with internationally recognised experience in ultrasound and diagnosis of ectopic pregnancies on ultrasound. This document is developed according to the manual for development of ESHRE recommendations for good practice. The recommendations were discussed until consensus by the working group, supported by a survey among the members of the ESHRE SIG-IEP.

Main results and the role of chance: A clear definition of normally sited pregnancy on ultrasound scan is important to avoid misdiagnosis of uterine ectopic pregnancies. A comprehensive classification of ectopic pregnancy must include definitions and descriptions of each type of ectopic pregnancy. Only a classification which provides descriptions and diagnostic criteria for all possible locations of ectopic pregnancy would be fit for use in routine clinical practice. The working group formulated 17 recommendations on the diagnosis of the different types of ectopic pregnancies on ultrasound. In addition, for each of the types of ectopic pregnancy, a schematic representation and examples on 2D and 3D ultrasound are provided.

Limitations reasons for caution: Owing to the limited evidence available, recommendations are mostly based on clinical and technical expertise.

Wider implications of the findings: This document is expected to have a significant impact on clinical practice in ultrasound for early pregnancy. The development of this terminology will help to reduce the risk of misdiagnosis and inappropriate treatment.

Study funding/competing interests: The meetings of the working group were funded by ESHRE. T.T. declares speakers' fees from GE Healthcare. The other authors declare that they have no conflict of interest.

Trial registration number: N/A.

Disclaimer: This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and where relevant based on the scientific evidence available at the time of preparation. ESHRE's GPRs should be used for informational and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. Furthermore, ESHRE's GPRs do not constitute or imply the endorsement, recommendation or favouring of any of the included technologies by ESHRE.

Keywords: ESHRE; early pregnancy; ectopic pregnancy; guideline; terminology; ultrasound.

Figure 1.

The normally sited pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 2.

Partial caesarean scar pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 3.

Complete caesarean scar pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 4.

Partial cervical ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 5.

Complete cervical ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 6.

Partial intramural ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 7.

Complete intramural ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 8.

Interstitial tubal ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image of an interstitial pregnancy confined to the interstitial tube; (d) 3D ultrasound image of an interstitial pregnancy protruding outside the uterus.

Figure 9.

Partial interstitial ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image; (d) 3D ultrasound image of more advanced pregnancy.

Figure 10.

Isthmic tubal ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 11.

Ampullary tubal ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) colour Doppler ultrasound image.

Figure 12.

Ovarian ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) colour Doppler ultrasound image.

Figure 13.

Abdominal ectopic pregnancy. (a) Schematic diagram; (b) 2D ultrasound image; (c) colour Doppler ultrasound image.

Figure 14.

Rudimentary horn ectopic pregnancy in separate non-communicating rudimentary cornu. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image of unicornuate uterus.

Figure 15.

Rudimentary horn ectopic pregnancy in fused non-communicating rudimentary horn. (a) Schematic diagram; (b) 2D ultrasound image; (c) 3D ultrasound image.

Figure 16.

Residual ectopic pregnancy. (a) 2D ultrasound image showing a solid lesion separate to the ovary typical of residual ectopic pregnancy; (b) colour Doppler image showing a vascular corpus luteum and avascular residual ectopic pregnancy.

Figure 17.

Flow diagram illustrating how to evaluate the morphology of an ectopic pregnancy.

Figure 18.

How to measure an ectopic pregnancy on ultrasound scan.

Figure 19.

Semi-quantitative grading of haemoperitoneum. (a) Mild; (b) moderate; (c) severe. F, fluid; C, blood clot; PoD, pouch of Douglas; VUP, vesico-uterine pouch.

Figure 20.

Flow diagram illustrating how to classify an early pregnancy.