Transvaginal ultrasound Diagnosis of Ectopic pregnancy Pregnancy is definitely diagnosed by demonstrating intrauterine sac. - A normal intrauterine sac appears regular and well defined on ultrasound. So ectopic pregnancy can be diagnosed by demonstrating the absence of the intrauterine sac. In a woman in whom ectopic pregnancy is suspected because of pain, bleeding and positive pregnancy test, performance of vaginal sonography is the logical first step. If the sonography demonstrates live intrauterine fetus then ectopic pregnancy is extremely unlikely. Alternatively if the uterus is empty, an ectopic pregnancy can be diagnosed based on the visualization of an adnexal mass separate from the ovaries. 3-hCG hormones also play an impoant role in the diagnosis of pregnancy. fi HCG is a hormone secreted during pregnancy. It is positive in viually 100% of ectopic pregnancies. However, a positive test only confirms pregnancy and does not indicate whether it is intrauterine or extrauterine. In normal pregnancy pHCG should double up every 2 days but in ectopic pregnancy the rate of increase of fl hCG is slow. 13 hCG litres and ultrasound complement one another in detecting ectopic pregnancy and have led to earlier detection. By correlating fl hCG titres with ultrasound .findings an ectopic pregnancy can often be differentiated.from intrauterine pregnancy. An intrauterine sac should be visible by transvaginal ultrasound when the p hCG is approximately 1000 ml p/m1 and by transabdominal ultrasound approximately 1 week later when the fi hCG is 1800-3600 ?nip/int. Thus when an empty uterine cavity is seen with a 13 hCG litre above this threshold, the patient is likely to have an ectopic pregnancy. An empty cavity is less of a concern when a fihCG below this threshold is obtained. Serum progesterone measuremen A single measurement of serum progesterone may sometimes clarify the diagnosis when ectopic pregnancy is suspected, but Its accuracy is crude and the customary thresholds are < 5 ng/m and > 25 'tend. i.e.a value exceeding 25 ng/m1 excludes ectopic pregnancy with 97.5% sensitivity, value below 5 ng/ml occur in only .3 percent of normal regnancies. So normal pregnancies can be excluded if the progesterone level is below 5%. Surgical diagnosis of ectopic pregnancy :- Laparoscopy Direct visualization of the ,fallopian tubes and pelvis by diagnostic laparoscopy offers a reliable diagnosis in most cases of suspected ectopic pregnancy and a ready transition to definitive operative therapy. At times, identification of an early unruptured tubal pregnancy may be difficult even if the tube is .fully visualized. Inspite of the low morbidity and quick recovery time, laparoscopy usually is performed when, on the basis of noninvasive test or curettage results, the diagnosis of ectopic pregnancy is fairly ceain and medical therapy is not planned. In these cases laporoscopy is used both for therapeutic and diagnostic purpose. Laparotomy Open abdominal surgery is preferred when the woman is hemodynamically unstable or when laparoscopy is not feasible. Laparotomy should not be delayed while laparoscopy is performed in a woman with obvious abdominal hemorrhage that required immediate definitive treatment. Culdocentesis Culdocentesis is the transvaginal passage of a needle into the posterior cul-de-sac in order to determine whether free blood is present in the abdomen. This procedure is useful in the diagnosis of intraperitoneal bleeding. This procedure will reveal nonclotting blood if intra-abdominal bleeding has occurred. If culdocentesis is positive, laparoscopy or laparotomy should be performed immediately. Indeed, some argue that the main purpose of culdocentesis is, not in diagnosis but to better prioritize patients so that those with positive culdocentensis are taken immediately to the operating room. More on imaging procedures used in the diagnosis of ectopic pregnancy Vaginal sonography There has been much improvement in the early diagnosis of ectopic pregnancy using vaginal sonography. Its use results in earlier and more specific diagnosis of uterine pregnancy than abdominal sonography and it has become the imaging method of choice in early pregnancy. Abdominal sonography:- Id entification of pregnancy products in the fallopian tube.