Emergency Radiology

, Volume 25, Issue 1, pp 61–72 | Cite as

First-trimester emergencies: a radiologist’s perspective

  • Catherine H. PhillipsEmail author
  • Jeremy R. Wortman
  • Elizabeth S. Ginsburg
  • Aaron D. Sodickson
  • Peter M. Doubilet
  • Bharti Khurana
Review Article


The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.


First-trimester emergency Ultrasound Ectopic pregnancy Assisted reproductive technology 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Kaplan B et al (1996) Ectopic pregnancy: prospective study with improved diagnostic accuracy. Annuals of Emergency Medicine 28(1):10–17CrossRefGoogle Scholar
  2. 2.
    Stovall TG et al (1990) Emergency department diagnosis of ectopic pregnancy. Ann Emerg Med 19(10):1098–1103PubMedCrossRefGoogle Scholar
  3. 3.
    Casanova BC et al (2009) Prediction of outcome in women with symptomatic first-trimester pregnancy: focus on intrauterine rather than ectopic gestation. J Women’s Health (Larchmt) 18(2):195–200CrossRefGoogle Scholar
  4. 4.
    Barnhart KT et al (2002) Presumed diagnosis of ectopic pregnancy. Obstet Gynecol 100(3):505–510PubMedGoogle Scholar
  5. 5.
    Condous G et al (2005) Diagnostic accuracy of varying discriminatory zones for the prediction of ectopic pregnancy in women with a pregnancy of unknown location. Ultrasound Obstet Gynecol 26(7):770–775PubMedCrossRefGoogle Scholar
  6. 6.
    Treloar AE et al (1967) Variation of the human menstrual cycle through reproductive life. Int J Fertil 12(1 Pt 2):77–126PubMedGoogle Scholar
  7. 7.
    Sherman BM, Korenman SG (1975) Hormonal characteristics of the human menstrual cycle throughout reproductive life. J Clin Invest 55(4):699–706PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Doubilet PM (2014) Ultrasound evaluation of the first trimester. Radiol Clin N Am 52(6):1191–1199PubMedCrossRefGoogle Scholar
  9. 9.
    Nagy S et al (2003) Clinical significance of subchorionic and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol 102(1):94–100PubMedGoogle Scholar
  10. 10.
    Bennett GL et al (1996) Subchorionic hemorrhage in first-trimester pregnancies: prediction of pregnancy outcome with sonography. Radiology 200(3):803–806PubMedCrossRefGoogle Scholar
  11. 11.
    Trop I, Levine D (2001) Hemorrhage during pregnancy: sonography and MR imaging. AJR Am J Roentgenol 176(3):607–615PubMedCrossRefGoogle Scholar
  12. 12.
    Thonneau PF, Almont T (2008) Contraceptive efficacy of intrauterine devices. Am J Obstet Gynecol 198(3):248–253PubMedCrossRefGoogle Scholar
  13. 13.
    Brahmi D et al (2012) Pregnancy outcomes with an IUD in situ: a systematic review. Contraception 85(2):131–139PubMedCrossRefGoogle Scholar
  14. 14.
    Kim SK et al (2010) The prognosis of pregnancy conceived despite the presence of an intrauterine device (IUD). J Perinat Med 38(1):45–53PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Ganer H et al (2009) Pregnancy outcome in women with an intrauterine contraceptive device. Am J Obstet Gynecol 201(4):381 e1–e5PubMedCrossRefGoogle Scholar
  16. 16.
    Boortz HE et al (2012) Migration of intrauterine devices: radiologic findings and implications for patient care. Radiographics 32(2):335–352PubMedCrossRefGoogle Scholar
  17. 17.
    Epperly TD, Fogarty JP, Hodges SG (1989) Efficacy of routine postpartum uterine exploration and manual sponge curettage. J Fam Pract 28(2):172–176PubMedGoogle Scholar
  18. 18.
    Sheiner E et al (2005) Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med 18(3):149–154PubMedCrossRefGoogle Scholar
  19. 19.
    Sellmyer MA et al (2013) Physiologic, histologic, and imaging features of retained products of conception. Radiographics 33(3):781–796PubMedCrossRefGoogle Scholar
  20. 20.
    Kamaya A et al (2009) Retained products of conception: spectrum of color Doppler findings. J Ultrasound Med 28(8):1031–1041PubMedCrossRefGoogle Scholar
  21. 21.
    Ustunyurt E et al (2008) Role of transvaginal sonography in the diagnosis of retained products of conception. Arch Gynecol Obstet 277(2):151–154PubMedCrossRefGoogle Scholar
  22. 22.
    Durfee SM et al (2005) The sonographic and color Doppler features of retained products of conception. J Ultrasound Med 24(9):1181–1186 quiz 1188-9PubMedCrossRefGoogle Scholar
  23. 23.
    Jacobs PA et al (1982) Complete and partial hydatidiform mole in Hawaii: cytogenetics, morphology and epidemiology. Br J Obstet Gynaecol 89(4):258–266PubMedCrossRefGoogle Scholar
  24. 24.
    Seckl MJ, Sebire NJ, Berkowitz RS (2010) Gestational trophoblastic disease. Lancet 376(9742):717–729PubMedCrossRefGoogle Scholar
  25. 25.
    Hou JL et al (2008) Changes of clinical features in hydatidiform mole: analysis of 113 cases. J Reprod Med 53(8):629–633PubMedGoogle Scholar
  26. 26.
    Fowler DJ et al (2006) Routine pre-evacuation ultrasound diagnosis of hydatidiform mole: experience of more than 1000 cases from a regional referral center. Ultrasound Obstet Gynecol 27(1):56–60PubMedCrossRefGoogle Scholar
  27. 27.
    Woo JS et al (1983) Sonographic appearances of the partial hydatidiform mole. J Ultrasound Med 2(6):261–264PubMedCrossRefGoogle Scholar
  28. 28.
    Dhanda S, Ramani S, Thakur M (2014) Gestational trophoblastic disease: a multimodality imaging approach with impact on diagnosis and management. Radiol Res Pract 2014:842751PubMedPubMedCentralGoogle Scholar
  29. 29.
    Wagner BJ, Woodward PJ, Dickey GE (1996) From the archives of the AFIP. Gestational trophoblastic disease: radiologic-pathologic correlation. Radiographics 16(1):131–148PubMedCrossRefGoogle Scholar
  30. 30.
    Allen SD et al (2006) Radiology of gestational trophoblastic neoplasia. Clin Radiol 61(4):301–313PubMedCrossRefGoogle Scholar
  31. 31.
    Ngan HY et al (2003) Gestational trophoblastic neoplasia, FIGO 2000 staging and classification. Int J Gynaecol Obstet 83(Suppl 1):175–177PubMedCrossRefGoogle Scholar
  32. 32.
    Kohorn EI (2002) Negotiating a staging and risk factor scoring system for gestational trophoblastic neoplasia. A progress report. J Reprod Med 47(6):445–450PubMedGoogle Scholar
  33. 33.
    Practice Committee of American Society for Reproductive Medicine (2013) Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril 100(3):638–644CrossRefGoogle Scholar
  34. 34.
    Barnhart KT (2009) Clinical practice. Ectopic pregnancy. N Engl J Med 361(4):379–387PubMedCrossRefGoogle Scholar
  35. 35.
    Lin EP, Bhatt S, Dogra VS (2008) Diagnostic clues to ectopic pregnancy. Radiographics 28(6):1661–1671PubMedCrossRefGoogle Scholar
  36. 36.
    Creanga AA et al (2011) Trends in ectopic pregnancy mortality in the United States: 1980–2007. Obstet Gynecol 117(4):837–843PubMedCrossRefGoogle Scholar
  37. 37.
    Centers for Disease Control and Prevention (1995) Ectopic pregnancy—United States, 1990–1992. MMWR Morb Mortal Wkly Rep 44(3):46–48Google Scholar
  38. 38.
    Bouyer J et al (2002) Sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. Hum Reprod 17(12):3224–3230PubMedCrossRefGoogle Scholar
  39. 39.
    Webb EM, Green GE, Scoutt LM (2004) Adnexal mass with pelvic pain. Radiol Clin N Am 42(2):329–348PubMedCrossRefGoogle Scholar
  40. 40.
    de Bennetot M et al (2012) Fertility after tubal ectopic pregnancy: results of a population-based study. Fertil Steril 98(5):1271–1276 e1–e3PubMedCrossRefGoogle Scholar
  41. 41.
    Alexander JM et al (1996) Treatment of the small unruptured ectopic pregnancy: a cost analysis of methotrexate versus laparoscopy. Obstet Gynecol 88(1):123–127PubMedCrossRefGoogle Scholar
  42. 42.
    Hajenius PJ et al (1997) Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Lancet 350(9080):774–779PubMedCrossRefGoogle Scholar
  43. 43.
    Moawad NS et al (2010) Current diagnosis and treatment of interstitial pregnancy. Am J Obstet Gynecol 202(1):15–29PubMedCrossRefGoogle Scholar
  44. 44.
    Ng S et al (2009) Laparoscopic management of 53 cases of cornual ectopic pregnancy. Fertil Steril 92(2):448–452PubMedCrossRefGoogle Scholar
  45. 45.
    American College of, O. and Gynecologists, ACOG Practice Bulletin No. 94: Medical management of ectopic pregnancy. Obstet Gynecol, 2008 111(6):1479–85Google Scholar
  46. 46.
    Panelli DM, Phillips CH, Brady PC (2015) Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. Fertility Research and Practice 1(15):1–20Google Scholar
  47. 47.
    Hofmann HM et al (1987) Cervical pregnancy: case reports and current concepts in diagnosis and treatment. Arch Gynecol Obstet 241(1):63–69PubMedCrossRefGoogle Scholar
  48. 48.
    Chukus A et al (2015) Uncommon implantation sites of ectopic pregnancy: thinking beyond the complex adnexal mass. Radiographics 35(3):946–959PubMedCrossRefGoogle Scholar
  49. 49.
    (1985) A multinational case-control study of ectopic pregnancy. The World Health Organization’s special programme of research, development and research training in human reproduction: task force on intrauterine devices for fertility regulation. Clin Reprod Fertil 3(2):131–143Google Scholar
  50. 50.
    Ko PC et al (2012) Twenty-one years of experience with ovarian ectopic pregnancy at one institution in Taiwan. Int J Gynaecol Obstet 119(2):154–158PubMedCrossRefGoogle Scholar
  51. 51.
    Di Luigi G et al (2012) Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report. Clin Exp Obstet Gynecol 39(3):390–393Google Scholar
  52. 52.
    Kiran G, Guven AM, Kostu B (2005) Systemic medical management of ovarian pregnancy. Int J Gynaecol Obstet 91(2):177–178PubMedCrossRefGoogle Scholar
  53. 53.
    Nadarajah S, Sim LN, Loh SF (2002) Laparoscopic management of an ovarian pregnancy. Singap Med J 43(2):095–096Google Scholar
  54. 54.
    Eskandar O (2010) Conservative laparoscopic management of a case of ruptured ovarian ectopic pregnancy by using a Harmonic scalpel. J Obstet Gynaecol 30(1):67–69PubMedCrossRefGoogle Scholar
  55. 55.
    Poole A, Haas D, Magann EF (2012) Early abdominal ectopic pregnancies: a systematic review of the literature. Gynecol Obstet Investig 74(4):249–260CrossRefGoogle Scholar
  56. 56.
    Molinaro TA, Barnhart KT (2007) Ectopic pregnancies in unusual locations. Semin Reprod Med 25(2):123–130PubMedCrossRefGoogle Scholar
  57. 57.
    Atrash HK, Friede A, Hogue CJ (1987) Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 69(3 Pt 1):333–337PubMedGoogle Scholar
  58. 58.
    Beddock R et al (2004) Diagnosis and current concepts of management of advanced abdominal pregnancy. Gynecol Obstet Fertil 32(1):55–61PubMedCrossRefGoogle Scholar
  59. 59.
    Gudu W, Bekele D (2015) A pre-operatively diagnosed advanced abdominal pregnancy with a surviving neonate: a case report. J Med Case Rep 9:228PubMedPubMedCentralCrossRefGoogle Scholar
  60. 60.
    Godin PA, Bassil S, Donnez J (1997) An ectopic pregnancy developing in a previous caesarian section scar. Fertil Steril 67(2):398–400PubMedCrossRefGoogle Scholar
  61. 61.
    Jurkovic D et al (2003) First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 21(3):220–227PubMedCrossRefGoogle Scholar
  62. 62.
    Rotas MA, Haberman S, Levgur M (2006) Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 107(6):1373–1381PubMedCrossRefGoogle Scholar
  63. 63.
    Timor-Tritsch IE et al (2015) Cesarean scar pregnancies: experience of 60 cases. J Ultrasound Med 34(4):601–610PubMedCrossRefGoogle Scholar
  64. 64.
    Chandra A, Copen CE, Stephen EH Infertility service use in the United States: data from the National Survey of Family Growth, 1982–2010. Natl Health Stat Report 2014(73):1–21Google Scholar
  65. 65.
    United S (1992) Fertility Clinic Success Rate and Certification Act of 1992: Public Law 102-493. US Statut Large, 106:3146–3152Google Scholar
  66. 66.
    Baron KT et al (2013) Emergent complications of assisted reproduction: expecting the unexpected. Radiographics 33(1):229–244PubMedCrossRefGoogle Scholar
  67. 67.
    Smolinski SE, Kreychman A, Catanzano T (2015) Ovarian torsion: multimodality review of imaging characteristics. J Comput Assist Tomogr 39(6):922–924PubMedCrossRefGoogle Scholar
  68. 68.
    Sasaki KJ, Miller CE (2014) Adnexal torsion: review of the literature. J Minim Invasive Gynecol 21(2):196–202PubMedCrossRefGoogle Scholar
  69. 69.
    Desai SK, Allahbadia GN, Dalal AK (1994) Ovarian torsion: diagnosis by color Doppler ultrasonography. Obstet Gynecol 84(4 Pt 2):699–701PubMedGoogle Scholar
  70. 70.
    Hasson J et al (2010) Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol 202(6):536 e1–e6PubMedCrossRefGoogle Scholar
  71. 71.
    Bider D et al (1991) Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 173(5):363–366PubMedGoogle Scholar
  72. 72.
    Zanetta G et al (2003) A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy. BJOG 110(6):578–583PubMedCrossRefGoogle Scholar
  73. 73.
    Mashiach S et al (1990) Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 53(1):76–80PubMedCrossRefGoogle Scholar
  74. 74.
    Albayram F, Hamper UM (2001) Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med 20(10):1083–1089PubMedCrossRefGoogle Scholar
  75. 75.
    Graif M et al (1984) Torsion of the ovary: sonographic features. AJR Am J Roentgenol 143(6):1331–1334PubMedCrossRefGoogle Scholar
  76. 76.
    Lee EJ et al (1998) Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med 17(2):83–89PubMedCrossRefGoogle Scholar
  77. 77.
    Shadinger LL, Andreotti RF, Kurian RL (2008) Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med 27(1):7–13PubMedCrossRefGoogle Scholar
  78. 78.
    Ben-Ami M, Perlitz Y, Haddad S (2002) The effectiveness of spectral and color Doppler in predicting ovarian torsion. A prospective study. Eur J Obstet Gynecol Reprod Biol 104(1):64–66PubMedCrossRefGoogle Scholar
  79. 79.
    Barrenetxea G et al (2007) Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 87(2):417 e9–e15PubMedCrossRefGoogle Scholar
  80. 80.
    Rojansky N, Schenker JG (1996) Heterotopic pregnancy and assisted reproduction—an update. J Assist Reprod Genet 13(7):594–601PubMedCrossRefGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2017

Authors and Affiliations

  1. 1.Department of RadiologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of Infertility and Reproductive Surgery, Obstetrics and GynecologyBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA

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