Transvaginal Ultrasound Best to Find Ectopic Pregnancy | Medpage Today
The Patient Portal Conundrum LATEST MEDICAL NEWS OB/Gyn 1 Comment --> Transvaginal Ultrasound Best to Find Ectopic Pregnancy MedpageToday Medpage Today --> --> savesaved Loading the player... For best viewing, click the bottom right corner for full screen. by Salynn Boyles Salynn Boyles Contributing Writer, MedPage Today April 23, 2013
This article is a collaboration between MedPage Today and: Action Points In women with abdominal pain or vaginal bleeding during early pregnancy, transvaginal sonography appears to be the single best diagnostic method for evaluating suspected ectopic pregnancy.Point out that the authors recommend that in the presence of abdominal pain or vaginal bleeding during early pregnancy, a transvaginal sonogram and quantitative serum human chorionic gonadotropin (hCG) testing should be done.
In women with abdominal pain or vaginal bleeding during early pregnancy, transvaginal sonography appears to be the single best diagnostic method for evaluating suspected ectopic pregnancy, a new meta-analysis found.
In a review of 14 studies with just over 12,000 patients, "when the transvaginal sonogram indicated the presence of an adnexal mass and absence of an intrauterine pregnancy, the summary [likelihood ratio] for an ectopic pregnancy was 111 (95% CI 12 to 1,028), reported Monique Chireau, MD, MPH, of Duke University Medical Center, and colleagues.
The authors also stated that patient history and clinical examination alone are insufficient to indicate or eliminate the possibility of ectopic pregnancy, emphasizing that "the presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum human chorionic gonadotropin (hCG) testing," they wrote in the April 24 issue of the Journal of the American Medical Association.
Studies suggest that as many as 2.6% of pregnancies are ectopic, and in the vast majority of these cases (93% to 97%) implantation of the fertilized ovum occurs within the distal portion of the fallopian tube, they said.
Abdominal pain and bleeding are common with ectopic pregnancy, but many patients do not exhibit these symptoms.
"Fewer than half of the women with an ectopic pregnancy have the classically described symptoms of abdominal pain and vaginal bleeding. In fact, these symptoms are more likely to indicate miscarriage," they wrote.
Even though transvaginal sonography and hCG testing are now routinely used in the work up of women suspected of having an ectopic pregnancy, between 8% and 31% of those who present with pain or vaginal bleeding will be initially diagnosed as a pregnancy of unknown location, Chireau told MedPage Today.
Between 7% and 20% of these patients have ectopic pregnancies, but as many as 40% of them are sent home from initial medical visits without a definite diagnosis, she added.
"Ectopic pregnancy is the leading cause of first trimester maternal death," Chireau said. "This is a diagnosis you don't want to miss, but the truth is we could probably do a better job of identifying these women."
The analysis was an effort to better understand the accuracy of patient history, clinical evaluation and diagnostic testing in the identification of patients with ectopic pregnancies.
It included prospective studies with 100 or more pregnant women who were experiencing abdominal pain or vaginal bleeding at presentation. The studies compared patient history, physical examination, laboratory values and sonography with either surgery to confirm ectopic pregnancy or clinical follow-up to show that ectopic pregnancy was not missed.
The authors reported that patient history and symptoms were of only limited clinical value. All components of patient history and symptoms had a positive likelihood ratio (LR+) of less than 1.5.
However, the presence of cervical motion tenderness during a digital vaginal examination (LR+ 4.9, 95% CI, 1.7 to 14) or the finding of abdominal pain with cough or tenderness during light palpation (LR range 4.2 to 4.5) were the most informative physical examination findings.
A lack of adnexal abnormalities on transvaginal sonography decreases the likelihood of ectopic pregnancy (negative LR 0.12, 95% CI 0.03 to 0.55).
They pointed out that current studies have not established a single hCG level that is diagnostic of ectopic pregnancy and that no single quantitative hCG value or reference range reliably predicted a viable intrauterine pregnancy.
The analysis confirmed that in stable patients without evidence of tubal rupture, appropriate evaluation of suspected ectopic pregnancy should include both serum hCG testing and transvaginal ultrasound.
"Access is certainly an issue," she said. "Many emergency departments don't offer transvaginal ultrasounds. This is especially true after hours at smaller hospitals and in more remote areas. But a key message is if this modality isn't available, the patient needs to be transferred to a facility that can do it."
Another key finding from the review is that if both the sonogram and hCG test are inconclusive, a follow up exam within 48 hours is critical. "98% of women with a viable pregnancy will show a significant increase in hCG during this 48-hour period. If hCG is not rising normally, that raises the suspicion of an ectopic pregnancy," she said.
Chireau added clinicians should consider admitting a woman to the hospital if she is at high risk for being lost to follow-up.
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