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PV card: Ectopic pregnancy

Posted May 09 2013 12:00am

Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy. A recent JAMA systematic review , from The Rational Clinical Examination series, looked to risk-stratify women in early pregnancy presenting with abdominal pain or vaginal bleeding for ectopic pregnancy. The authors, Crochet et al, set out to identify the accuracy and precision of elements in the history, physical examination, beta hCG, and ultrasound in ectopic pregnancy. 

The systematic review consisted of 14 studies (n=12,101). The search consisted only of English language studies from 1965 to 2012 in which ectopic pregnancy was the final diagnosis with 100 or more patients per article. The summary prevalence of ectopic pregnancy was 15% (95% CI, 10-22%) in women presenting with abdominal pain or vaginal bleeding. 

History and Physical:
  • Patients symptoms had limited clinical value. Most symptoms had an unhelpful positive LR of less than 1.5.
  • The absence of cervical motion tenderness, peritoneal signs, adnexal mass, or adnexal tenderness did not significantly decrease likelihood of ectopic pregnancy.
  • In descending order, the most significant physical exam findings were: 
    • Cervical motion tenderness (Positive LR = 4.9)
    • Peritoneal findings (Positive LR = 4.2-4.5)
    • Adnexal mass (Positive LR = 2.4)
Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac

Ultrasound:
  • Findings of an intrauterine pregnancy (IUP) such as gestational sac or fetal pole ruled out ectopic pregnancy, except in rare cases of heterotropic prengnacy.
  • Bedside ultrasound is the single most useful diagnostic test. Positive LR = 111. 
hCG:
  • The "discriminatory zone" continues to be debated - no consensus on the number.
  • A one-time hCG level does not rule out ectopic pregnancy.



Feel free to download this card and print on a 4'' x 6'' index card. [ MS Word ] [ PDF ] See  other Paucis Verbis cards .
Javier Benítez  


Javier Benítez, MD ( @jvrbntz )

Reference
Crochet JR, et al. Does This Woman Have an Ectopic Pregnancy? The Rational Clinical Examination Systematic Review. JAMA.2013;309(16):1722-1729. PMID [ 23613077 ]

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