gynecology and obstetrics
Ectopic Pregnancy
Diagnosis of Ectopic Pregnancy
Quantitative serum beta–human chorionic gonadotropin(beta-hCG) Pelvic ultrasonography Sometimes laparoscopy Ectopic pregnancy is suspected in any female patient of reproductive age with pelvic pain, vaginal bleeding, or unexplained syncope or hemorrhagic shock, regardless of menstrual, contraceptive, and sexual history. Findings of physical (including pelvic) examination are neither sensitive nor specific. A ruptured ectopic pregnancy is a surgical emergency because it causes maternal hemorrhage and risk of death; prompt diagnosis is essential. Suspect ectopic pregnancy in any female patient of reproductive age with pelvic pain, vaginal bleeding, or unexplained syncope or hemorrhagic shock, regardless of menstrual, contraceptive, and sexual history and examination findings. The first step in diagnosis is a urine pregnancy test, which is approximately 99% sensitive for pregnancy (ectopic and otherwise). If urine beta-hCG is negative and if clinical findings do not strongly suggest ectopic pregnancy, further evaluation is unnecessary unless symptoms recur or worsen. If urine beta-hCG is positive or if clinical findings strongly suggest ectopic pregnancy and pregnancy may be too early to detect based on urine beta-hCG, quantitative serum beta-hCG and pelvic ultrasonography should be done. If ultrasonography detects an intrauterine pregnancy, a concurrent ectopic pregnancy (heterotopic pregnancy) is extremely unlikely except in women who have used assisted reproductive technologies (which increase risk of heterotopic pregnancy, although it is still rare in these patients). However, cornual and interstitial pregnancies may appear to be intrauterine pregnancies on ultrasound. Ultrasonographic findings diagnostic of an intrauterine pregnancy are a gestational sac with a yolk sac or an embryo (with or without a heartbeat) within the uterine cavity. In addition to absence of an intrauterine pregnancy, ultrasonographic findings suggesting ectopic pregnancy include a complex (mixed solid and cystic) pelvic mass, particularly in the adnexa, and echogenic free fluid in the cul-de-sac. If serum beta-hCG is above a certain level (called the discriminatory zone), ultrasonography should be able to detect a gestational sac with a yolk sac; the presence of a yolk sac confirms an intrauterine pregnancy. The appropriate hCG threshold for the discriminatory zone for women with suspected ectopic pregnancy has been reevaluated. To minimize overdiagnosis of ectopic pregnancy and preserve desired intrauterine pregnancies, the recommended threshold has been increased to 3500 mIU/mL) ( Diagnosis reference ). If the beta-hCG level is below the discriminatory zone and ultrasonography is unremarkable, patients may have an early intrauterine pregnancy or an ectopic pregnancy. If clinical evaluation suggests ectopic pregnancy with active bleeding or rupture (eg, signs of significant hemorrhage or peritoneal irritation), diagnostic laparoscopy may be necessary for diagnosis and treatment. If ectopic pregnancy has not been confirmed and the patient is stable, serum levels of beta-hCG are measured serially on an outpatient basis (typically every 2 days). Normally, the level doubles every 1.4 to 2.1 days up to 41 days; in ectopic pregnancy (and in potential spontaneous abortions), levels may be lower than expected by dates and usually do not double as rapidly. If beta-hCG levels do not increase as expected or if they decrease, diagnosis of Spontaneous Abortion or ectopic pregnancy is likely. Vaginal Bleeding During Early Pregnancy is common in early pregnancy (see table Pelvic Pain During Early Pregnancy or pressure is also a common pregnancy symptom (see table 