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The Rational Clinical Examination | Clinician's Corner

Does This Woman Have an Ectopic Pregnancy?  The Rational Clinical Examination Systematic Review

John R. Crochet, MD; Lori A. Bastian, MD, MPH; Monique V. Chireau, MD, MPH
JAMA. 2013;309(16):1722-1729. doi:10.1001/jama.2013.3914.
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Importance The rapid identification and accurate diagnosis of women who may have an ectopic pregnancy is critically important for reducing the maternal morbidity and mortality associated with this condition.

Objective To systematically review the accuracy and precision of the patient history, clinical examination, readily available laboratory values, and sonography in the diagnosis of ectopic pregnancy in women with abdominal pain or vaginal bleeding during early pregnancy.

Data Sources We conducted MEDLINE and EMBASE searches for English-language articles from 1965 to December 2012 reporting on the diagnosis of ectopic pregnancy.

Study Selection The analysis included prospective studies of 100 or more pregnant women with abdominal pain or vaginal bleeding that evaluated patient history, physical examination, laboratory values, and sonography compared with a reference standard of either (1) direct surgical visualization of ectopic pregnancy or (2) clinical follow-up for all pregnancies to prove that ectopic pregnancy was not missed. Of 10 890 articles identified by the search, 14 studies with 12 101 patients met the inclusion criteria.

Data Extraction and Synthesis Two authors (J.R.C. and M.V.C.) independently extracted data and assessed the quality of each study. A third author (L.A.B.) resolved any discrepancies.

Results All components of the patient history had a positive likelihood ratio (LR+) less than 1.5. The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography (LR+ 111; 95% CI, 12-1028; n = 6885), and the physical examination findings of cervical motion tenderness (LR+ 4.9; 95% CI, 1.7-14; n = 1435), an adnexal mass (LR+ 2.4; 95% CI, 1.6-3.7; n = 1378), and adnexal tenderness (LR+ 1.9; 95% CI, 1.0-3.5; n = 1435) all increase the likelihood of ectopic pregnancy. A lack of adnexal abnormalities on transvaginal sonography (negative LR [LR−] 0.12; 95% CI, 0.03-0.55; n = 6885) decreases the likelihood of ectopic pregnancy. Existing studies do not establish a single serum human chorionic gonadotropin (hCG) level that is diagnostic of ectopic pregnancy.

Conclusions and Relevance Transvaginal sonography is the single best diagnostic modality for evaluating women with suspected ectopic pregnancy. The presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum hCG testing.

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Figure. Transvaginal Sonographic Appearance of a Tubal Ectopic Pregnancy
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The transvaginal sonogram image was obtained in an asymptomatic woman 7 weeks and 4 days after her last menstrual period. A, The right tubal ectopic pregnancy can be seen in the transverse plane of the right adnexa as an echogenic ring (blue overlay) immediately lateral to the uterus (red overlay) and medial to the right ovary (purple overlay). A yolk sac and fetal pole can also be seen within the extrauterine gestational sac. The fetal pole was noted to measure 5.48 mm (6 weeks, 2 days) and a fetal heart rate of 123/min by M mode was detected (eFigures 13). B, The illustration shows the anteverted and anteflexed uterus (red outline) and transvaginal sonogram probe in the right lateral fornix. The sonographic plane of view (gray) is transverse and oblique through the right adnexa. The ectopic pregnancy (blue outline) is noted to be within the junction of the isthmic or ampullary portions of the right fallopian tube lateral to the uterus (red outline) and medial to the right ovary (purple outline).

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Original Article: Does This Woman Have an Ectopic Pregnancy?

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