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Transvaginal ultrasound recommended for suspected ectopic pregnancy

Transvaginal sonography is the best way to evaluate women with suspected ectopic pregnancy, a study indicates.

The study

Systematic review looked at studies of approaches to evaluate suspected ectopic pregnancy, comparing patient history, physical examination, laboratory values and transvaginal sonography with either direct surgical visualisation or clinical follow-up to prove ectopic pregnancy was not missed. Researchers analysed 14 studies that each included between 141 and 6,621 women with abdominal pain, vaginal bleeding or a clinical suspicion of ectopic pregnancy during early gestation. None of the women had evidence of hypovolemic shock.

The findings

Transvaginal sonography detected ectopic pregnancy with a sensitivity of 0.88 and specificity of 0.99;  the presence of an adnexal mass in the absence of intrauterine pregnancy on transvaginal sonography increased the likelihood of ectopic pregnancy with a positive likelihood ratio (LR+) of 111. By comparison, all components of patient history had limited clinical value, with LR+ ratios less than 1.5, while physical examination findings of cervical motion tenderness on digital vaginal examination (LR+ 4.9) and abdominal pain with cough or tenderness during light palpation (LR+ 4.2–4.5) were the most informative physical examination findings. Presence of adnexal mass on bimanual examination also suggested ectopic pregnancy, with a LR+ of 2.4. No single serum human chorionic gonadotropin (hCG) threshold could be established for diagnosing ectopic pregnancy.

What this means for GPs

The researchers say their findings confirm patient history and clinical examination alone cannot be relied on to rule in or out the possibility of ectopic pregnancy. They conclude: ‘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.’

JAMA 2013; 309: 1722-1729

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