Archivesof Arch Gynecol Obstet (1992) 252:5-9
Gynecology and Obstetrics
© Springer-Verlag1992
Culdocentesis is an obsolete diagnostic tool in suspected ectopic pregnancy M. Glezerman, F. Press, and M. Carpman Department of Obstetrics and Gynecology, Soroka University Hospital and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel Received February 26, 1992/Accepted April 7, 1992
Summary. We studied 332 patients with proven pregnancies. Prediction of hemoperitoneum by assessment of the Douglas pouch during bimanual examination had a false negative rate of 42.1%. The false negative rate for culdocentesis was 14.8%. It is therefore concluded that culdocentesis is not a useful tool in the diagnosis of suspected ectopic pregnancies. Key words: Ectopic pregnancy - Culdocentesis - Hemoperitoneum - Douglas pouch - Abstract Introduction The incidence of ectopic pregnancies is rising (Stabile and Grudzinska 1990) and ectopic pregnancy is now the leading cause of maternal mortality in the United States (Atrash et al. 1987). It has been pointed out that clinicians suspect ectopic pregnancies 10 times more often than these actually occur (Kadar et al. 1981). It is therefore tempting to perform a relatively easy procedure like culdocentesis in order to detect the presence of a hemoperitoneum. Culdocentesis is an easy procedure, requires no special instrumentation, can be performed in an office setting and the results are immediately available. No wonder, that this procedure has gained wide acceptance and has been used extensively to rule out intra-abdominal hemorrhage in general and ectopic pregnancy in particular. However, the procedure is not devoid of side effects, the most serious of them perhaps a false sense of security when a negative result is obtained. With the advent of sophisticated diagnostic methods such as sensitive radioimmunoassay for human chorionic gonadotrophins and high resolution ultrasound the value of this procedure has to be critically reassessed. The main aim of the present study is to address this issue.
Correspondence to." Prof. Dr. M. Glezerman (address see above)
6
M. Glezerman et al.
Materials and methods This retrospective study includes 332 women in whom ectopic pregnancy had been confirmed during laparoscopy or laparatomy. All of them had undergone bimanual examination of the Douglas pouch for prediction of the presence or absence of hemoperitoneum and 246 women had undergone culdocentesis as part of their work up. Patients with inconclusive results for culdocentesis or patients whose files did not provide sufficient information concerning the presence or absence of hemoperitoneum at surgery were excluded. At admission the mean length of pregnancy as defined by last menstrual period was 50.5 days (range 32-90 days). Hemoperitoneum was considered to be present if at surgery at least 50 ml of blood was noted. During bimanual examination before surgery an attempt was made to predict the presence of hemoperitoneum by assessment of the Douglas pouch. The presence of a hemoperitoneum was assumed if there was tenderness or fullness in the pouch of Douglas. Two hundred and forty-six patients then underwent culdocentesis under anesthesia. With the patient in Trendelenburg position, a 18 gauge needle attached to a 20 ml syringe was used to puncture the Douglas pouch. After insertion of the needle the operating table was tilted into anti-Trendelenburg position, the syringe was lifted so that the tip of the needle was as caudal as possible when the contens of the cul-de-sac were aspirated. The result was considered positive if non-clotting blood or blood with micro clots was aspirated. Culdocentesis was classified as negative when clear or blood-tinged fluid was aspirated and inconclusive when no aspirate could be obtained, FoUowing the procedure all patients underwent laparoscopy and/or laparatomy and various surgical procedures for treatment of their ectopic pregnancies.
Results Bimanual examination B i m a n u a l e x a m i n a t i o n was i n d i c a t i v e o f h e m o p e r i t o n e u m i n 190 of 332 cases. I n 57.9% of these, hemoperitoneum was present. However, hemoperitoneum was also p r e s e n t i n 4 2 . 1 % cases (false n e g a t i v e ) i n w h o m b i m a n u a l e x a m i n a t i o n was n o t i n d i c a t i v e o f h e m o p e r i t o n e u m ( T a b l e 1). T h e s e n s i t i v i t y o f t h e test w a s 57.9%.
Culdocentesis C u l d o c e n t e s i s w a s p o s i t i v e i n 201/236 cases ( s e n s i t i v i t y 8 5 . 2 % ) a n d false n e g a tive i n 1 4 . 8 % of 236 p a t i e n t s w i t h h e m o p e r i t o n e u m ( T a b l e 2). Table 1. Correlation between manual examination of Douglas pouch and presence/absence of hemoperitoneum in ectopic pregnancies Hemoperitoneum
Bimanual examination Positive
Negative
Total
Present Absent
183 (57.9%) 7 (43.8%)
133 (42.1%) 9 (56,2%)
316 16
Total
190 (100%)
142 (100%)
332
Chi-square: 0.736; P = > 0.736 (not significant)
Obsoleteness of culdocentesis
7
Table 2. Correlation between results of culdocentesis and presence/absence of hemoperitoneum in ectopic pregnancies Hemoperitoneum
Culdocentesis Positive
Negative
Total
Present Absent
201 (85.2%) 4 (40%)
35 (14.8%) 6 (60%)
236 10
Total
205
41
246
Chi-square: 11.03; P = > 0.9 (not significant) Table 3. Localization and stares of ectopic pregnancies in 246 patients Localization
Status Ruptured
Unruptured
Total
Abdomen Ovary Cornua Fallopian tube
0 3 3 142 (59.7%)
(1) 1 0 96 (40.3%)
1 4 3 238 (100%)
Total
148 (60.2%)
98 (39.8%)
246 (99.8%)
Table 4. Condition of structure hosting ectopic pregnancy and presence or absence of hemoperitoneum Hemoperitoneum
Condition Ruptured
Unruptured
Total
Present Absent
148 (100%) 0 (0%)
88 (89.8%) 10 (10.2%)
236 10
Total
148 (100%)
98 (100%)
246
Chi-square: 13.23; P = > 0.9 (not significant)
In 96.7% of patients the p r e g n a n c y was located in o n e of the fallopian tubes and 59.7% of these were f o u n d to be r u p t u r e d (Table 3). In total 60.2% of the ectopic pregnancies w e r e ruptured. In all 148 cases with r u p t u r e d ectopic pregnancies h e m o p e r i t o n e u m was present. H o w e v e r , h e m o p e r i t o n e n m was also present in 89.8% of patients with u n r u p t u r e d ectopic pregnancies. O n l y in 10 out of 246 w o m e n with ectopic p r e g n a n c y was t h e r e no h e m o p e r i t o n e u m at surgery (Table 4). In these ten cases the p r e g n a n c y was located in an u n r u p t u r e d fallopian tube. Culdocentesis was false positive in 4 o u t o f these 10 cases.
8
M, Glezerman et al.
Discussion
The most common indication for culdocentesis in the investigation of a suspected ectopic pregnancy is to assess the presence or absence of a hemoperitoneum. Since positive culdocentesis is highly predictive of hemoperitoneum it has been common practice at our department as in many other clinics to bypass laparoscopy in these cases and to proceed directly to laparotomy. This approach seemed reasonable as long as laparoscopy was considered mainly a diagnostic tool. This is no longer the case. Most patients with ectopic pregnancy can now be treated by laparoscopy (Pouly et al. 1986, Silva 1988, Vermesh et al. 1990). Culdocentesis with positive results will therefore not shorten the surgical procedure. On the other hand, negative results do not exclude the presence of hemoperitoneum nor do they indicate absence of an unruptured ectopic pregnancy. In our series the false negative rate for culdocentesis was nearly 15% and 60% in the series reported by Vermesh et al. 1990. Delay of treatment due to a sense of false security obtained by a negative result (equal to the false negative rate of this procedure) may put the patient in serious danger. We conclude that the sensitivity of culdocentesis is too low to permit reliable assessment of hemoperitoneum in cases of suspected ectopic pregnancy. The relatively small number of patients without hemoperitoneum in our study does not allow one to give a false positive rate for culdocentesis. This fact however, is a conclusion by itself: During the study period a total of 400 women with ectopic pregnancies underwent surgery. The present study includes 246 of these. Only in 23 of the 400 women wffh proven ectopic pregnancy (5.8%) was no blood present in the abdominal cavity at open surgery. Hemoperitoneum was present in the remaining 94.2%. It is remarkable that the majority of unruptured ectopic pregnancies are associated with hemoperitoneum (88/89 = 98.8%). Others (DeCherney et al. 1981, Romero et al. 1985) have reported a positive culdocentesis rate exceeding 60% in unruptured ectopic pregnancy. Tubal abortion is probably the most common reason for a hemoperitoneum in the presence of a unruptured ectopic pregnancy. Another conclusion which may be reached from the present study relates to the value of bimanual examination to assess the presence of hemoperitoneum. Our false negative rate exceeded 42% and a false positive result was obtained in 43.8%. Thus sensitivity of bimanual examination for the prediction of hemoperitoneum was rather low. The availability of rapid tests for H C G permit immediate diagnosis of pregnancy and high resolution ultrasound usually locates the amniotic sac. But these tools or the expertise to use them are not always available. We suggest that whenever an immediate exact diagnosis cannot be obtained and the symptomatology of the patient permits, expectant management or laparoscopy should be employed. We feel that culdocentesis does not offer any diagnostic advantage and its results may be dangerously misleading. Acklowledgement. The authors wish to thank Dr. Ilana Shoham for assistance in statistical analysis of the data.
Obsoleteness of culdocentesis
9
References Atrash HK, Friede A, Hogue CJR (1987) Ectopic mortality in the United States, 1970-1983. Obstet Gynecol 70:817 DeCherney AH, Minkin AJ, Spangler S (1981) Contemporary management of ectopic pregnancy. J Reprod Med 26:519 Kadar N, Caldwetl BV, Romero R (1981) A method of screening for ectopic pregnancy and its indications. Obstet Gyneco158:162 Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA (1986) Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steri146:1093 Romero R, Copel JA, Kadar N, Jeanty P, DeCherney A, Hobbins JC (1985) Value of culdocentesis in the diagnosis of ectopic pregnancy. Obstet Gynecol 65:519 Silva PD (1988) A laparoscopic approach can be applied to most cases ectopic pregnancy. Obstet Gynecol 72:944 Stabile I, Grudzinskas JG (1990) Ectopic pregnancy. A review of incidence, etiology and diagnostic aspects. Obstet Gynecol Survey 45:335 Vermesh M, Graczykowski JW, Sauer MV (1990) Reevaluation of the role of culdocentesis in the management of ectopic pregnancy. Am J Obstet Gynecol 162:411
Gynecology and Obstetrics
© Springer-Verlag1992
Culdocentesis is an obsolete diagnostic tool in suspected ectopic pregnancy M. Glezerman, F. Press, and M. Carpman Department of Obstetrics and Gynecology, Soroka University Hospital and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel Received February 26, 1992/Accepted April 7, 1992
Summary. We studied 332 patients with proven pregnancies. Prediction of hemoperitoneum by assessment of the Douglas pouch during bimanual examination had a false negative rate of 42.1%. The false negative rate for culdocentesis was 14.8%. It is therefore concluded that culdocentesis is not a useful tool in the diagnosis of suspected ectopic pregnancies. Key words: Ectopic pregnancy - Culdocentesis - Hemoperitoneum - Douglas pouch - Abstract Introduction The incidence of ectopic pregnancies is rising (Stabile and Grudzinska 1990) and ectopic pregnancy is now the leading cause of maternal mortality in the United States (Atrash et al. 1987). It has been pointed out that clinicians suspect ectopic pregnancies 10 times more often than these actually occur (Kadar et al. 1981). It is therefore tempting to perform a relatively easy procedure like culdocentesis in order to detect the presence of a hemoperitoneum. Culdocentesis is an easy procedure, requires no special instrumentation, can be performed in an office setting and the results are immediately available. No wonder, that this procedure has gained wide acceptance and has been used extensively to rule out intra-abdominal hemorrhage in general and ectopic pregnancy in particular. However, the procedure is not devoid of side effects, the most serious of them perhaps a false sense of security when a negative result is obtained. With the advent of sophisticated diagnostic methods such as sensitive radioimmunoassay for human chorionic gonadotrophins and high resolution ultrasound the value of this procedure has to be critically reassessed. The main aim of the present study is to address this issue.
Correspondence to." Prof. Dr. M. Glezerman (address see above)
6
M. Glezerman et al.
Materials and methods This retrospective study includes 332 women in whom ectopic pregnancy had been confirmed during laparoscopy or laparatomy. All of them had undergone bimanual examination of the Douglas pouch for prediction of the presence or absence of hemoperitoneum and 246 women had undergone culdocentesis as part of their work up. Patients with inconclusive results for culdocentesis or patients whose files did not provide sufficient information concerning the presence or absence of hemoperitoneum at surgery were excluded. At admission the mean length of pregnancy as defined by last menstrual period was 50.5 days (range 32-90 days). Hemoperitoneum was considered to be present if at surgery at least 50 ml of blood was noted. During bimanual examination before surgery an attempt was made to predict the presence of hemoperitoneum by assessment of the Douglas pouch. The presence of a hemoperitoneum was assumed if there was tenderness or fullness in the pouch of Douglas. Two hundred and forty-six patients then underwent culdocentesis under anesthesia. With the patient in Trendelenburg position, a 18 gauge needle attached to a 20 ml syringe was used to puncture the Douglas pouch. After insertion of the needle the operating table was tilted into anti-Trendelenburg position, the syringe was lifted so that the tip of the needle was as caudal as possible when the contens of the cul-de-sac were aspirated. The result was considered positive if non-clotting blood or blood with micro clots was aspirated. Culdocentesis was classified as negative when clear or blood-tinged fluid was aspirated and inconclusive when no aspirate could be obtained, FoUowing the procedure all patients underwent laparoscopy and/or laparatomy and various surgical procedures for treatment of their ectopic pregnancies.
Results Bimanual examination B i m a n u a l e x a m i n a t i o n was i n d i c a t i v e o f h e m o p e r i t o n e u m i n 190 of 332 cases. I n 57.9% of these, hemoperitoneum was present. However, hemoperitoneum was also p r e s e n t i n 4 2 . 1 % cases (false n e g a t i v e ) i n w h o m b i m a n u a l e x a m i n a t i o n was n o t i n d i c a t i v e o f h e m o p e r i t o n e u m ( T a b l e 1). T h e s e n s i t i v i t y o f t h e test w a s 57.9%.
Culdocentesis C u l d o c e n t e s i s w a s p o s i t i v e i n 201/236 cases ( s e n s i t i v i t y 8 5 . 2 % ) a n d false n e g a tive i n 1 4 . 8 % of 236 p a t i e n t s w i t h h e m o p e r i t o n e u m ( T a b l e 2). Table 1. Correlation between manual examination of Douglas pouch and presence/absence of hemoperitoneum in ectopic pregnancies Hemoperitoneum
Bimanual examination Positive
Negative
Total
Present Absent
183 (57.9%) 7 (43.8%)
133 (42.1%) 9 (56,2%)
316 16
Total
190 (100%)
142 (100%)
332
Chi-square: 0.736; P = > 0.736 (not significant)
Obsoleteness of culdocentesis
7
Table 2. Correlation between results of culdocentesis and presence/absence of hemoperitoneum in ectopic pregnancies Hemoperitoneum
Culdocentesis Positive
Negative
Total
Present Absent
201 (85.2%) 4 (40%)
35 (14.8%) 6 (60%)
236 10
Total
205
41
246
Chi-square: 11.03; P = > 0.9 (not significant) Table 3. Localization and stares of ectopic pregnancies in 246 patients Localization
Status Ruptured
Unruptured
Total
Abdomen Ovary Cornua Fallopian tube
0 3 3 142 (59.7%)
(1) 1 0 96 (40.3%)
1 4 3 238 (100%)
Total
148 (60.2%)
98 (39.8%)
246 (99.8%)
Table 4. Condition of structure hosting ectopic pregnancy and presence or absence of hemoperitoneum Hemoperitoneum
Condition Ruptured
Unruptured
Total
Present Absent
148 (100%) 0 (0%)
88 (89.8%) 10 (10.2%)
236 10
Total
148 (100%)
98 (100%)
246
Chi-square: 13.23; P = > 0.9 (not significant)
In 96.7% of patients the p r e g n a n c y was located in o n e of the fallopian tubes and 59.7% of these were f o u n d to be r u p t u r e d (Table 3). In total 60.2% of the ectopic pregnancies w e r e ruptured. In all 148 cases with r u p t u r e d ectopic pregnancies h e m o p e r i t o n e u m was present. H o w e v e r , h e m o p e r i t o n e n m was also present in 89.8% of patients with u n r u p t u r e d ectopic pregnancies. O n l y in 10 out of 246 w o m e n with ectopic p r e g n a n c y was t h e r e no h e m o p e r i t o n e u m at surgery (Table 4). In these ten cases the p r e g n a n c y was located in an u n r u p t u r e d fallopian tube. Culdocentesis was false positive in 4 o u t o f these 10 cases.
8
M, Glezerman et al.
Discussion
The most common indication for culdocentesis in the investigation of a suspected ectopic pregnancy is to assess the presence or absence of a hemoperitoneum. Since positive culdocentesis is highly predictive of hemoperitoneum it has been common practice at our department as in many other clinics to bypass laparoscopy in these cases and to proceed directly to laparotomy. This approach seemed reasonable as long as laparoscopy was considered mainly a diagnostic tool. This is no longer the case. Most patients with ectopic pregnancy can now be treated by laparoscopy (Pouly et al. 1986, Silva 1988, Vermesh et al. 1990). Culdocentesis with positive results will therefore not shorten the surgical procedure. On the other hand, negative results do not exclude the presence of hemoperitoneum nor do they indicate absence of an unruptured ectopic pregnancy. In our series the false negative rate for culdocentesis was nearly 15% and 60% in the series reported by Vermesh et al. 1990. Delay of treatment due to a sense of false security obtained by a negative result (equal to the false negative rate of this procedure) may put the patient in serious danger. We conclude that the sensitivity of culdocentesis is too low to permit reliable assessment of hemoperitoneum in cases of suspected ectopic pregnancy. The relatively small number of patients without hemoperitoneum in our study does not allow one to give a false positive rate for culdocentesis. This fact however, is a conclusion by itself: During the study period a total of 400 women with ectopic pregnancies underwent surgery. The present study includes 246 of these. Only in 23 of the 400 women wffh proven ectopic pregnancy (5.8%) was no blood present in the abdominal cavity at open surgery. Hemoperitoneum was present in the remaining 94.2%. It is remarkable that the majority of unruptured ectopic pregnancies are associated with hemoperitoneum (88/89 = 98.8%). Others (DeCherney et al. 1981, Romero et al. 1985) have reported a positive culdocentesis rate exceeding 60% in unruptured ectopic pregnancy. Tubal abortion is probably the most common reason for a hemoperitoneum in the presence of a unruptured ectopic pregnancy. Another conclusion which may be reached from the present study relates to the value of bimanual examination to assess the presence of hemoperitoneum. Our false negative rate exceeded 42% and a false positive result was obtained in 43.8%. Thus sensitivity of bimanual examination for the prediction of hemoperitoneum was rather low. The availability of rapid tests for H C G permit immediate diagnosis of pregnancy and high resolution ultrasound usually locates the amniotic sac. But these tools or the expertise to use them are not always available. We suggest that whenever an immediate exact diagnosis cannot be obtained and the symptomatology of the patient permits, expectant management or laparoscopy should be employed. We feel that culdocentesis does not offer any diagnostic advantage and its results may be dangerously misleading. Acklowledgement. The authors wish to thank Dr. Ilana Shoham for assistance in statistical analysis of the data.
Obsoleteness of culdocentesis
9
References Atrash HK, Friede A, Hogue CJR (1987) Ectopic mortality in the United States, 1970-1983. Obstet Gynecol 70:817 DeCherney AH, Minkin AJ, Spangler S (1981) Contemporary management of ectopic pregnancy. J Reprod Med 26:519 Kadar N, Caldwetl BV, Romero R (1981) A method of screening for ectopic pregnancy and its indications. Obstet Gyneco158:162 Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA (1986) Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steri146:1093 Romero R, Copel JA, Kadar N, Jeanty P, DeCherney A, Hobbins JC (1985) Value of culdocentesis in the diagnosis of ectopic pregnancy. Obstet Gynecol 65:519 Silva PD (1988) A laparoscopic approach can be applied to most cases ectopic pregnancy. Obstet Gynecol 72:944 Stabile I, Grudzinskas JG (1990) Ectopic pregnancy. A review of incidence, etiology and diagnostic aspects. Obstet Gynecol Survey 45:335 Vermesh M, Graczykowski JW, Sauer MV (1990) Reevaluation of the role of culdocentesis in the management of ectopic pregnancy. Am J Obstet Gynecol 162:411
