ANNALS OF EMERGENCY MEDICINE
-
2015
Systematic Review Snapshot TAKE-HOME MESSAGE Transvaginal sonography should be used in conjunction with quantitative serum b-hCG testing to rule out ectopic pregnancy in hemodynamically stable patients. No single level of b-hCG can be used in isolation to rule out ectopic pregnancy.
The Diagnosis of Ectopic Pregnancy
METHODS
EBEM Commentator
Lisa T. Barker, MD
DATA SOURCE Authors used the established Journal of the American Medical Association rational clinical examination search strategy to identify English-language articles in MEDLINE and EMBASE databases (1965 to 2012). STUDY SELECTION Included studies were prospective, with a sample size greater than 100, and included reproductiveage women with complaints of abdominal pain or vaginal bleeding in the context of a positive pregnancy test result. Ectopic pregnancy was verified or excluded by surgical visualization or clinical follow-up. Identified studies were rated for quality with an adapted 5-point rational clinical examination scale. Fourteen studies achieved a minimum rating of 3 and were included in the qualitative analysis; 7 reported sufficient detail to be included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS Two authors independently assessed each study for inclusion criteria, quality, and data extraction. A third author resolved discrepancies.
Volume
-,
no.
-
:
-
2015
University of Illinois College of Medicine at Peoria/OSF St. Francis Medical Center Peoria, IL
Shelly Zhou, MD Medical University of South Carolina Charleston, SC
Results Table. Findings supporting the diagnosis of ectopic pregnancy. Finding
LR (D)
95% CI
LR (–)
95% CI
Abdominal pain with cough or light palpation Bimanual examination Cervical motion tenderness Palpated adnexal mass Transvaginal sonography (þ) adnexal mass, absent IUP
4.2–4.5
*
0.78–0.81
*
4.9 2.4 111
1.7–14 1.6–3.7 (12–1,208)
0.62 0.94 0.12
0.47–0.83 0.87–1.0 (0.03–0.55)
ectopic
pregnancy
IUP, Intrauterine pregnancy. *Finding only included in 2 studies.
All subjects were hemodynamically stable; however, the credibility of pooled findings was limited by heterogeneity.1 Key physical examination findings were more specific than sensitive. A single beta-human chorionic gonadotropin (b-hCG) level at any value was neither sensitive nor specific. An adnexal mass by transvaginal sonography with absence of intrauterine pregnancy was the most sensitive (0.88; 95% confidence interval 0.52 to 0.98) and specific (0.99; 95% confidence interval 0.96 to 1.0) finding for
confirming (Table).
Commentary Ectopic pregnancy is estimated to affect 20.7 of every 1,000 pregnancies,2 and delayed diagnosis increases maternal morbidity and This meta-analysis mortality.3 demonstrated the value of transvaginal sonography in the diagnostic evaluation of possible ectopic pregnancy and suggested that b-hCG levels may provide supporting evidence, but only when followed Annals of Emergency Medicine 1
Systematic Review Snapshot
Extracted data were organized into contingency (22) tables to determine the sensitivity, specificity, and likelihood ratios for all reported diagnostic findings.
serially. Only identification of intrauterine pregnancy by transvaginal sonography safely rules out ectopic pregnancy in patients at low risk for heterotopic pregnancy,4 and transvaginal sonography is accurate when performed by emergency physicians.5 For hemodynamically stable patients, therefore, inconclusive ultrasonography results should prompt close follow-up with
2 Annals of Emergency Medicine
serial b-hCG and ultrasonography to both protect an undetectable intrauterine pregnancy and ensure early detection of ectopic pregnancy.
2.
care: users’ guides to the medical literature. JAMA. 2014;312:171-179. Van Den Eeden SK, Shan J, Bruce C, et al. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol. 2005;105(5 pt 1):1052-1057. Anderson FWJ, Hogan JG, Ansbacher R. Sudden death: ectopic pregnancy mortality. Obstet Gynecol. 2004;103:1218-1223. Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol. 2006;107(2 pt 1): 399-413. Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. 2010;56:674-683.
Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this SRS is: Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? the rational clinical examination systematic review. JAMA. 2013;309:1722-1729. http://dx.doi.org/10.1001/jama.2013. 3914.
3.
1. Murad MH, Montori VM, Ioannidis JPA, et al. How to read a systematic review and metaanalysis and apply the results to patient
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
4.
5.
Volume
-,
no.
-
:
-
2015
-
2015
Systematic Review Snapshot TAKE-HOME MESSAGE Transvaginal sonography should be used in conjunction with quantitative serum b-hCG testing to rule out ectopic pregnancy in hemodynamically stable patients. No single level of b-hCG can be used in isolation to rule out ectopic pregnancy.
The Diagnosis of Ectopic Pregnancy
METHODS
EBEM Commentator
Lisa T. Barker, MD
DATA SOURCE Authors used the established Journal of the American Medical Association rational clinical examination search strategy to identify English-language articles in MEDLINE and EMBASE databases (1965 to 2012). STUDY SELECTION Included studies were prospective, with a sample size greater than 100, and included reproductiveage women with complaints of abdominal pain or vaginal bleeding in the context of a positive pregnancy test result. Ectopic pregnancy was verified or excluded by surgical visualization or clinical follow-up. Identified studies were rated for quality with an adapted 5-point rational clinical examination scale. Fourteen studies achieved a minimum rating of 3 and were included in the qualitative analysis; 7 reported sufficient detail to be included in the meta-analysis. DATA EXTRACTION AND SYNTHESIS Two authors independently assessed each study for inclusion criteria, quality, and data extraction. A third author resolved discrepancies.
Volume
-,
no.
-
:
-
2015
University of Illinois College of Medicine at Peoria/OSF St. Francis Medical Center Peoria, IL
Shelly Zhou, MD Medical University of South Carolina Charleston, SC
Results Table. Findings supporting the diagnosis of ectopic pregnancy. Finding
LR (D)
95% CI
LR (–)
95% CI
Abdominal pain with cough or light palpation Bimanual examination Cervical motion tenderness Palpated adnexal mass Transvaginal sonography (þ) adnexal mass, absent IUP
4.2–4.5
*
0.78–0.81
*
4.9 2.4 111
1.7–14 1.6–3.7 (12–1,208)
0.62 0.94 0.12
0.47–0.83 0.87–1.0 (0.03–0.55)
ectopic
pregnancy
IUP, Intrauterine pregnancy. *Finding only included in 2 studies.
All subjects were hemodynamically stable; however, the credibility of pooled findings was limited by heterogeneity.1 Key physical examination findings were more specific than sensitive. A single beta-human chorionic gonadotropin (b-hCG) level at any value was neither sensitive nor specific. An adnexal mass by transvaginal sonography with absence of intrauterine pregnancy was the most sensitive (0.88; 95% confidence interval 0.52 to 0.98) and specific (0.99; 95% confidence interval 0.96 to 1.0) finding for
confirming (Table).
Commentary Ectopic pregnancy is estimated to affect 20.7 of every 1,000 pregnancies,2 and delayed diagnosis increases maternal morbidity and This meta-analysis mortality.3 demonstrated the value of transvaginal sonography in the diagnostic evaluation of possible ectopic pregnancy and suggested that b-hCG levels may provide supporting evidence, but only when followed Annals of Emergency Medicine 1
Systematic Review Snapshot
Extracted data were organized into contingency (22) tables to determine the sensitivity, specificity, and likelihood ratios for all reported diagnostic findings.
serially. Only identification of intrauterine pregnancy by transvaginal sonography safely rules out ectopic pregnancy in patients at low risk for heterotopic pregnancy,4 and transvaginal sonography is accurate when performed by emergency physicians.5 For hemodynamically stable patients, therefore, inconclusive ultrasonography results should prompt close follow-up with
2 Annals of Emergency Medicine
serial b-hCG and ultrasonography to both protect an undetectable intrauterine pregnancy and ensure early detection of ectopic pregnancy.
2.
care: users’ guides to the medical literature. JAMA. 2014;312:171-179. Van Den Eeden SK, Shan J, Bruce C, et al. Ectopic pregnancy rate and treatment utilization in a large managed care organization. Obstet Gynecol. 2005;105(5 pt 1):1052-1057. Anderson FWJ, Hogan JG, Ansbacher R. Sudden death: ectopic pregnancy mortality. Obstet Gynecol. 2004;103:1218-1223. Seeber BE, Barnhart KT. Suspected ectopic pregnancy. Obstet Gynecol. 2006;107(2 pt 1): 399-413. Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. Ann Emerg Med. 2010;56:674-683.
Editor’s Note: This is a clinical synopsis, a regular feature of the Annals’ Systematic Review Snapshot (SRS) series. The source for this SRS is: Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? the rational clinical examination systematic review. JAMA. 2013;309:1722-1729. http://dx.doi.org/10.1001/jama.2013. 3914.
3.
1. Murad MH, Montori VM, Ioannidis JPA, et al. How to read a systematic review and metaanalysis and apply the results to patient
Michael Brown, MD, MSc, Alan Jones, MD, and David Newman, MD, serve as editors of the SRS series.
4.
5.
Volume
-,
no.
-
:
-
2015
