Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review

Abstract

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.