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The Rational Clinical Examination
Clinician's Corner
April 24, 2013

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

Author Affiliations
 

The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor.

Author Affiliations: Center of Reproductive Medicine, Webster, Texas (Dr Crochet); Division of Reproductive Endocrinology and Fertility (Dr Crochet), Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina (Drs Crochet and Chireau); Department of Internal Medicine, University of Connecticut Health Center, Farmington (Dr Bastian); Veterans Affairs Connecticut Healthcare System, Newington (Dr Bastian); and Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham (Dr Chireau).

JAMA. 2013;309(16):1722-1729. doi:10.1001/jama.2013.3914
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.

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