Transvaginal ultrasound is the best diagnostic method for ectopic pregnancy

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1. With a sensitivity of 88% and specificity of 88% for detecting ectopic pregnancy, transvaginal sonography was the single best diagnostic method of those tested.

2. Physical exam findings that significantly increase the likelihood of ectopic pregnancy include: cervical motion tenderness, peritoneal findings, adnexal mass, and adnexal tenderness. 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Ectopic pregnancies represent a serious cause of mortality in reproductive aged women, and it should be ruled out in women who present with abdominal pain or vaginal bleeding. Undiagnosed ectopic pregnancies can ultimately result in tubal rupture, intraperitoneal hemorrhage, and catastrophic consequences. In reviewing 14 prospective studies, this systematic review concluded that transvaginal sonography is the single best diagnostic method for suspected ectopic pregnancy.

While transvaginal ultrasound appears to be the single best diagnostic method for diagnosing ectopic pregnancy, this study reports a likelihood ratio (LR) of 111 with a wide LR confidence interval of 12-1028. This statistical heterogeneity may in part be due to user variability in performing transvaginal ultrasounds; however, the study provides robust evidence that the transvaginal ultrasound operated by a radiologist or emergency medicine physician provides great clinical utility regardless. While the review is inherently limited by the limitations of each individual study, strict criteria allowed for the inclusion of only high-quality studies.

Click to read the study published today in JAMA 

Relevant Reading: Diagnosis of ectopic pregnancy with ultrasound

In-Depth [systematic review]: This systematic review included 14 prospective studies encompassing 12,101 women with symptoms of ectopic pregnancy such as abdominal pain and vaginal bleeding. Women of childbearing age with symptoms of ectopic pregnancy were found to have a 15% prevalence of ectopic pregnancy. The patient’s history and symptoms were found to have minimal clinical value with all the parameters having a likelihood ratio of less than 1.5. The physical exam findings included cervical motion tenderness (SN 45%, SP 91%, LR 4.9), peritoneal findings (SN 23-27%, SP 94-95%, LR 4.2-4.5), adnexal mass (SN 9%, SP 96%, LR 2.4), and adnexal tenderness (SN 61%, SP 65%, LR 1.9) were significant, as each finding increased the likelihood of ectopic pregnancy. Of note, however, normal findings on physical exam did not decrease the likelihood of an ectopic pregnancy. Among diagnostic modalities, transvaginal sonography was the single best diagnostic method for women with suspected ectopic pregnancy (SN 88%, SP 99%, LR 111).  Also, there were no operator discrepancies between transvaginal sonography when performed by an ED physician versus a radiologist.

By Brittany Hasty and Rif Rahman 

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