OB: Ectopic Diagnosis References ================================= Ankum WM; Van der Veen F; Hamerlynck JV; Lammes FB Transvaginal sonography and human chorionic gonadotrophin measurements in suspected ectopic pregnancy: a detailed analysis of a diagnostic approach. Hum Reprod, 8: 8, 1993 Aug, 1307-11 In this prospective study among 208 high-risk patients with suspected ectopic pregnancy, the diagnostic value of transvaginal sonography and serum human chorionic gonadotrophin (HCG) measurements were analysed in detail. The absence of an intra-uterine gestational sac obviously was the most constant sonographic finding among patients with ectopic pregnancy (n = 89), with a very high sensitivity (0.99) but a low specificity (0.41). The application of different HCG cut-off levels improved specificity to 1.00 for values exceeding 4500 IU/l. Clinical utility obviously decreased, as many patients presented with HCG values well below this level. The additional effect of adnexal findings was analysed. Sonographic identification of an ectopic pregnancy was very specific (0.99) but had low sensitivity (0.56) because many ectopics were not detected. The additional effect of HCG values on these results was minor. The low HCG cut-off levels advocated in recent studies are questioned by the results of our analysis: whereas the combined use of sonography and HCG measurements is shown to be of great benefit, the limitations are also documented, underlining the need for re-evaluation at intervals of patients with low HCG values. The question of which cut-off level should be used in practice, however, hinges on a difficult choice between a certa Letterie GS; Hibbert ML; Ramirez EJ Expectant management of abnormal concentrations of human chorionic gonadotropin during the first trimester of pregnancy. Gynecol Obstet Invest, 31: 3, 1991, 176-8 Abnormal serum human chorionic gonadotropin (hCG) levels during the first trimester may be associated with a nonviable intrauterine pregnancy or ectopic pregnancy. With the availability of sensitive hCG assays, expectant management of these patients may provide a viable alternative to surgery. To evaluate this approach, we managed 20 patients with low levels of serum hCG expectantly using serial hCG monitoring and clinical examination only. Serum hCG concentrations were followed to levels of less than 10 mIU/ml. Peak levels of serum hCG ranged from 72 to 5,685 mIU/ml. Duration of expectant management ranged from 7 to 97 days. No patient required intervention due to acute symptoms. These data suggest that a select group of patients with decreasing hCG concentrations may be managed expectantly without undue morbidity thereby avoiding surgical intervention. Enk L; Wikland M; Hammarberg K; Lindblom B The value of endovaginal sonography and urinary human chorionic gonadotropin tests for differentiation between intrauterine and ectopic pregnancy. J Clin Ultrasound, 18: 2, 1990 Feb, 73-8 Effectiveness of vaginal sonography combined with urinary human chorionic gonadotropin (hCG) for identification of ectopic pregnancy (EP) was studied in 107 pregnant women. Eighty-nine women had clinical symptoms suspicious of EP. It was suggested that 18 women carried an increased risk for developing EP. In 63 women endovaginal sonography showed no evidence of intrauterine pregnancy. Fifty-eight of these turned out to be pathological pregnancies. In 44 women endovaginal ultrasonography revealed intrauterine pregnancies. Thirty-two of these turned out to be viable, 10 were not viable and resulted in spontaneous abortions, and 2 turned out to be EP. The sensitivity of vaginal sonography to identify a viable intrauterine pregnancy thus was 81% and its specificity was 97%. The sensitivity and the specificity for endovaginal ultrasonography for identifying EP was 96% and 71%, respectively. Endovaginal ultrasonography demonstrated an intrauterine gestational sac in 54% of the women with urinary HCG as low as 40 IU/L to 500 IU/L. These results show that endovaginal ultrasonography is a sensitive instrument for identifying both early normal intrauterine pregnancies as well as pathological pregnancies. Thyssen HH; Christensen H; Schebye O; Berget A; Arends J; Larsen SO Elimination of human chorionic gonadotropin in serum and urine after uncomplicated induced abortion during the first trimester] Ugeskr Laeger, 154: 30, 1992 Jul 20, 2071-2 Serum chorion gonadotropin was measured weekly in 12 women from the time of legal first trimester abortion until values were below 10 IU/L. The elimination followed a 2-component curve. The half-life in the first few days was 1.1 day, hereafter 4.2 days. Serum-HCG decreased to less than 10 IU/L within 22 to 40 days. The elimination of serum-HCG was found to decrease so uniformly, that values which do not decrease must be considered abnormal. A sensitive bedside urine-HCG test was found to be positive from 13 to 31 days after the abortion. Haenel AF; Hugentobler W; Brunner S [The postpartum course of the HCG titer of maternal blood and its clinical relevance] Z Geburtshilfe Perinatol, 190: 6, 1986 Nov-Dec, 275-8 In 62 postpartum patients serial beta-HCG-measurements were performed. These tests show that beta-HCG should disappear entirely during the third week postpartum. Significant titers beyond this time are seen when placental tissue remains in utero. This condition may lead to late postpartum hemorrhage which is best treated by curettage. If there is only mild bleeding and beta-HCG-titers are negative, a hormonal curettage with subsequent estrogen administration (3 weeks) can be performed. In doing so, unnecessary and potentially harmful intrauterine manipulations can be avoided. Trio D; Strobelt N; Picciolo C; Lapinski RH; Ghidini A Prognostic factors for successful expectant management of ectopic pregnancy. Fertil Steril, 63: 3, 1995 Mar, 469-72 OBJECTIVE: To determine the independent ability of initial hCG titers, trend of hCG titers, and ultrasonographic findings in the prediction of successful expectant management in ectopic pregnancy (EP). DESIGN: Case-control study. SETTING: University hospital. PATIENTS: Sixty-seven patients with EP managed expectantly, 49 of whom (73%) had a spontaneous resolution, whereas 3 (5%) underwent medical treatment, and 15 (22%) eventually underwent surgical treatment. RESULTS: Univariate analysis showed that the initial hCG titer, the trend in hCG titers between first and second sample, and ultrasonographic visualization of absence of an ectopic gestational sac were significant predictors of a successful expectant management. Using receiver operating characteristic curve analysis, an hCG titer < 1,000 mIU/mL was chosen as the optimal cutoff for this prediction, identifying 88% of women destined to have spontaneous resolution of the EP. Multivariate analysis showed that both initial hCG titer and trend in hCG titers but not ultrasonographic visualization of an ectopic gestational sac were independent predictors of a successful or failed expectant management. CONCLUSION: Expectant management of EP is successful in the majority of patients with initial hCG titer < 1,000 mIU/mL. Weigel M; Friese K; Schmitt W; Strittmatter HJ; Melchert F [What is the predictive value of ultrasound diagnosis in suspected extra-uterine pregnancy in routine clinical practice?] Zentralbl Gynakol, 115: 5, 1993, 228-32 In this retrospective study the data of 340 patients who underwent invasive diagnostics in suspected ectopic pregnancy from 1985 to 1991 are being analyzed. The aim of this study is to examine the prognostic value of ultrasonic findings after the introduction of transvaginal sonography and highly sensitive urine pregnancy tests in the every day clinical routine. In transvaginal ultrasound significantly more direct signs of an ectopic pregnancy than in the abdominal technique were found showing a markedly higher positive predictive value: 93.5% for an extrauterine double ring, 90.7% for inhomogeneous adnexal masse with the simultaneous finding of echogenic fluid in the pouch of Douglas and 79.3% for isolated inhomogeneous adnexal masses. The predictive values for indirect sonographic hints of suspected extrauterine gravidity were 78.4% for an empty uterine cavity and 87.3% for echogenic fluid in the pouch of Douglas. With growing experience in the vaginal ultrasound technique the positive predictive values of all these signs reached 91% to 98%. Additionally the rate of false-negative urine pregnancy tests in patients with ectopic pregnancy sank with increasing sensitivity from 49% (1000 IU HCG/l) to 3.2% (50 IU/l). Summarizing all these factors the reliability of conservative diagnostic means in suspected ectopic pregnancy raised considerably from 56.4% to 94.3% during the course of our study. Cartwright, P.S., et al Performance of a new enzyme-linked immunoassay urine pregnancy test for the detection of ectopic gestation. Ann Emeg Med 15(10):1198, October 1986 The authors report on their experience with use of the Hybritech Urine Tandem ICON pregnancy test, a new rapid enzyme-linked immunoassay test for detection of beta hCG in urine, in 884 patients evalu ated at the Metropolitan Nashville General Hospital. The ICON test was positive in 96% of the patients with ectopic pregnancies (26 of 27). The one false negative occurred in a patient with dilute ur ine, and a serum beta hCG concentration below 50mlU/mL at the time of urine collection. Eighteen patients with documented pregnancies (including four with ectopic pregnancies) had serum beta hCG conc entrations of 10-50mIU/mL. The ICON test was positive in three of the four patients with ectopic pregnancies, and in ten of the remaining fourteen patients in this group. All five patients with negat ive ICON tests had dilute urine specimens, with a specific gravity of 1.010 or lower. The potential for a falsely negative ICON test in patients with urine having a low specific gravity (<1.015) may be reduced if the test is performed with 20 drops of urine rather than five drops. Repeat testing was positive when the 20 drop technique was utilized in the five aforementioned falsely negative spec imens. The ICON test was negative in all 619 patients in whom the serum beta hCG concentration was below 5mlU/mL. It is concluded that the ICON urine pregnancy test appears to be a rapid and reliable means of screening for ectopic pregnancy in ED patients. 3 references Holt, J.A., et al Effects of iv hydration on levels of hcg in the serum and urine of women with possible ectopic pregnancy Lab Med 5(3):701, October 1989 The authors, from the University of Chicago, compared the results of three high-sensitivity bench top immunoabsorption-immunoenzymatic tests for measuring hCG in urine (Testpack hCG Urine, Abbott Lab oratories; Tandem Icon hCG; Quest Pregnancy Test, Quidel) and an agglutination-inhibition type slide test (UCG-Beta Slide Monoclonal II, Wampole Laboratories) before and after IV hydration in 24 pati ents with suspected ectopic pregnancies. Urine and blood specimens were obtained before and after completion of IV hydration with 300-2,000ml of crystalloid (average, 900ml). Ectopic pregnancies were confirmed in 14 patients, and intrauterine pregnancies were diagnosed in seven. Both the serum and urine hCG levels were affected by IV hydration. The dilutional effect was more pronounced in the ur inary concentration (44% reduction of the hCG level vs. a 13% reduction in serum levels). However, even after hydration, urine testing with the immunoabsorption-immunoenzymatic membrane- or dipstick- based tests detected all of the ectopic and intrauterine pregnancies. The agglutination-inhibition urine slide test was less sensitive, providing false-negative results in six cases prior to hydratio n (three of which occurred in patients with ectopic pregnancies) and in eight cases after hydration (four in patients with ectopic pregnancies). The authors suggest that the rapid immunoabsorption-im munoenzymatic type tests appear to be reliable in the evaluation of possible ectopic pregnancy, and note that a rapid serum qualitative hCG test may be helpful in those rare situations in which the d ilutional effect of IV hydration may reduce the urinary hCG concentration to levels below the threshold of these tests. 9 references