Cervical ectopic pregnancy case report: findings for the bedside sonographer

The evaluation of first trimester vaginal bleeding or pelvic pain is an important task for the emergency physician. The early identification of an ectopic pregnancy can help prevent significant morbidity and mortality for patients seeking emergency care. The increased use of bedside sonography by the emergency physician in the evaluation of these patients requires an increased knowledge about the variants and their appearance on sonogram. We present the case of a patient found to have a cervical ectopic pregnancy. A discussion of the diagnosis and management, as well as the findings on bedside sonogram are presented.     

Is Ultrasound the New Gold Standard for the Diagnosis of Ectopic Pregnancy?

Ultrasound technology and in particular the use of transvaginal imaging has taken the guesswork out of ectopic pregnancy diagnosis. The vast majority of ectopic pregnancies can and should be diagnosed with a high degree of certainty before management is commenced. More and more women with ectopic pregnancy are eligible for nonsurgical intervention because ultrasound has enabled clinicians to make the diagnosis much earlier in its natural history. We believe that laparoscopy, traditionally the gold standard in diagnosis of ectopic pregnancy, should not be used in modern management. There is more and more evidence to support the use of transvaginal ultrasound as the primary diagnostic tool for ectopic pregnancy. In this review we hoped to demonstrate that transvaginal ultrasound is the new gold standard for the diagnosis of ectopic pregnancy.     

Diagnosis and management of ectopic pregnancy

Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. The condition is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should perform a pregnancy test. If the patient is pregnant, the physician should perform a work-up to detect possible ectopic or ruptured ectopic pregnancy. Prompt ultrasound evaluation is key in diagnosing ectopic pregnancy. Equivocal ultrasound results should be combined with quantitative beta subunit of human chorionic gonadotropin levels. If a patient has a beta subunit of human chorionic gonadotropin level of 1,500 mIU per mL or greater, but the transvaginal ultrasonography does not show an intrauterine gestational sac, ectopic pregnancy should be suspected. Diagnostic uterine curettage may be appropriate in patients who are hemodynamically stable and whose beta subunit of human chorionic gonadotropin levels are not increasing as expected. Appropriate treatment for patients with nonruptured ectopic pregnancy may include expectant management, medical management with methotrexate, or surgery. Expectant management is appropriate only when beta subunit of human chorionic gonadotropin levels are low and declining. Initial levels determine the success of medical treatment. Surgical treatment is appropriate if ruptured ectopic pregnancy is suspected and if the patient is hemodynamically unstable.     

Sonography in first trimester bleeding

Vaginal bleeding is the most common cause of presentation to the emergency department in the first trimester. Approximately half of patients with first trimester vaginal bleeding will lose the pregnancy. Clinical assessment is difficult, and sonography is necessary to determine if a normal fetus is present and alive and to exclude other causes of bleeding (eg, ectopic or molar pregnancy). Diagnosis of a normal intrauterine pregnancy not only helps the physician in terms of management but also gives psychologic relief to the patient. Improved ultrasound technology and high-frequency endovaginal transducers have enabled early diagnosis of abnormal and ectopic pregnancies, decreasing maternal morbidity and mortality. The main differential considerations of first trimester bleeding are spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease. This article reviews the causes of first trimester bleeding and the sonographic findings, including normal features of first trimester pregnancy.     

Ectopic pregnancy

Ectopic pregnancy is a high-risk diagnosis that is increasing in frequency and is still commonly missed in the emergency department. The emergency physician needs a high index of suspicion and must understand that the history, physical examination, and a single quantitative beta-hCG level cannot reliably rule out an ectopic pregnancy. Most pregnant patients who present to the emergency department during the first trimester with abdominal or pelvic pain, regardless of the presence of vaginal bleeding, should undergo further evaluation with ultrasonography. Ultrasound findings in conjunction with quantitative beta-hCG levels guide the management of the patient.     

发生在输卵管以外的异位妊娠96例诊治体会

目的 探讨发生在输卵管以外的异位妊娠的诊断与治疗。方法 回顾性分析我院1991～1998年收治的96例输卵管以外的异住妊娠的诊治经过。结果 96例均经手术和病理证实为异位妊娠，其中卵巢妊娠63例，宫角妊娠17例，宫颈妊娠11例，子宫肌壁间妊娠2例，子宫骶骨韧带妊娠、阔韧带妊娠、肝脏妊娠各1例。结论 发生在输卵管以外的异位妊娠术前诊断较困难，临床应提高对此类特殊异位妊娠的认识，提高诊治水平。     

Point-of-Care Ultrasound Diagnosis of Cesarean Scar Ectopic Pregnancy: A Case Series

BackgroundA cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy.Case ReportWe present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department.Why Should an Emergency Physician Be Aware of This?Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.     

Ultrasonographic Examination by Emergency Physicians of Patients at Risk for Ectopic Pregnancy

Objective: To evaluate a diagnostic protocol that includes the early use of endovaginal sonography (EVS) by emergency physicians of patients at risk for ectopic pregnancy.
Methods: During this prospective study. pregnant patients ≥ 18 years old and at risk for ectopic pregnancy were assessed. Emergency physicians who had completed a training program performed EVS on a convenience sample of eligible women. Clinical disposition was based on predetermined clinical, laboratory, and ultrasonographic criteria. The EVS examinations were reviewed on video by a gynecologist whose interpretation was correlated with the emergency physician EVS readings and with the final clinical diagnoses. Quantitative serum P-human chorionic gonadotropin (βhCG) levels were determined for patients who had no definite intrauterine pregnancy (IUP) on EVS.
Results: Of 157 patients studied during a 12-month period. four were lost to follow-up. Emergency physician ultrasonographic diagnoses included: definite IUP, 87/146 (59%): probable abnormal IUP. 17/148 (11%); definite ectopic pregnancy. 31148 (2%); and no definite IUP. 41/148 (28%). The gynecologist agreed with 93% of the initial interpretations. Twelve of 16 patients who had the final diagnosis of ectopic pregnancy were admitted from the ED with this diagnosis. The ultrasonographic diagnosis of the other four was no definite IUP. and no mass or free fluid. For the latter four patients, the presenting serum βhCG level was < 2,000 mlU/mL (First International Reference Preparation). They were diagnosed as having ectopic pregnancy after serial outpatient EVS and βhCG measurements.
Conclusions: The application of EVS to emergency practice appears promising. Emergency physicians trained in its use and who apply this diagnostic tool in conjunction with a defined protocol can stratify the risk of patients who have the potential for ectopic pregnancy.     

Conservative microsurgical management of ectopic gestation

The current management of ectopic gestation has been greatly affected by two apparent trends: a world-wide dramatic increase in its incidence; and a tendency for women to delay childbearing into later life. In the past, the objective of surgery for ectopic pregnancy was saving lives, and salpingectomy was the procedure of choice. At present, with improved methods of an early diagnosis, namely quantitative beta-HCG, ultrasonography, and laparoscopy, preservation of maximal reproductive potential of the affected women becomes a primary surgical goal. Conservative microsurgical approach with the reconstruction of the affected oviduct may be the procedure of choice. Following standard salpingectomy for ectopic gestation, two-thirds of such patients will not subsequently reproduce successfully. On the other hand, statistics indicate that microsurgical repair of the affected oviduct at the time of operation for an ectopic pregnancy will be followed by term pregnancy in 50 to 72% of patients. In this presentation, a variety of conservative surgical approaches are described and discussed. They represent a spectrum from operative laparoscopy to laparotomy with linear salpingotomy, segmental excision with or without an immediate anastomosis, to the management of tubal abortion. General principles of microsurgical techniques applicable to the management of unruptured ectopic gestation are outlined. The analysis of available data indicate that conservative approach is advantageous for preservation and enhancement of future reproductive potential of the affected patient. Since ectopic tubal gestation is an unqualified human reproductive disaster, preservation and restoration of normal pelvic architecture appears logical and applicable, especially in cases of chronologically older women whose first pregnancy is an ectopic location.     

Heterotopic pregnancy diagnosed by emergency ultrasound

We present a case of heterotopic pregnancy rapidly diagnosed by an emergency physician. To the best of our knowledge, this is the first report of an emergency physician using bedside ultrasound to diagnose an ectopic pregnancy present simultaneously with an intrauterine pregnancy. Other unique features of this case include the diagnosis being made on initial evaluation and the patient's lack of risk factors for heterotopic pregnancy. A review of the cases of heterotopic pregnancy reported in the emergency medicine literature, the rising prevalence of the disease, and factors that may facilitate in making the diagnosis are discussed as well.     

Acute urinary retention due to ectopic pregnancy

Two cases of ectopic pregnancy are presented in which acute urinary retention was a salient clinical feature. The emergency physician must consider ectopic pregnancy in the differential diagnosis in any woman of child-bearing age with abdominal, pelvic, or urinary complaints.     

Ectopic pregnancy: a review

Ectopic pregnancy is a major clinical problem, occurring in 75,000 cases per year in the United States. With in vitro fertilization, embryo transfer, microsurgical techniques, and better early diagnosis, the rates of ectopic pregnancies have increased. Transvaginal sonography along with beta-human chorionic gonadotrophin monitoring are the standards for evaluation of suspected ectopic pregnancy. When ectopic pregnancy is present, transvaginal sonography most often demonstrates an adnexal finding directly related to the extra-uterine gestation itself, a hematoma caused by it, or both. Although tubal location is most common, it is important to recognize unusual locations of ectopic pregnancy such as isthmic, cervical, ovarian, and abdominal. Ultrasound is the mainstay of diagnosis, but magnetic resonance imaging can be helpful in unusual or complicated cases. Current therapeutic options for an ectopic pregnancy are expectant management, systemic methotrexate injections, sonographically guided minimal invasive treatment, and surgery. This review encompasses diagnosis, treatment, and management of ectopic pregnancy.     

经阴道超声结合腹部加压法对异位妊娠的诊断

目的：探讨经阴道超声结合腹部加压法诊断异位妊娠的价值。方法回顾性分析以异位妊娠收入住院的157例患者的经阴道超声声像图特征,并与临床最终诊断结果相对照。结果157例患者中临床最后诊断为异位妊娠156例（包括宫内妊娠并异位妊娠1例）,宫内妊娠1例;经阴道超声结合腹部加压法检出异位妊娠154例,漏诊异位妊娠2例,检出宫内妊娠1例,检出异位妊娠敏感性为98.72%（154/156）、准确性为98.73%（155/157）。结论经阴道超声能够为临床诊断异位妊娠提供可靠的线索。     

Early detection of ectopic pregnancy visualizing the presence of a tubal ring with ultrasonography performed by emergency physicians

Early diagnosis of ectopic pregnancy (EP) continues to be problematic for emergency physicians. With the increasing availability of endovaginal ultrasonography (EVS) for emergency physicians, recognizing additional EVS findings, ie, the presence of a tubal ring, in patients with risk factors or clinical presentation for EP can assist the emergency physician in diagnosing EP.     

Vaginal bleeding in the first 20 weeks of pregnancy

The first and foremost diagnosis to exclude in the pregnant patient presenting with vaginal bleeding is ectopic pregnancy. Once ectopic pregnancy is ruled out, miscarriage should be considered as a clinical spectrum. Its management is directed according to the integrity of the internal cervical os and patient hemodynamic status. Treatment with anti-D immune globulin is warranted for all Rh-negative patients. Urgent obstetric consultation is necessary for most miscarriage presentations.     

动态观察阴道超声对异位妊娠早期诊断的前瞻性研究

目的　通过阴道超声检查临床疑诊异位妊娠患者 ,进行动态观察对异位妊娠早期诊断的前瞻性研究 .方法　采用HPImagePoint多特色超声系统 ,探头频率 7.5MHz。应用阴道超声反复多次检查 ,参照异位妊娠阴道超声诊断标准 ,结合手术对照 ,比较阴道超声单次检查与多次检查对异位妊娠早期诊断的准确性。结果　 15 5例临床疑诊异位妊娠经过阴道超声反复多次检查 ,异位妊娠 80例 ,占 5 1.6 % ,宫内妊娠 75例 ,占 4 8.4 %。异位妊娠诊断率初次检查82 .5 % ,二次检查 94 .0 % ,三次检查 10 0 %。异位妊娠假阳性 2例 (初次检查诊断 ) ,假阳性率 1.3%。结论　阴道超声较腹部超声能较早地确定宫内妊娠和发现异位妊娠 ;反复多次检查较单次检查对异位妊娠的早期诊断准确性有较大的提高 ;动态观察可降低异位妊娠的假阳性率。     

Ovarian Ectopic Pregnancy: A Clinical Analysis

Ovarian ectopic pregnancy is a rare form of ectopic pregnancy and constitutes approximately 3% of all ectopic cases. Its presentation mimics the symptoms of tubal ectopic pregnancy and can be difficult to distinguish based on ultrasound imaging and presentation alone. Laparoscopic management is required for definitive diagnosis and treatment. Identifying these emergent cases early is imperative because of the high risk of maternal death. The nurse practitioner should consider this emergent diagnosis in all women of childbearing age who present to the emergency department with acute lower abdominal pain.     

子宫部位异位妊娠临床分析

目的探讨子宫部位异位妊娠的临床特征和处理对策。方法回顾分析2002年9月-2009年9月间收治的31例子宫部位异位妊娠患者的临床资料。结果 31例患者中,初诊确诊仅8例,误诊率74.2%。除5例因难以控制的大出血行经腹病灶清除术加子宫修补术或全子宫切除术外,其余26例患者均经氨甲喋呤（MTX）治疗加清宫术或宫腔镜下病灶清除术保守治疗成功。结论子宫部位异位妊娠容易误诊,超声检查是诊断的主要方法。保守治疗安全、有效,可保留生育能力。氨甲喋呤治疗加清宫术可作为治疗子宫部位异位妊娠的主要方法。     

Ectopic pregnancy.

The incidence of ectopic pregnancy has been increasing for many years and currently is two to three times higher than it was 20 or 25 years ago. The reasons for this are complex and include increased rates of pelvic and tubal infection, the use of the IUD, surgery in the pelvis for infertility, sterilization and other surgical procedures, in vitro fertilization, and improved diagnosis. Normal tubal physiology, the findings in affected tubes, and the mechanisms of how the ectopic pregnancy develops and involves the tube are considered. The cardinal points of the history and physical examination are presented in considerable detail. Further, the evolution of the tools of diagnosis--curettage, culdocentesis, laparotomy, laparoscopy, hormonal tests, and ultrasound-is considered. The different approaches to therapy are presented. Salpingectomy was once the method of accepted therapy, but currently conservative management (salpingostomy) is the most acceptable approach. More recently, selected patients are being treated with observation and a small subgroup are being managed with methotrexate and other chemical agents injected directly into the ectopic pregnancy. Ectopic pregnancy is still a leading cause of maternal death despite improved diagnosis and therapy. It should be remembered, however, that the total number of women who die from this condition is less than ever before and this is despite the rising incidence of ectopic pregnancy. There is still much to be learned about ectopic pregnancy, its etiology, diagnosis, and management.