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Does This Women Have an Ectopic Pregnancy? Interview With Dr John R. Crochet
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Does This Women Have an Ectopic Pregnancy? Interview With Dr John R. Crochet
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>> Hello, and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I'm David Simel, the Editor of the Rational Clinical Examination Series, and a Professor of Medicine at the Durham Veterans Affairs Medical Center in Duke University in Durham, North Carolina. Today we're talking to an author of a recent article on "Does This Woman Have an Ectopic Pregnancy?" Dr. John Crochet is a reproductive endocrinologist at the Center of Reproductive Medicine in Houston, Texas, and an adjunct faculty member of the University of Texas Medical Branch, Galveston, Texas.
Welcome, John. I wonder if you could tell us exactly what is an ectopic pregnancy? >> An ectopic pregnancy is the implantation of a fertilized egg and embryo outside of the uterine cavity. >> Tell us about the risk factors for who would develop that. >> So the interesting thing about ectopic pregnancies and risk factors is that more than half of the women who are ultimately diagnosed with ectopic pregnancy have no identifiable risk factors. There are some risk factors that have been associated with the presence of an ectopic pregnancy, and the ones that have the strongest association is a woman who's had a prior ectopic pregnancy, a woman who's had pelvic inflammatory disease, or has a documented infection with chlamydia.
Those would be the most common. There are some other risk factors that have a weaker association, and those would include a woman that currently has an IUD in place, concern for pelvic adhesions, maybe prior surgeries, a woman who's got endometriosis, and also cigarette smoking. >> So if the risk factors aren't strong, when should we consider an ectopic pregnancy, and how often do they occur? >> Ectopic pregnancies are common. As a subset of all pregnancies, ectopic pregnancies account for about 2 percent of all pregnancies, so it is common and it's something that should be on our radar in certain groups of women.
In women who are of reproductive age and have pain and/or bleeding, lower abdominal pain, pelvic pain, and vaginal bleeding, that would be the patient where we're concerned about the potential for ectopic pregnancy. In particular, in that group of women who have had either a urine pregnancy test or a serum pregnancy test that indicates that they are, in fact, pregnant, that would increase your concern for the possibility of ectopic pregnancy. >> So while a serum human chorionic gonadotropin, or the hCG test, I think is the serum test you're referring to, establishes that a woman is pregnant, does the level of that result or any other lab test help establish the presence of an ectopic pregnancy?
>> It doesn't. And I was referring to the serum hCG human chorionic gonadotropin. It simply lets us know whether or not the woman is pregnant. Of course, the value is quantitative, so there are things to consider at certain levels of that hormone, but in general, a single serum hCG does not predict pregnancy viability or location at all. There are instances clinically where it's important to obtain serial hCGs, so hCGs over several days.
By convention, it's usually every 48 hours. And when you look at the change in hCG over that 48 hours, that can be a very helpful tool to assess the viability of the pregnancy. Still, serum hCG is not helpful at predicting pregnancy location. >> So we've discussed that the risk factors aren't strong predictors, and the serum pregnancy test, as a single test, is not a particularly strong predictor. I think we better tell our listeners about physical exam findings and whether they're helpful for diagnosing an ectopic pregnancy.
>> Right. Unfortunately, there's limitations there. As with any condition, a woman comes into your office or comes into the emergency room and she's got these complaints that are concerning for the potential for ectopic pregnancy, and we're going to perform a detailed history and physical. And although there are the presence of risk factors that we would be looking for, there's no components of the patient history that is predictive or helpful really in ruling out or ruling in an ectopic pregnancy.
And when you look at specific physical exam findings, there are physical exam maneuvers or findings that would be helpful at increasing your suspicion or lowering your suspicion or concern for ectopic pregnancy, such as cervical motion tenderness or the presence of an adnexal mass or adnexal tenderness on a bimanual examination. These are specific physical exam findings that would increase the examiner's suspicion for that condition. >> So we have a woman who's pregnant, who comes in with abdominal pain and we may find cervical motion tenderness or an adnexal mass or adnexal tenderness on her exam.
It sounds to me like we're moving to ultrasound as the next test. So tell us about the role of ultrasound. >> Ultrasound is crucial. That's really the bottom line take home, is that it's absolutely imperative, if there's pain and bleeding in the early part of pregnancy, the next step is to evaluate with specifically a vaginal ultrasound. There are, you know, different modalities of ultrasounds, one of those being abdominal ultrasound, and although many years ago that was an acceptable practice, in this day and age abdominal ultrasound is just not sensitive enough to fully evaluate the adnexa, the area next to the uterus where the fallopian tube would be and the most common location for an ectopic pregnancy.
So it makes a vaginal ultrasound necessary. And what we've seen or what has been shown is that in these women, when you can do a vaginal ultrasound and prove that there is, in fact, an intrauterine pregnancy, that virtually rules out the possibility of that woman also having an ectopic pregnancy. Now, there are circumstances where women can have both, we call this a heterotopic pregnancy, and that would be more common in a woman who's done fertility treatment, but in general, that is still very, very uncommon.
Also, when a woman has a vaginal ultrasound, in a patient like you described, and you do detect an adnexal mass and it doesn't necessarily have to be a gestational sac or an obvious fetal pole, but when you have an adnexal mass, in the setting of also having an empty uterus, it almost makes the diagnosis of an ectopic pregnancy a certainty. >> Well, is there anything else you'd like to tell our listeners about the clinical examination for ectopic pregnancy? >> I think the most important thing is that ectopic pregnancy is still a significant source of maternal morbidity, especially in the early part of pregnancy.
Ectopic pregnancy is employing the right diagnostic modalities of serial hCGs and transvaginal ultrasounds. We can make diagnoses early and that gives us the opportunity to treat these women in less invasive ways, ways that not only preserves their health, but preserves their future fertility. And most importantly, it allows us to get a diagnosis long before an ectopic pregnancy becomes an immediate health risk. One of the concerns with ectopic pregnancy is that the tube can become so distended that it ruptures and causes bleeding into the abdomen, into the pelvis, and that would require, you know, immediate surgery for that patient, and also possibly blood transfusions.
So with early diagnosis we can prevent these things. >> Well, John, I want to thank you for talking with us today. More information about this topic is available on the Rational Clinical Exam and on our website, JAMAevidence.com, where you can listen to our entire roster of podcasts. I'm David Simel and I'll be back with you soon for another edition of JAMAevidence.
