Team Sono Chronicles: Ectopic Pregnancy

Written by: Dr. Randi Ozaki

Team Sono recently had its first meeting, and it was a resounding success! We met up at Black Forrest Brooklyn for some beer, bratz and pretzels and discussed two papers about sonographic findings in ectopic pregnancy. Here is a brief summary of the two papers for those of you who couldn’t make it to the meeting.

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Paper 1: Adnexal Sonographic Findings in Ectopic Pregnancy and Their Correlation with Tubal Rupture and hCG Levels

The first paper was a retrospective review from July 1, 2008 to August 31, 2011 of patients who underwent a transvaginal sonogram to rule-out ectopic pregnancy and were not found to have an intrauterine gestation. Findings were confirmed either by surgical confirmation or pathology results. Patients treated nonsurgically for presumed ectopic were also included in the study.

A reviewer blinded to the clinical outcome graded the ultrasound findings (1, nonspecific mass; 2, tubal ring; 3, yolk sac without heart beat; 4, embryo with heart beat) and made note of the degree of color flow and the presence and degree of free fluid. Pathology, surgical findings, beta-hCG level and presence or absence of tubal rupture were recorded.

The study included 231 ectopic pregnancies. An adnexal mass was identified on ultrasound in 218 cases. Ultrasound showed a grade 1 adnexal mass in 125 (54.1%), grade 2 mass in 57 (24.7%), grade 3 mass in 19 (8.3%), and grade 4 mass in 17 (7.4%).

  • hCG levels ranged from 7 – 107,949 mIU/mL (7!!!!).
  • Mean hCG levels increased with the grade of adnexal mass.
  • The degree of color flow did not significantly correlate with the presence or absence of a tubal rupture.
  • Rate of rupture was found to be higher in those found to have moderate to large amount of free fluid when compared to those with small or no free fluid.

Bottom line: Sonographic findings cannot accurately predict presence or absence of tubal rupture and there was no correlation between hCG level and tubal rupture. Notably, 9.7% of patients with hCG levels < 500 mIU/mL were found to have tubal rupture at surgery

Limitations:

  • Adnexal mass findings and measurements were somewhat subjective and may have represented blood clots instead of the ectopic contents.
  • Those treated nonsurgically did not have any surgical or pathologic confirmation of diagnosis.
  • Some patients had multiple ultrasounds done, and the study done closest to the time of treatment was used for the review; this may have biased the results.

1

Left: Pelvic free fluid; Right: Empty uterus with extrauterine cystic structure (pc: Dr. Bon).

 

Paper 2: Do All Women with Indeterminate Pregnancies Need a Formal Ultrasound Before Discharge from the Emergency Department?

This was a retrospective review from August 2010 to March 2011 of women who only received an ED ultrasound with indeterminate findings and were then discharged with referral for 48-72 hour re-evaluation. Women with a beta-hCG greater than 3000 mIU/mL were excluded. The primary outcome was the fetal outcome and incidence of ectopic pregnancy.

  • 49 patients were included in the study with a beta-hCG range of 7-2903 mIU/mL
    • 29 (59.2%) had spontaneous abortions
    • 18 (36.7%) had normal pregnancies
    • 2 (4.1%) had ectopic pregnancies

Patients with ectopic pregnancy had no adverse outcomes. They also had no classic risk factors. One was treated successfully with methotrexate and the other ectopic pregnancy resolved spontaneously after a period of observation.

Of the other women, 9 had a history of GC/CT of which 4 had normal pregnancies and 5 had spontaneous abortions. Three women had a history of pelvic surgery, and all of them had spontaneous abortions.

Bottom Line: Patients with indeterminate ultrasounds with beta-hCG levels within the discriminatory zone (< 3000 mIU/mL) may be safely discharged as long as good follow-up is ensured.

Limitations: This was a small study population; a larger study needs to be done to validate findings and to evaluate for more ectopic pregnancy outcomes.

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Right adnexal ectopic (pc: Drs. Donnelly and Schechter)

Conclusion: There are no sonographic findings that can accurately predict tubal rupture in patients with suspected ectopic pregnancies. While beta-hCG levels cannot predict presence or absence of ectopic pregnancy, this study suggests that patients with indeterminate ultrasounds with beta-hCG within the discriminatory zone may be safely discharged with close follow-up.

 

Agree? Disagree? Leave your thoughts below.

 

References:

1. Frates M, Doubilet P, Peters HE, Benson CB. Adnexal Sonographic Findings in Ectopic Pregnancy and Their Correlation With Tubal Rupture and Human Chorionic Gonadotropin Levels. J Ultrasound Med. 2014; 33: 697-703.

2. Kus MS and Juliano ML. Do All Women with Indeterminate Pregnancies Need a Formal Ultrasound Before Discharge from the Emergency Department. Military Medicine. 2014. 11: 1263-1265.

 

Edited by: Shibata

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jshibata

  • Editor in Chief of The Original Kings of County 
  • EM/IM PGY4

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4 comments for “Team Sono Chronicles: Ectopic Pregnancy

  1. iandesouza
    July 30, 2016 at 5:27 pm

    Great post and it looks like it was a fun event. What should we do if we has pregnant patient with pain or bleeding whose sono is indeterminate but there is free fluid in the pelvis (any amount)? Should a formal US then be performed? Also, does the beta-hCG matter in this case?

    • Randi Ozaki
      July 31, 2016 at 5:06 pm

      I think the answer to this question is easy if the patient is unstable. If a patient is pregnant, hypotensive with free fluid and no definitive IUP, this is a patient that should go the OR immediately as they likely have a ruptured ectopic.

      If a patient is stable but with free fluid and abdominal pain, they should still be considered to have an ectopic until proven otherwise, no matter what the beta-hcg level. As these papers show, patients with beta-HCGs as low as 7 were found to have an ectopic and in the first paper 9.7% of those found to have intraoperative findings of tubal rupture had a beta hcg level <500. These patients should have a stat gyn consult and probably should not wait for a formal US to be performed before a gyn evaluation.

  2. iandesouza
    July 31, 2016 at 5:28 pm

    So then, referring to the 2nd paper (which was limited in design) and to further clarify, only those patients with indeterminate US (defined as empty uterus or gestational sac), no adnexal mass or free fluid on bedside US, and beta-hCG < 3000 MAY be be safe for discharge/close f/u without undergoing a formal US.

    • Randi Ozaki
      August 1, 2016 at 1:14 pm

      Yes as long as they have good follow-up for a repeat beta/ultrasound.

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