Archive for the ‘ectopic’ Category

Key Points In hemodynamically stable patients, the history and physical are insufficiently accurate to either rule in or rule out ectopic pregnancy.  The threshold should be very low to enter a patient with early pregnancy and symptoms or signs potentially referable to ectopic pregnancy into a rule out ectopic process. In contrast to what most of us were taught, the index beta HCG measurement does not discriminate among ectopic pregnancy, failed/failing intrauterine pregnancy, and early/healthy intrauterine pregnancy with sufficient accuracy to guide decision-making. Put more simply, the beta does not help you. If the ultrasound shows no IUP or ectopic, do not be reassured by a low beta and do not be alarmed by a high beta. The patient may have a healthy IUP, she may have a nonviable IUP that is miscarrying or will miscarry, or she may have an ectopic pregnancy; the beta doesn’t make any of these three diagnoses more or less likely enough to be a useful test to us, on the index visit. This is not controversial, the evidence is plentiful [1, 2, 3, 4, 5, 6, 7], and ACEP’s recent clinical policy states at a Level B recommendation, “Do not use the beta-hCG value to exclude the diagnosis of ectopic pregnancy in patients who have an indeterminate ultrasound.” If the beta is a million zillion, feel free to diagnose molar pregnancy. If IUP is confirmed by ultrasound, measurement of quantitative beta is unnecessary. If ultrasound shows no evidence of IUP or ectopic, a quantitative HCG level should be sent but the…