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Rapid diagnosis of ectopic pregnancy using emergency bedside ultrasonography

Is your patient’s abdominal pain a pregnancy gone wrong? Using bedside ultrasonography can improve your diagnostic proficiency and provide expedient care for your patients.

Barbara Piccirillo, MS, RPA-C

A 40-year-old woman presented to the emergency

department (ED) complaining of sharp, localized

right lower quadrant (RLQ) abdominal pain for 1

day associated with vaginal spotting for 1 week. Her his- tory included four previous pregnancies resulting in healthy births, with the last pregnancy being 5 years previously. The patient denied being pregnant, stating that her menstrual cycle had always been regular and reporting her last menstrual period (LMP) as 2 weeks ago. She had no fever, chills, vomiting, dizziness, or uri- nary tract symptoms. The patient denied any history of pelvic inflammatory disease (PID) or any sexually trans- mitted disease. Hypertension was diagnosed 2 years before and treated successfully with diet and exercise. There were no previous surgeries. The patient was tak- ing no medications, and she denied any allergies, smok- ing, alcohol abuse, or use of recreational drugs. The review of symptoms was otherwise negative. Vital signs were BP, 138/84 mm Hg; pulse, 85 beats per minute and regular; respirations, 19 breaths per minute; and temperature, 98ºF (36.7ºC). The patient’s general appearance revealed mild distress, due to ab- dominal pain. The heart and lung examinations were unremarkable. The abdominal examination was positive for RLQ tenderness with voluntary guarding. The pelvic examination revealed right adnexal tenderness with an associated palpable mass and scant blood in the vaginal vault, with a closed cervical os. The result of a

The author works in emergency medicine at New York Methodist Hospital, Brooklyn, NY, and is Assistant Professor and Clinical Coordinator at the New York Institute of Technology Physician Assistant Program, Old Westbury, NY. She has indicated no rela- tionships to disclose relating to the content of this article.

urine pregnancy test was positive. Emergent bedside ultrasonography (US) was performed in the ED.

Ectopic pregnancy

As the initial screening method to rule out ectopic preg- nancy (EP), bedside US is increasingly used in many EDs. In the United States, EP is still the leading cause of first- trimester maternal death. The incidence increased more than fourfold from 1970 to 1992; the CDC estimates that almost 2% of all pregnancies are ectopic. 1 Up to 50% of cases of EP are misdiagnosed at initial presentation, and morbidity and mortality can be significantly decreased if EP is promptly identified and treated prior to rupture. 2-4

Pelvic US examinations that evaluate early pregnancy are low-frequency TAS and high-frequency TVS.

The causes and risk factors for EP are numerous, but most patients have no identifiable risk factor. 5 Evidence supports a history of prior tubal damage leading to physiologic alterations in embryo transport. The most common associated pathology is PID caused by Chla- mydia trachomatis. 6 Other risk factors are previous tubal ligation and surgery, prior EP, endometriosis, pre- vious pelvic surgery, use of a progesterone-impregnated intrauterine contraceptive device, increased maternal age, a history of infertility and infertility treatments, uterotubal anomalies, in utero exposure to diethylstil-

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Bedside ultrasonography

IN THIS ARTICLE Key Points ➤ Transabdominal or transvaginal ultrasonography performed at the bedside is
IN THIS ARTICLE
Key Points
Transabdominal or transvaginal ultrasonography
performed at the bedside is fast, feasible, accu-
rate, and associated with improved patient out-
come in the emergency department.
Ectopic pregnancy is a common clinical condition
associated with high morbidity and mortality. Al-
though its prevalence appears to be increasing, the
clinical outcome is improving, thanks to advances in
early diagnosis, management, and treatment.
The clinician should maintain a high index of suspi-
cion for high-risk patients and women of childbear-
ing age who present with unexplained hypotension,
abdominal pain, amenorrhea, or vaginal bleeding.
Competencies
Medical knowledge
◆◆◆◆◆
Interpersonal & communication skills
◆◆
Patient care
◆◆◆◆
Professionalism
Practice-based learning and improvement
Systems-based practice
For an explanation of competencies ratings, see the table of contents.

bestrol, and cigarette smoking. 7-13 Lesser risk factors include multiple sexual partners, early age at first inter- course, and vaginal douching. 9-11

Diagnosis

The fallopian tube is the site of 95% of EPs, with the bal- ance in the cervix, ovary, or abdomen. Physical examina- tion may demonstrate cervical motion tenderness, ab- dominal tenderness, an adnexal mass, or mild uterine enlargement but can be unreliable since findings are most often nonspecific, particularly with a small, unruptured EP. Traditionally, the diagnosis has been based on the overall clinical picture with an emphasis on the signs and symptoms (see Tables 1 and 2, page 33). Laboratory tests should include a CBC, urinalysis, blood typing with determination of Rh factor, and test for quantitative beta-human chorionic gonadotropin (hCG). The rate of increase in serum beta-hCG levels is predictable and measurable in pregnancy, rising rapidly, doubling in concentration every 2 to 3 days, and peaking at around 100,000 to 200,000 mIU/mL, which corre- sponds approximately to the 10th week of pregnancy. The discriminatory zone is the range of quantita- tive serum beta-hCG concentrations above which a ges- tational sac can be visualized consistently by US. 12 The

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transabdominal sonography (TAS) examination should consistently detect an intrauterine sac when the beta- hCG level is greater than 6,500 mIU/mL (corresponding to a 6-week gestation). The transvaginal sonogram (TVS) has increased sensitivity, with higher resolution, and can diagnose an intrauterine pregnancy (IUP) 1 week earlier, with a lower discriminatory zone (beta-hCG level between 1,000 and 1,800 mIU/mL). 14 Urinary beta-hCG testing is the most common meth- od for confirming pregnancy. Urine enzyme-linked immunosorbent assays detect beta-hCG levels of 50 mIU/mL, which correspond to a pregnancy at 3 to 4 days after implantation. Serum and urinary assays for beta-hCG have become so sensitive and specific that they are nearly always positive by the time an EP be- comes symptomatic. Thus, in nearly all cases, a negative pregnancy test effectively rules out the diagnosis of EP, allowing the practitioner to focus on other gynecologic, GI, or renal causes of symptoms. 15 Upon confirmation of pregnancy, pelvic US and serum quantitative beta-hCG levels can provide the necessary data to accurately as- sess early pregnancy.

Pelvic ultrasonography

The two pelvic US examinations that evaluate early

pregnancy are low-frequency TAS and high-frequency TVS. They provide complementary imaging and should be employed together in the routine evaluation of a sus- pected EP. The axiom is that the higher the frequency, the greater the resolution. When scanning through deeper structures, as with TAS, a lower resolution of 3.5 to 5 MHz is employed. Conversely, TVS imaging with higher frequencies (5-7.5 MHz) permits precise imaging of near structures; therefore, early gestational age pregnancies are seen sooner. The limitation of using TVS exclusively is that high- er frequency means shorter focal length, with decreased ability to clearly see structures located outside of the pelvic brim. The diagnosis of an IUP can be made 1 week earlier (at 4 weeks’ gestation) with TVS than with TAS, which can make the diagnosis at approximately 5 weeks’ gestation. Both techniques can evaluate the contents of the endometrial cavity and assess the pres- ence and amount of free peritoneal fluid within the pouch of Douglas (retrouterine pouch). TAS is a noninvasive procedure with easier orienta- tion and a wider field of visualization. It requires a full urinary bladder that permits a near-perfect acoustic window for transmitting US waves and displaces bowel loops from the pelvis to permit adequate visualization of the uterus and its contents. TVS has a more complex ori- entation, a narrower field of vision, and no requirement for a full urinary bladder (some urine within the bladder is helpful for orientation). Continued on page 33

Bedside ultrasonography

Methodology A pelvic examination should always precede pelvic US. In the stable patient, begin with a speculum examination assessing cervical os integrity and/or the presence of the products of conception within the vaginal vault, followed by a bimanual pelvic exam- ination to determine the relative position of the uterus and to detect tenderness or a palpable mass. TAS utilizes two perpendicular planes for viewing the pelvic organs and abdominal cavity: the longitudinal (sagittal) and transverse planes. Place the patient in the supine position, exposing the pelvic and abdominal area from the mons pubis to the xiphoid process. Apply con- duction gel to the pelvic area prior to examination. Ex- amining the patient’s right upper quadrant (RUQ) is important because blood may pool in the subhepatic area rather than in the pelvis, particularly in the supine position. Proceed with an endovaginal scan in both the longitudinal and coronal planes. In the unstable patient, the appropriate sequence is simultaneous resuscitation efforts, confirmation of a pos- itive urinary pregnancy test result, and TAS in the RUQ (Morison’s pouch) in search of intraperitoneal hemorrhage. This approach decreases time to diagnosis and operative intervention; patients are taken directly to the OR. 16-18 TAS The triangular area in Figure 1 (page 34) outlines the imaging field. The transducer is placed just above the pubic symphysis, with the marker pointing cranially. Starting in the midline, the anechoic bladder should be immediately visible. A full urinary bladder displaces bow- el loops and outlines the pear-shaped empty uterus. There is fluid in the posterior cul-de-sac (pouch of Douglas). Figure 2 (page 34) shows an image obtained in the transverse plane. The transducer is rotated 90 degrees from the long axis of the uterus (longitudinal plane) in a counterclockwise direction (the marker points to the pa- tient’s right). Imaging starts by angling the transducer caudally (toward the pubic bone), then moving it in a slow sweeping motion in the cranial direction to visual- ize and expose the pelvic contents. This image reveals an empty uterus. RUQ (Morison’s pouch) Abdominal US of the hep- atorenal space should be performed on every patient with a possible EP. 19,20 Morison’s pouch is normally a space between Glisson’s capsule of the liver and Gerota’s fascia, surrounding the kidney. Studies have shown that fluid in Morison’s pouch seen on RUQ US indicates that there is 400 to 700 mL of free fluid in the abdomen. 21,22 Patients who have a positive pregnancy test, no IUP on US, and free fluid in the hepatorenal recess have near- ly a 100% chance of having a ruptured EP. 23 Figure 3 (page 34) is a TAS longitudinal scan of the RUQ demonstrating an anechoic area between the liver and kidney in a patient with intraperitoneal hemor- rhage from a ruptured EP.

TABLE 1

 

Ectopic pregnancy signs and symptoms

Common early signs and symptoms

Patient can be asymptomatic

• Abdominal pain (especially one-sided and/or low)

• Late or missed menses (although a woman can start experiencing symptoms before she misses

a

period)

• Vaginal spotting or bleeding

• Tissue passage from the vagina

• Symptoms associated with pregnancy (nausea, vomiting, breast tenderness, and fatigue)

Late signs and symptoms

Usually related to fallopian tube rupture

• Dizziness and syncope (hypovolemic shock)

• Shoulder pain in Trendelenburg’s position (blood irritating the diaphragm)

• Weakness, tachycardia, bloating, hypotension, and

a

tense lower abdomen

TABLE 2

 

Differential diagnosis of ectopic pregnancy

Acute salpingitis

Appendicitis

Gastroenteritis

Normal intrauterine pregnancy

Ruptured corpus luteum cyst

Threatened or incomplete abortion

Torsion of an enlarged ovary

TVS Two basic planes are addressed in TVS scanning, the sagittal (longitudinal) and coronal planes. There is no transverse plane because the probe can never be truly oriented transversely to the long axis of the patient’s body. Cover the probe with a condom or latex glove, after placing conducting gel inside along the tip of the probe. Situate the patient in the lithotomy position. Insert the probe gently into the vaginal canal with the marker facing the anterior abdominal wall. Figure 4 (page 34) is a transvaginal image in the lon- gitudinal plane revealing an empty uterus with free fluid in the posterior cul-de-sac. To obtain images in the coronal plane, the transducer is rotated 90 degrees in a counterclockwise direction. (The marker is pointing to the patient’s right.) The actual image appears reversed on the monitor, as demonstrated in Figure 5 (page 35),

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Bedside ultrasonography

FIGURES Abdominal transducer Outline of TAS transducer Bladder FIGURE 1: Transabdominal longitudinal sonogram
FIGURES
Abdominal
transducer
Outline of TAS
transducer
Bladder
FIGURE 1: Transabdominal longitudinal sonogram
Urinary bladder
Right
ovary
Left
ovary
Fluid in the cul-de-sac
FIGURE 2: TAS image obtained in the transverse
plane
Liver
Free fluid in
hepatorenal
space
Right kidney
FIGURE 3: An anechoic area between the liver
and kidney on a longitudinal TAS
Urinary bladder
Free fluid
in posterior
cul-de-sac
Anterior
FIGURE 4: TVS longitudinal image of an empty
uterus with free fluid in the posterior cul-de-sac

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a transvaginal scan in the coronal plane revealing an empty uterus and a full urinary bladder. Early normal IUP structures The gestational sac

(GS) is the first indication of pregnancy. A true GS is char- acterized by a sonolucent center surrounded by two bright, echogenic concentric rings referred to as the dou- ble decidual sac sign (DDSS): the decidua capsularis (the inner ring) and the decidua vera (the outer ring). The decidua is the endometrial lining. In a normal IUP, the DDSS is located eccentrically to the endometrial stripe. The fertilized ovum embeds in the endometrial tissue that forms the chorionic vesicle, which envelops the develop- ing embryo. The earliest detection on TAS is at 6 weeks from the LMP, compared to TVS, which visualizes it at 4.5 weeks. When the GS is identified, the gestational age can be approximated in days by utilizing the following for- mula: longitudinal plane length and height, transverse plane width (L + W + H / 3 + 30 = days). Figure 6 shows

a TVS coronal scan illustrating the DDSS. Pseudogestational sac A GS with a vague or absent DDSS is not diagnostic of an IUP and may be a pseudo- gestational sac, which is merely a collection of fluid sur- rounded by the endometrium. Seen in 25% of EPs, a pseudo sac represents reactive changes and is oval in contour with thin margins, in contrast to a true GS. Figure 7 shows a transvaginal longitudinal scan of a uterus containing a pseudo sac in a patient who had an EP. An echogenic chorionic ring does not surround the pseudo sac. Early normal IUP The yolk sac, also referred to as

a balloon on a string, is the first visible extraembryon-

ic structure, visualized at 5 to 6 weeks’ gestation on TVS. At this stage, the embryo is much smaller than the yolk sac. The yolk sac disappears after 10 to 12 weeks, forming part of the fetal gut and placenta. If the GS is larger than 10 mm on TVS, the yolk sac should be visible. An IUP is probably abnormal if the GS is larger than 20 mm without a yolk sac or is a fetal pole without cardiac pulsations. This becomes a good predictor of embryonic demise and is commonly referred to as a blighted ovum. 20,24,25 Figure 8 is a transvaginal longitu- dinal image showing a small embryo and yolk sac with- in an intrauterine GS in a normal early pregnancy. Figure 9 (page 36) shows a transabdominal transverse scan of an early IUP. Normal implantation is eccentric. Interstitial pregnancy Asymmetrical implantation within the uterine cavity is consistent with an interstitial EP, an uncommon form of EP with a high morbidity and mortality. The most specific finding is an incomplete myometrial mantle around the sac. 26 The myometrial mantle is the measurement of the uterine myometrium surrounding the GS and the echogenic decidual layer. This thickness should measure 5 mm or more. A finding of less than 7 mm suggests the diagnosis of interstitial

pregnancy. Figure 10 (page 36) shows a myometrial mantle measurement of 1.33 cm between the calipers. Early normal pregnancy The fetal pole is the earli- est embryonic structure and can be visualized intimate- ly adjacent to the yolk sac. The measurement of the fetal pole is referred to as crown-rump length (CRL) and is the most accurate sonographic measurement for dating the pregnancy. Figure 11 (page 36) is a transvaginal lon- gitudinal scan showing proper placement of cursors for CRL measurement. The maximal embryo length is measured, excluding the yolk sac. To estimate the gesta- tional age in weeks, 6.5 is added to the CRL in centime- ters. For example, a CRL of 1.5 cm + 6.5 = 8 weeks. Embryonic cardiac activity is the gold standard for the diagnosis of a living IUP. Trace and document this motion with M-mode on the US machine. Subtle EP findings There are several nonspecific, nondiagnostic sonographic findings that are highly sug- gestive of an EP in the patient with a positive level of beta-hCG and an empty uterus. Some are subtle and can be easily missed, so a “formal” US should be obtained if no IUP or EP is identified. Findings on pelvic US suggesting EP are an empty uterus, a pseudo sac within the uterus, fluid in the cul-de-sac, a complex pelvic mass, a tubal ring, and hepatorenal free fluid in Morison’s pouch. 23,27-31 A def- inite EP in the adnexa is visualized as a thick, brightly echogenic ringlike structure (tubal ring) outside the uterus with an obvious GS containing a visible fetal pole and/or yolk sac. Figure 12 (page 36) is a transvaginal lon- gitudinal scan illustrating an echogenic tubal ring in the adnexa. The inset image shows the bladder outlined in blue, the uterus in pink, and the EP in red (tubal ring).

Outcome of the case

The patient had a formal pelvic scan revealing an empty uterus with significant fluid in the posterior cul-de-sac. The quantitative beta-hCG was 11,800 mIU/mL. An obstetric consultation was requested, and a laparoscopy was performed. The intraoperative findings consisted of positive products of conception in the right adnexa. Free fluid is the only abnormal sonographic finding in approximately 15% of EPs. 30 The greater the volume of free intraperitoneal fluid, the greater the likelihood of EP. 20 Free fluid may be due to a slow blood leak from the end of the fallopian tube. Although a small amount of hypoechoic free pelvic fluid may be normal, it must be considered suspicious in the setting of a pregnant patient with an empty uterus. 23,28-30 This case under- scores the challenges involved in diagnosing vaginal bleeding and abdominal pain in early pregnancy and demonstrates how the combination of bedside pelvic US and discriminatory laboratory tests are employed to arrive at the eventual diagnosis.

Figures 9-12 and references are on page 36

 

FIGURES

Urinary bladder Right ovary Uterus
Urinary
bladder
Right
ovary
Uterus

FIGURE 5: An empty uterus and a full urinary bladder on coronal TVS

Early normal IUP Double decidual sac sign of early pregnancy Decidua capsularis Decidua vera
Early normal IUP
Double decidual sac sign
of early pregnancy
Decidua capsularis
Decidua vera

FIGURE 6: TVS coronal scan illustrating the DDSS

Urinary bladder Pseudo- gestational sac within the uterus
Urinary bladder
Pseudo-
gestational
sac within
the uterus

FIGURE 7: TVS longitudinal scan of a pseudo sac in EP

Yolk sac, “balloon on a string” Small embryo
Yolk sac,
“balloon on
a string”
Small embryo

FIGURE 8: TVS longitudinal image of a small intrauterine embryo and yolk sac

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Bedside ultrasonography

FIGURES

FIGURES FIGURE 9: TAS transverse scan of an early IUP FIGURE 11: TVS scan showing proper
FIGURES FIGURE 9: TAS transverse scan of an early IUP FIGURE 11: TVS scan showing proper

FIGURE 9: TAS transverse scan of an early IUP

FIGURE 11: TVS scan showing proper placement of cursors for CRL measurement

scan showing proper placement of cursors for CRL measurement FIGURE 10: A myometrial mantle measurement of
scan showing proper placement of cursors for CRL measurement FIGURE 10: A myometrial mantle measurement of

FIGURE 10: A myometrial mantle measurement of 1.33 cm between the calipers

FIGURE 12: TVS longitudinal scan of an echogenic tubal ring in the adnexa

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