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Three Part Question

When a [woman of childbearing age presents to A&E with vaginal bleeding] is [the physical examination beneficial] in [diagnosing/ruling out an ectopic pregnancy]?

Clinical Scenario

A 26 year old woman presents to accident and emergency with vaginal bleeding. She has a positive pregnancy tes. You suspect she may have an ectopic pregnancy and wonder if any findings on examination are can help rule in/out this diagnosis?

Search Strategy

Medline 1966-06/05 using the OVID Interface
Embase 1980-06/05
CINAHL 1982-06/05
The Cochrane Library Issue 2, 2005
({[physical examination.mp. or exp Physical Examination or examination.mp or medical examination.mp] AND [tubal pregnancy.mp or exp PREGNANCY, TUBAL or ectopic pregnancy.mp or exp PREGNANCY, ECTOPIC or abdominal pregnancy.mp or exp PREGNANCY, ABDOMINAL or extrauterine pregnancy.mp]} LIMIT to humans and english language)
Cochrane 'ectopic pregnancy' AND 'examination'

Search Outcome

435 papers were found using medline, of which 4 were relevant. No additional papers were found using the other databases.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dart RG et al 1999 UNITED STATES	Consecutive patients from 1 Aug 1991-31 Aug, who had abdominal pain or vaginal bleeding and a positive beta-human chorionic gonadotropin level	Prospective observational study	Findings that increase risk of ectopic pregnancy	Odds ratio (95% CI): Pain intensity mod-severe 3.4 (1.6-7.1), Pain location lateral 2.2 (1.2-4.0), Pain quality sharp 2,0 (1.0-4.0), Cervical motion tenderness 3.3 (1.6-6.6), Lateral or bilat pelvic tenderness 2.4 (1.3-4.4) Lateral or bilat abdo tenderness 2.0 (1.1-3.7), Positive peritoneal signs 7.9 (3.1-20.0)	Only 57 patients with an ectopic pregnancy
			Findings that decrease risk of ectopic pregnancy	Odds ratio (95% CI): Pain midline 0.31 (0.14-0.66) and uterine size >8 weeks 0.42 (0.19-0.96)
			Hx and findings not predictive of ectopic pregnancy	Odds ratio (95% CI): Passed tissue 0.66 (0.19-2.1), Os open 0.48 (0.14-1.46), Bleeding: none to mild 1.2 (0.6-2.2), Pulse >100 beats/min 1.4 (0.6-3.0), Systolic BP <100mm Hg 0.33 (0.02-2.4), Adnexal mass 2.2 (0.63-6.6)
Stovall TG et al 1990 UNITED STATES	All ED patients with a positive urine pregnancy test treated between 1 Jan-31 Dec, 1988	Prospective, consecutive case series	IUP (n=349)	Vaginal bleeding 16%,* Adnexal tenderness 14.3%,* Adnexal mass 7.4% & Cervical motion tenderness 13%.* *p<0.05
			Unruptured ectopic pregnancy (n=100)	Vaginal bleeding 39%,* Adnexal tenderness 28%,* Adnexal mass 4%,*& Cervical motion tenderness 25%.* *p<0.05
Kaplan BC et al. 1996 UNITED STATES	481 consecutive pregnant patients who presented to an urban ED with first-trimester abdominal pain or vaginal bleeding History, physical examination findings, quantitative beta-hCG values, sonography findings, surgical findings, and final diagnosis were collected after patient enrollment in the study	Prospective, consecutive case study	Examination findings	Adnexal tenderness: 64%, Cervical motion tenderness 43%	Did not look at many findings
			Physical examination	Sensitivity: 64%
Buckley RG et al 1999, Nov UNITED STATES	All hemodynamically stable, first-trimester patients with abdominal pain or vaginal bleeding who presented to a military teaching hospital emergency department underwent follow-up until an outcome of intrauterine pregnancy (IUP) or EP was established	Prospective cohort	High risk	Peritoneal irritation on abdominal examintaion or definite cervical motion tenderness: Senitivity(95% CI) 32% (17%-49%), specificity 95% (92%-97%), PPV 32% (17%-49%), NPV 95% (92%-97%), Positive likelihood ratio 6.1, Negative likelihood ratio 0.7	There are a few limitations: Protocol instruced physicians to code findings before obtaining an US or other data, this might have introduced classification bias Only included symptomatic patients
			Intermediate risk	No fetal heart tones by handheld doppler AND tissue visible at the cervical os AND pain (other than midline suprapubic cramping or tenderness (any cervical motion tenderness, uterine or adnexal tenderness): Sensitivity (95% CI) 100% (84%-100%), specificity 28% (23%-32%), PPV 7.1% (5%-11%), NPV 100% (97%-100%), Positive likelihood ratio 1.4, Negative likelihood ratio 0
			Low risk	Patients not meeting high or intermediate risk criteria

Comment(s)

There are a number of findings that can help determine if a woman has high or low risk of having an ectopic pregnancy, but there was no sinlge finding or a combination of findings that could give a definite diagnosis.

Clinical Bottom Line

Physical examination is not sensitive enough to give a definite diagnosis of ectopic pregnancy.

References

1. Dart RG. Kaplan B. Varaklis K Predictive value of history and physical examination in patients with suspected ectopic pregnancy Annals of Emergency Medicine 1990;33(3):283-90
2. Stovall TG. Kellerman AL. Ling FW. Buster JE Emergency department diagnosis of ectopic pregnancy Annals of Emergency Medicine 1990;19(10):1098-103
3. Kaplan BC. Dart RG. Moskos M. Kuligowska E. Chun B. Adel Hamid M. Northern K. Schmidt J. Kharwadkar A Ectopic pregnancy: prospective study with improved diagnostic accuracy Annals of Emergency Medicine 1996;28(1):10-7
4. Buckley RG. King KJ. Disney JD. Gorman JD. Klausen JH History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical prediction model Annals of Emergency Medicine 1999;34(5):589-94