Clinical Approach And Disposition

With the goal of early diagnosis, when a patient with signs or symptoms suggestive of EP is found to be pregnant, further testing to determine if the pregnancy is intrauterine should be undertaken. The nature and timing of additional diagnostic measures depends upon the clinical condition of the patient. Unstable patients suspected of ectopic pregnancy should receive resuscitation, urgent consultation, and operative intervention. Surgery may be both diagnostic and therapeutic if an EP is found or may reveal another cause for the patients condition. When bedside ED sonography is available, it may be valuable even in unstable patients if it does not interfere with resuscitation, consultation, and rapid transfer to the operating room.

Ideally, all pregnant patients with suspected EP should receive immediate sonography. However, issues of availability during off hours may make this impractical. Stable patients who are judged to be at low risk for EP can be considered for discharge and outpatient follow-up. At a minimum, such patients should have a quantitative bhCG level obtained to facilitate subsequent management. Culdocentesis remains an option where sonography is unavailable but at this time is used infrequently.

There are a number of options for stable patients with a bhCG level outside the discriminatory zone and negative sonography. These include consultation or discharge for follow-up in 2 days for reexamination and repeat bhCG levels. Culdocentesis, D&C, and laparoscopy are also options in this circumstance. The flowchart illustrates a suggested diagnostic approach (Fig 100-1).

FIG. 100-1. Diagnostic pathway for suspected ectopic pregnancy.
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