Peer VI Q70 - Ectopic Preg

[bulgethetwine]

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Peer VI Q70:

"A 23 y/o female 7 wks pregnant c/o pelvic pain and vag bleeding without tissue passage. Exam is remarkable for minimal blood in vault, minimal uterine tenderness, and no adnexal tenderness or masses. Quant beta is 8, 230. Transvag u/s shows no adnexal mass, no free fluid, and a normal-sized, empty uterus. What is the most likely diagnosis?

Answer is: Ectopic.

The answer makes sense, but I have a question about the broader learning point. What would you do at this point?

Does one call OB and restate that I have a woman with the above symptoms, a beta above threshold, and a non-diagnositc u/s (seemingly ok if I'm in a big academic center and not so concerned with getting the definitive diagnosis myself);

Is there a better test I can order? ie. if the presumed ectopic is not in the adnexa based on u/s, is CT of any value?

Is the u/s so "operator dependent" than a repeat is warranted?

 

[BKN]

Peer VI Q70:

"A 23 y/o female 7 wks pregnant c/o pelvic pain and vag bleeding without tissue passage. Exam is remarkable for minimal blood in vault, minimal uterine tenderness, and no adnexal tenderness or masses. Quant beta is 8, 230. Transvag u/s shows no adnexal mass, no free fluid, and a normal-sized, empty uterus. What is the most likely diagnosis?

Answer is: Ectopic.

The answer makes sense, but I have a question about the broader learning point. What would you do at this point?

Does one call OB and restate that I have a woman with the above symptoms, a beta above threshold, and a non-diagnositc u/s (seemingly ok if I'm in a big academic center and not so concerned with getting the definitive diagnosis myself);

Is there a better test I can order? ie. if the presumed ectopic is not in the adnexa based on u/s, is CT of any value?

Is the u/s so "operator dependent" than a repeat is warranted?

T&C, call the OB, you're done.

 

[bartleby]

While you are correct that ultrasound is operator dependent, the key sonographic finding in managing these cases is a rather simple yes/no question: is there evidence of an IUP or not? This is one of the easier findings to demonstrate on transvaginal ultrasound. While it would be great to be able to have an image of the ectopic in hand while calling OB, it's besides the point when you're calling them about a young woman with a good story for an ectopic (pain, no passed products of conception, a closed cervix on exam) and no visualized IUP with a quantitative HCG well above the level where you would expect to be able to visualize one on transvaginal ultrasound. Say you go ahead and get a CT at this point and it's "NAD" per the radiologist. Would you send the patient home? At this point you've done a thorough workup and identified that the pt requires admission for a presumed ectopic so it's time to make the call.

 

[bulgethetwine]

While you are correct that ultrasound is operator dependent, the key sonographic finding in managing these cases is a rather simple yes/no question: is there evidence of an IUP or not? This is one of the easier findings to demonstrate on transvaginal ultrasound. While it would be great to be able to have an image of the ectopic in hand while calling OB, it's besides the point when you're calling them about a young woman with a good story for an ectopic (pain, no passed products of conception, a closed cervix on exam) and no visualized IUP with a quantitative HCG well above the level where you would expect to be able to visualize one on transvaginal ultrasound. Say you go ahead and get a CT at this point and it "NAD" per the radiologist. Would you send the patient home? At this point you've done a thorough workup and identified that the pt requires admission for a presumed ectopic so it's time to make the call.

Thanks, guys/gals.

Anyone know if/when PEER VII is due out? 6 is from 2002...

 

[Seaglass]

Just to stress that point - the goal is finding an IUP or not. If you find the ectopic that's just icing on the cake.

 

[macdaddy23]

Anyone know if/when PEER VII is due out? 6 is from 2002...[/QUOTE]

They say that VII is going to be released at the Scientific Assembly in New Olreans in October. It was in some announcement of the conference I received.