Diagnostic evaluation

A. Women with moderate- or high-risk factors for EP and those who conceived after in-vitro fertilization (IVF) should be evaluated for EP as soon as their first missed menses.

B. Transvaginal ultrasound is most useful for identifying an intrauterine gestation. An extrauterine pregnancy will be visualized in only 16 to 32 percent of cases, thus a pelvic ultrasound showing "no intrauterine or extrauterine gestation" does not exclude the diagnosis of EP.

1. The identification of an intrauterine pregnancy effectively excludes the possibility of an ectopic in almost all cases. However, pregnancies conceived with assisted reproductive technology are an exception, since the incidence of combined intrauterine and extrauterine pregnancy may be as high as 1/100 pregnancies.

2. An early intrauterine pregnancy is identified sonographically by the presence of a true gestational sac. Using TVS, the gestational sac is usually visible at 4.5 to 5 weeks of gestation with the double decidual sign at 5.5 to 6 weeks, the yolk sac appears at 5 to 6 weeks and remains until 10 weeks, and a fetal pole with cardiac activity is first detected at 5.5 to 6 weeks.

C. beta-hCG concentration. The gestational sac is usually identified at beta-hCG concentrations above 1500 to 2000 IU/L. The absence of an intrauterine gestational sac at beta-hCG concentrations above 2000 IU/L strongly suggests an EP.

D. Progesterone concentrations are higher in intrauterine than ectopic pregnancies. A concentration of greater than 25 ng/mL is usually (98 to 99 percent) associated with a viable intrauterine pregnancy, with lower concentrations in ectopic and intrauterine pregnancies that are destined to abort A concentration less than 5 ng/mL almost always (99.8 percent) means the pregnancy is nonviable. However, there is no difference in the progesterone concentration between ectopic and arrested pregnancies. Progesterone measurements are useful only to confirm diagnostic impressions already obtained by hCG measurements and transvaginal sonography.

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