GENERAL APPROACH TO WOMEN OF CHILDBEARING AGE
The differential diagnosis for women of childbearing potential who present with abdominal or pelvic symptoms or abnormal vaginal bleeding is broad (Table 98-1). The major clinical goals are, first, diagnosis of pregnancy, and then if pregnant, differentiating ectopic pregnancy from threatened abortion. Consider ectopic pregnancy in women of childbearing age who report abdominal or pelvic pain or discomfort, vaginal spotting or a cycle of amenorrhea, or unexplained signs or symptoms of hypovolemia. There are rare case reports of ectopic pregnancy in patients with ovaries but without a uterus. No combination of signs or symptoms is sufficient to exclude ectopic pregnancy. If pregnancy is detected, ectopic pregnancy remains in the differential diagnosis until it can be either confirmed or excluded with conviction.
TABLE 98-1Differential Diagnosis of Ectopic Pregnancy |Favorite Table|Download (.pdf) TABLE 98-1 Differential Diagnosis of Ectopic Pregnancy
|All Patients ||Pregnant Patients |
|Appendicitis ||Normal (intrauterine pregnancy) |
|Inflammatory bowel disease ||Threatened abortion |
|Ovarian pathology ||Inevitable abortion |
|Cyst ||Molar pregnancy |
|Torsion ||Heterotopic pregnancy* |
|Pelvic inflammatory disease ||Implantation bleeding |
|Endometriosis ||Corpus luteum cyst |
|Sexual assault/trauma || |
|Urinary tract infection |
|Ureteral colic |
The diagnosis of pregnancy is central to the diagnosis of ectopic pregnancy. Pregnancy tests currently in use rely on the detection of the β subunit of human chorionic gonadotropin (β-hCG) in the urine or serum. hCG is a hormone produced by the trophoblast. Intact hCG consists of the α and β subunits. Tests based on detection of the intact molecule or the α subunit can cross-react on immunologic assays with hormones found in the nonpregnant individual and are thus less specific than tests for the β-hCG subunit.
hCG preparations are currently standardized in relation to the Third International Reference Preparation. Other standard preparations are not equivalent. A preparation often referred to in earlier literature is the Second International Standard. The Third International Reference Preparation is roughly equal to 1.7 times the Second International Standard. To avoid confusion when interpreting the literature, pay attention to the standard used. In this chapter, hCG and β-hCG concentrations refer to the Third International Reference Preparation unless otherwise noted.
Very early in either an intrauterine pregnancy (IUP) or an ectopic pregnancy, detectable amounts of β-hCG are released into the serum and filtered into the urine. The concentration of β-hCG is fairly closely correlated in the urine and serum, with urinary concentration also depending on urine specific gravity. Qualitative urine and serum tests for pregnancy usually use the enzyme-linked immunosorbent assay methodology. In the laboratory setting, enzyme-linked immunosorbent assay tests can detect β-hCG at concentrations <1 mIU/mL.
Qualitative tests in clinical use are typically reported as "positive" when the β-hCG concentration is ≥20 mIU/mL in urine and ≥10 mIU/mL in serum. A positive qualitative test ...