Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery – The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood

Abstract

Objectives Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency.

Methods Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves.

Results Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794–0.879) and high urgency (AUC 0.902, 95 % CI 0.860–0.945).

Conclusion Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.

Zusammenfassung

Ziele Die Beurteilung der Dringlichkeit bei ektopen Schwangerschaften ist aufgrund des breiten klinischen Spektrums schwierig. Schwere Verläufe (akutes Abdomen oder hämodynamische Instabilität) sind meist mit intraabdominalem Blutverlust verbunden, welcher als freie Flüssigkeit (FF) mittels transvaginaler Sonografie (TVS) diagnostiziert werden kann. Ziel der vorliegenden Studie war es, den diagnostischen Wert der FF sowie andere potenziell prädiktive Parameter für die Beurteilung der Dringlichkeit zu untersuchen.

Methode Retrospektive Kohortenanalyse von prospektiv erhobenen Fällen (n=343) mit nachgewiesener ektopen Schwangerschaft. Demografische Daten, Klinik, Laborparameter, sonografische und Befunde der Laparoskopie (LSC) wurden einbezogen. Die Bewertung von FF in der TVS und freiem Blut (FB) in der LSC erfolgte anhand des Bildmaterials. FB < 100ml wurde als wenig- und ≥ 300ml als hochdringlich definiert. Die besten Variablen für die Vorhersage von FB wurden bestimmt und ihre Prädiktion der Dringlichkeit mittels ROC-Kurven bewertet.

Ergebnisse Klinik, Alter, β-HCG, präoperatives Hämoglobin (HB) und FF wurden in einer multivariaten Analyse für die Cut-off-Werte 100ml und 300ml untersucht. Zur Bestimmung geringer (AUC 0,837, 95% CI 0,794–0,879) und hoher Dringlichkeit (AUC 0,902, 95% CI 0,860–0,945) war FF ein hervorragend diskriminierender Parameter; das HB erbrachte nur eine marginale Verbesserung der Vorhersagekraft und nur für hohe Dringlichkeit.

Schlussfolgerungen FF ist für die Beurteilung der Dringlichkeit am wertvollsten, wobei die genauen Grenzwerte für eine Niedrigrisiko- oder Hochrisikosituation festzulegen bleiben.

Keywords

ultrasound - free fluid - urgency - laparoscopy - ectopic pregnancy

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