JAMA：诊断异位妊娠 经阴道超声是更佳单种检测方法

　　美国一项系统综述研究表明，对于可疑异位妊娠患者，其病史的临床诊断价值有限。经阴道超声检查（图2）发现无宫内妊娠的附件包块[阳性似然比（+LR）=111]，体格检查发现宫颈触痛（+LR=4.9）、附件包块（+LR=2.4）、附件压痛（+LR=1.9）均提示异位妊娠的可能性增加。经阴道超声检查未发现附件异常，则异位妊娠的可能性降低。

　　对于妊娠早期出现腹痛或阴道流血者，经阴道超声是诊断可疑异位妊娠的单种最佳检查方法。该论文发表于《美国医学会杂志》[JAMA 2013，309（16）：1722]。

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Does This Woman Have an Ectopic Pregnancy?: The Rational Clinical Examination Systematic Review
Importance 
The rapid identification and accurate diagnosis of women who may have an ectopic pregnancy is critically important for reducing the maternal morbidity and mortality associated with this condition.
Objective 
To systematically review the accuracy and precision of the patient history, clinical examination, readily available laboratory values, and sonography in the diagnosis of ectopic pregnancy in women with abdominal pain or vaginal bleeding during early pregnancy.
Data Sources 
We conducted MEDLINE and EMBASE searches for English-language articles from 1965 to December 2012 reporting on the diagnosis of ectopic pregnancy.
Study Selection 
The analysis included prospective studies of 100 or more pregnant women with abdominal pain or vaginal bleeding that evaluated patient history, physical examination, laboratory values, and sonography compared with a reference standard of either (1) direct surgical visualization of ectopic pregnancy or (2) clinical follow-up for all pregnancies to prove that ectopic pregnancy was not missed. Of 10 890 articles identified by the search, 14 studies with 12 101 patients met the inclusion criteria.
Data Extraction and Synthesis 
Two authors (J.R.C. and M.V.C.) independently extracted data and assessed the quality of each study. A third author (L.A.B.) resolved any discrepancies.
Results 
All components of the patient history had a positive likelihood ratio (LR+) less than 1.5. The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography (LR+ 111; 95% CI, 12-1028; n = 6885), and the physical examination findings of cervical motion tenderness (LR+ 4.9; 95% CI, 1.7-14; n = 1435), an adnexal mass (LR+ 2.4; 95% CI, 1.6-3.7; n = 1378), and adnexal tenderness (LR+ 1.9; 95% CI, 1.0-3.5; n = 1435) all increase the likelihood of ectopic pregnancy. A lack of adnexal abnormalities on transvaginal sonography (negative LR [LR−] 0.12; 95% CI, 0.03-0.55; n = 6885) decreases the likelihood of ectopic pregnancy. Existing studies do not establish a single serum human chorionic gonadotropin (hCG) level that is diagnostic of ectopic pregnancy.
Conclusions and Relevance 
Transvaginal sonography is the single best diagnostic modality for evaluating women with suspected ectopic pregnancy. The presence of abdominal pain or vaginal bleeding during early pregnancy should prompt a transvaginal sonogram and quantitative serum hCG testing.