**Clinical Application of One-Step Diagnosis for Ectopic Pregnancy by HCG Ratio: Hemoperitoneum Versus Venous Serum**

Yu-dong Wang, Wei-wei Cheng and Xiao-ping Wan *International Peace Maternal and Child Health hospital, Shanghai Jiaotong University China* 

#### **1. Introduction**

136 Ectopic Pregnancy – Modern Diagnosis and Management

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> Suspected ectopic pregnancy (SEP) means a woman whose hemoperitoneum and pregnancy test are positive but the gestational sac is uncertain, which is finally diagnosed as an ectopic pregnancy (EP) or a hemoperitoneum with intrauterine pregnancy (hIUP). For emergency physicians, it is mostly important to differentiate EPs rapidly from hIUPs of which the vast majority can be managed without surgery. The combination of transvaginal ultrasound and serum HCG determination seem to be reliable for the early diagnosis of EP (Kaplan et al., 1996; Mol et al., 1998.). However, in most of the emergency rooms (especially on the night shift) in the general hospital, transvaginal ultrasound is often unavailable or instead of transabdominal ultrasound operated by a nonprofessional gynecologist in developing countries, which limits the prompt and accurate diagnosis of EP. Besides, the serial transvaignal ultrasound and HCG quantity result in a lot of workload for the gynecologist and additional medical costs for the patients (Condous et al., 2005.).

> A serum: cerebrospinal fluid (CSF) HCG ratio less than 40 is an accurate indication of the presence of brain metastases of gestational trophoblastic tumor, and may have considerable predictive value. However, false-negative serum: CSF HCG ratio (greater than 40) frequently occur in patients with proven brain deposits, and the cerebrospinal fluid puncture or lumbar puncture is difficult to perform for the gynecologist (Bakri et al., 2000.). Magnetic resonance imaging head scan, hence, is now preferred as the most sensitive and safe technology available for brain metastases of gestational trophoblastic tumor.

> Culdocentesis is the transvaginal passage of a needle into the posterior cul-de-sac in order to determine whether free blood is present in the abdomen. It is a simple procedure to determine whether there is intraperitoneal hemorrhage. It has been used less frequently in recent years because many gynecologists think it useless for the diagnosis of EP. In the light of the idea that serum: CSF HCG ratio is indication of the presence of brain metastases, making use of the simple operation of culdocentesis, we have proved that HCG ratio of hemoperitoneum versus venous serum (Rp/v-HCG) of EPs is apparently different from that of hIUPs (Wang, et al., 2010.). Hence, in order to provide a single-visit method for predicting EP from SEP, we want to prospectively further assess the diagnostic value of the Rp/v-HCG for early EP. Furthermore, we want to discuss the availability of Rp/v-HCG for rare EP such as abdominal pregnancy et cetera.

Clinical Application of One-Step Diagnosis for

SEPs) and hIUP group (51 cases, 17.1 percent of SEPs).

**Group EP** 

miscarriage treatment (progesterone).

between the two groups.

the final diagnosis of the EPs.

were reported.

\*P<0.001 vs hIUP

respectively (Figure 2).

**2.5 Results** 

Ectopic Pregnancy by HCG Ratio: Hemoperitoneum Versus Venous Serum 139

independent sample wilcoxon test or chi-squared test was used to compare variables

The diagnostic performance of Rp/v-HCG for active tubal hemorrhage was expressed using a scatter diagram. The one-step diagnostic value of the Rp/v-HCG for EP was evaluated in terms of the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) with 95% confidence intervals (CI). The simple kappa coefficient of Rp/v-HCG test was also given for the 2×2 table to assess how the prediction of Rp/v-HCG agreed with

Significance was defined as p-values less than 0.05 for all the tests and two sided P-values

A total of 299 SEPs (average age, 33.1 years; range, 19-42 years) were enrolled and followed to the final diagnosis, which were finally divided into EP group (248 cases, 82.9 percent of

Table 1 shows a statistically significant difference (P < 0.001) between the EP group and the hIUP group in terms of the Rp/v-HCG (18.1 ± 40.75 and 0.72 ± 0.29, respectively) and the conservative treatment (23.0 % and 90.2 %, respectively). The culdocentesis before surgery was performed successfully for 255 SEPs except thirteen patients who rejected the culdocentesis, the success rate of the culdocentesis was 89.2 % (255/ 286), the success rate of the "first-time-right" was 76.9 % (220/ 286), even though the peritoneal fluid depth by ultrasound was only 8-12 mm (Figure 1). No complications of culdocentesis were recorded in this study. Of all the hIUPs, 90.2 percent of patients (46/ 51) were cured relying on the hemostatic therapy (Reptilase) instead of the surgical intervention (laparoscopy). 77.8 percent of patients (14/ 18) who desire to fertility succeeded to continue pregnancy with

(n=248)

EP: ectopic pregnancy; hIUP: hemoperitoneum or hematocolpos with intrauterine pregnancy; Rp/v-HCG: HCG ratio of peritoneal serum versus venous serum; PFD: peritoneal fluid depth by ultrasound.

We further confirmed the same cut-off value of the Rp/v-HCG (Rp/v-HCG = 1.0) as the previous results. At this point, the sensitivity and specificity was 98.5% and 100%,

The SEPs were predicted as EP group and hIUP group according to the Rp/v-HCG cut-off value. The final diagnosis versus the "predicted" diagnosis for suspected EPs were represented in Table 2. When the protocol was tested prospectively on the 299 SEPs, The overall sensitivity of Rp/v-HCG in the diagnosis of ectopic pregnancy was 98.4 % with a specificity of 100 %, a PPV of 100 % and an NPV of 93 %, whilst the likelihood ratio of a

Table 1. Comparison of managements between hIUP guoup and EP group.

Rp/v-HCG 18.1±40.75 0.72±0.29 *P* < 0.001 Successful culdocentesis 89.2 % (215/241) 88.9 % (40/45) *P* > 0.05 PFD (mm) 39±24 41±22 *P* > 0.05 Non-surgical treatment 23.0 % (57/248) 90.2 % (46/51) *P* < 0.001

**hIUP** 

(n=51) *P value* 
