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(click for larger image) Table 1. Translation of Classes of Evidence to Recommendation Levels

Level A recommendations: None specified.

Level B recommendations: Perform or obtain a pelvic ultrasound for symptomatic pregnant patients with any β-hCG level.

Level C recommendations: None specified.

2. In patients who have an indeterminate transvaginal ultrasound result, what is the diagnostic utility of β-hCG for predicting possible ectopic pregnancy? 

Patient Management Recommendations

Level A recommendations: None specified.

Level B recommendations: Do not use the β-hCG value to exclude the diagnosis of ectopic pregnancy in patients who have an indeterminate ultrasound result.

Level C recommendations: Obtain specialty consultation or arrange close outpatient follow-up for all patients with an indeterminate pelvic ultrasound result.

All patients with symptomatic early pregnancy should have an ultrasound, and this has been designated as a Centers for Medicare & Medicaid Services Core Quality Measure, with a few exclusions such as lack of ultrasound availability. If the ultrasound result is indeterminate, the disposition should be based on the clinical scenario (taking into account mitigating system and patient factors), and all patients should have specialty consultation and/or close follow-up.

Reference

1. Kohn MA, Kerr K, Malkevich D, et al. Beta-human chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding. Acad Emerg Med. 2003;10(2):119-126.

Dr. Hahn is an associate professor of emergency medicine at the Icahn School of Medicine at Mount Sinai in New York City.