PV Card: Focused 1st Trimester Pregnancy Transabdominal Ultrasound

Intrauterine pregnancy first trimester ultrasound transaabdominal

Although history, physical, and lab tests are obtained for patients with first trimester vaginal bleeding and abdominal pain, none compare to the utility of bedside ultrasonography. Today’s PV card reviews the transabdominal approach to the focused pregnancy ultrasound and was written by Drs. Matt Lipton, Mike Mallon, and Mike Stone.

PV Card: Focused 1st Trimester Pregnancy Transabdominal Ultrasound

Adapted from [1, 2]


  1. Tayal V, Cohen H, Norton H. Outcome of patients with an indeterminate emergency department first-trimester pelvic ultrasound to rule out ectopic pregnancy. Acad Emerg Med. 2004;11(9):912-917. [PubMed]
  2. Wang R, Reynolds T, West H, et al. Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography. Ann Emerg Med. 2011;58(1):12-20. [PubMed]
By |2021-10-05T13:01:43-07:00Feb 25, 2015|ALiEM Cards, Ob/Gyn, Ultrasound|

Is Pelvic Exam in the Emergency Department Useful?

graves-vag-speculum-lg-30-20-miltexWomen with undifferentiated abdominal pain and/or vaginal bleeding commonly present to the emergency department. Many textbooks advocate for the pelvic exam as an essential part of the history and physical exam. Performance of the pelvic exam is time consuming to the physician and uncomfortable for the patient. It is with great regularity that emergency physicians make clinical decisions, based on information derived from the pelvic examination, but is this information reliable and does it effect the clinical plan of patients?


By |2019-09-10T13:34:48-07:00Jan 30, 2014|Ob/Gyn|

PV card: Ectopic pregnancy

Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy. A recent JAMA systematic review,1 from The Rational Clinical Examination series, looked to risk-stratify women in early pregnancy presenting with abdominal pain or vaginal bleeding for ectopic pregnancy. The authors set out to identify the accuracy and precision of elements in the history, physical examination, beta hCG, and ultrasound in ectopic pregnancy.

The systematic review consisted of 14 studies (n=12,101). The search consisted only of English language studies from 1965 to 2012 in which ectopic pregnancy was the final diagnosis with 100 or more patients per article. The summary prevalence of ectopic pregnancy was 15% (95% CI, 10-22%) in women presenting with abdominal pain or vaginal bleeding.

History and Physical

  • Patients symptoms had limited clinical value. Most symptoms had an unhelpful positive LR of less than 1.5.
  • The absence of cervical motion tenderness, peritoneal signs, adnexal mass, or adnexal tenderness did not significantly decrease likelihood of ectopic pregnancy.
  • In descending order, the most significant physical exam findings were:
    • Cervical motion tenderness (Positive LR = 4.9)
    • Peritoneal findings (Positive LR = 4.2-4.5)
    • Adnexal mass (Positive LR = 2.4)
Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac

Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac


  • Findings of an intrauterine pregnancy (IUP) such as gestational sac or fetal pole ruled out ectopic pregnancy, except in rare cases of heterotropic prengnacy.
  • Bedside ultrasound is the single most useful diagnostic test. Positive LR = 111. 


  • The “discriminatory zone” continues to be debated – no consensus on the number.
  • A one-time hCG level does not rule out ectopic pregnancy.

PV Card: JAMA Review on Ectopic Pregnancy

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.


  1. Crochet J, Bastian L, Chireau M. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. [PubMed]
By |2021-10-08T09:20:50-07:00May 9, 2013|ALiEM Cards, Ob/Gyn|

Trick of the Trade: No pelvic bed? No problem

Pelvic SpeculumOften finding a pelvic examination bed for a female patient needing a speculum exam can be challenging. Without the elevated foot stirrups, the bed under the patient’s buttocks obstructs the pelvic speculum handle so that it can’t rotate completely into a 6 o’clock position.
Some people place an upside-down bed pan to elevate the patient’s buttocks slightly in order to create more space for the speculum. Not only is the position uncomfortable for the patient, it seems a waste of a perfectly good bed pan. Fortunately there is an alternative approach.
By |2019-01-28T22:00:26-08:00Mar 26, 2013|Ob/Gyn, Tricks of the Trade|

PE in pregnancy: which diagnostic tests do you use?

Pulmonary embolism (PE) can be a deadly disease and one of the most challenging diagnosis to make in a pregnant patient. Patients may present with signs and symptoms that might also be present in a normal uncomplicated pregnancy. Even in nonpregnant patients, the diagnosis of venous thromboembolism (VTE) such as PE can be quite challenging.


By |2017-03-05T14:18:48-08:00Mar 6, 2013|Cardiovascular, Ob/Gyn, Pulmonary|
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