The New Pregnancy Test

When I began my career in medicine, pregnancy tests were relatively insensitive. You had to wait until about 4-6 weeks after the last menstrual period before the results could be regarded as reliable. Real time ultrasounds was a gleam in a few researchers' eyes. Most women with a tubal pregnancy had the diagnosis made when they arrived in the emergency room with serious intra-abdominal bleeding. The confirmative diagnostic test of choice was a culdocentesis - the insertion of a long needle into the abdominal cavity through the vagina. Aspiration of non-clotting blood was considered diagnostic of internal bleeding. An unruptured ectopic pregnancy was considered a reportable case. The treatment was removal of the affected tube at laparotomy.

All that has changed. Today, thanks to Dr. Yalow's development of radioimmunoassay, pregnancy can be diagnosed sometimes before a period is missed. Transvaginal ultrasaound can diagnose an ectopic pregnancy often prior to the onset of significant symptoms. Surgery is done, not via large incisions, but via small laparoscopes - the so-called "bandaid surgery." And often, tubal pregnancy is treated medically or even followed expectantly. These have been truly remarkable developments.

In fact, the new pregnancy test may well be the vaginal sonogram. The new protocol for a woman who is seeing her gynecologist for suspected early pregnancy to empty her bladder and save that specimen of urine for the lab. But today, the office doesn't run the urine test yet. Today, her gyn performs a vaginal sonogram. If pregnancy is seen, that's it - she's pregnant. Done! If a small embroy/fetus is seen, a measurement yields an estimated delivery date which is more accurate than that predicted by last period. Early diagnosis of twins can also be made. If a fetus is seen, so can the heartbeat be seen. Everyone is ahead of the game.

The flip side is if no evidence of pregnancy is found on the sonogram. Now, that urine test is crucial and should be run. Urine tests are far more reliable than they were in the 1960's and early 1970's. If the test is negative, pregnancy is doubtful. Conversely, if the test is positive, then blood should be taken right then and there to look for the level of pregnancy hormone - the Beta HCG. Further management would then depend on that level which could be available often in less than a day. An investigative work up which often took weeks can sometimes be compressed into a few days or less.

Of course, I am oversimplifying but the change in the investigation and treatment of suspected tubal pregnancy has been truly remarkable stuff.

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Transvaginal Ultrasound - The Rest of the Story

Recently, an incredibly useful diagnostic tool for women's health has become embroiled in the firestorm of abortion politics. I'm speaking of transvaginal ultrasound and I'm here to try to set the record straight. Transvaginal sonography, or TVS, has been around for longer than you think, having come a long way from the first use by the Japanese in 1971. The technique was popularized in the late 1980's as a logical extention of women's healthcare. Rather than have a woman fill her bladder to point of significantt pain and disttress, a small, high frequency transducer is simply placed close to the organs of interest, resulting in images usually far more detailed than those obtained from the transabdominal route.

During this introductory phase of TVS, I was a practicing gynecologist and it seemed a natural extension of my pelvic examination. I was initially using a small standard pediatric transducer which was easily introduced, but switched over to the standard long-handled probe when I got the chance. As a shameless plug, I'd like to say I was, at least in my neck of the woods, a pioneer in this regard. I found quickly that I could evaluate potential difficulties in early pregnancy for those women who thought they were miscarrying and usually reassuring them that things were OK. I could also confirm the location of an early pregnancy, often a week earlier than transabdominally. This came in handy in those cases of suspected tubal pregnancy, which previously wasn't diagnosed until the woman presented to the emergency room in significant distress.

TVS also was able to characterize ovarian cysts, with endometriomas and dermoids usually exhibiting such a distinctive appearance that a definitive diagnosis became possible. Now, when coupled with sensitive color and power doppler, vascular signatures can be determined, facilitating the diagnosis of ovarian cancer, often at an earlier stage than before.

Today, TVS has many uses in both obstetrics and gynecology. Monitoring cervical length in patients at risk for preterm delivery is routine. TVS is often useful in evaluating fetuses for certain abnormalities such as anencephaly. In women undergoing IVF, monitoring of follicles and obtaining eggs via the transvaginal route is standard of care. TVS, especially with 3D probes, facilitates the monitoring of the location of possibly malpositioned IUD's. Three dimensional multiplanar transvaginal sonography produces images of the uterus which can rival an MRI, allowing cost-effective diagnosis of uterine malformations and location of fibroids and polyps. Instillation of saline into the uterus in patients with abnormal bleeding is now a standard technique for triaging therapy for these women.

So, once the political smoke is allowed to clear, we're left with one impression. Transvaginal ultrasound is an impressive advance in women's healthcare. It's truly frustrating that this diagnostic modality has become such a political football. I truly hope that the dust settles sooner rather than later.

If you have any questions, feel free to leave a comment or tweet me @sonodoc99 on Twitter.