When is an ultrasound required before a speculum (gynecologic examination) exam?

From the Guidelines

An ultrasound is required before a speculum exam in pregnant patients with suspected placenta previa, ectopic pregnancy, or unknown pregnancy location, as well as in non-pregnant patients with suspected pelvic masses or anatomical abnormalities. In these situations, an ultrasound helps to identify potential risks and complications before proceeding with the speculum examination. The American College of Physicians recommends against routine pelvic examinations in asymptomatic, nonpregnant, adult women, citing a lack of evidence for benefits and potential harms, including pain, discomfort, fear, anxiety, and embarrassment 1. However, in certain situations, such as suspected placenta previa or ectopic pregnancy, an ultrasound is necessary to ensure patient safety before proceeding with a speculum examination 1. Key considerations for requiring an ultrasound before a speculum exam include:

• Suspected placenta previa in pregnant patients
• Suspected ectopic pregnancy with hemodynamic instability
• Unknown pregnancy location with concerning symptoms
• Vaginal bleeding in pregnancy with unknown placental location
• Suspected pelvic masses or anatomical abnormalities in non-pregnant patients By prioritizing patient safety and using ultrasound to identify potential risks, clinicians can minimize the risk of complications and ensure the best possible outcomes for their patients.

From the Research

Ultrasound Requirement Before Speculum Exam

• An ultrasound is required before a speculum exam in certain situations, such as:
  • Suspected ectopic pregnancy, as physical examination has limited additional information compared to transvaginal sonography and serum hCG measurement alone 2
  • Early pregnancy bleeding, where ultrasonography and quantitative beta human chorionic gonadotropin assays are first-line in diagnosing the condition, and pelvic examination is limited in providing further diagnostic information 3
• Specific scenarios where an ultrasound is necessary before a speculum exam include:
  • Patients presenting with severe bleeding or hypotension, as removal of obstructing endocervical products can be a crucial resuscitative measure 3
  • Diagnosis of ectopic pregnancy, where transvaginal sonography is the imaging modality of choice, with overall reported sensitivities of >90% 4
• In cases where ultrasonography and beta human chorionic gonadotropin testing are unavailable or the results are inconclusive, a pelvic examination, including speculum exam, may be considered to identify possible life-threatening conditions, such as ectopic pregnancy 3

Ectopic Pregnancy Diagnosis

• Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain, and intrauterine pregnancy has not yet been established 5
• The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa, but most ectopic pregnancies do not reach this stage 5
• Patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are often used to make the diagnosis of ectopic pregnancy 5

Speculum Exam Indications

• Speculum examination is indicated in patients presenting with severe bleeding or hypotension, as removal of obstructing endocervical products can be a crucial resuscitative measure 3
• In cases of suspected cervical ectopic pregnancy, diagnosis can be made with endovaginal ultrasound examination, and successful treatment with methotrexate is possible 6