scholarly journals P070: Excluding ectopic pregnancy in patients presenting to a community emergency department with first trimester bleeding

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S81-S82
Author(s):  
E. Hoe ◽  
C. Varner ◽  
M. Ivankovic
Keyword(s):  
Emergency Department ◽  
Ectopic Pregnancy ◽  
Community Hospital ◽  
Transvaginal Ultrasound ◽  
Retrospective Chart Review ◽  
First Trimester ◽  
Point Of Care Ultrasound ◽  
Intrauterine Pregnancy ◽  
Missed Abortion ◽  
Diagnostic Modality

Introduction: Current guidelines recommend patients with first trimester bleeding without previously documented intrauterine pregnancy undergo urgent transvaginal ultrasound (TVUS) to exclude ectopic pregnancy. However, in Canadian practice to receive urgent TVUS, particularly out of daytime hours is difficult, if not impossible. Thus, when TVUS is not available to exclude ectopic pregnancy, providers use point of care ultrasound (POCUS) or their best clinical judgment to determine if the patient can be safely discharged home while awaiting outpatient follow-up. The objective of this study was to determine what proportion of first trimester patients presenting to a community hospital emergency department (ED) with vaginal bleeding undergo either TVUS or POCUS to exclude ectopic pregnancy. Methods: This is an ongoing retrospective chart review of pregnant women gestational age (GA) less than 20 weeks presenting to a community hospital ED (103,000 visits/year) with a discharge diagnosis of vaginal bleed, first trimester bleed, threatened abortion, spontaneous abortion, missed abortion, rule out ectopic pregnancy, and ectopic pregnancy from January 2016 - January 2017. Patients are excluded if they are diagnosed with a ruptured ectopic pregnancy during their index ED visit. To date, 98 patient charts have been reviewed. Results: Of the 98 included patients, 13 (13.3%) had a viable pregnancy, 37 (37.8%) had a spontaneous or missed abortion, 4 (4.1%) had an ectopic pregnancy, and 45 (45.9%) had unknown outcomes. Of included patients, 4 (4.1%) only had POCUS, 66 (67.4%) only had a radiologist-interpreted TVUS, and 3 (3.1%) had both POCUS and radiologist-interpreted TVUS during their ED index visits. Thus, 73 (74.5%) had either a radiologist-interpreted TVUS or ED provider-performed POCUS during their index ED visit. After their index ED visits, 2 (2.0%) patients returned with ruptured ectopic pregnancies, 1 of whom had not undergone initial US investigations. Conclusion: Although TVUS is standard of care to exclude ectopic pregnancy in patients presenting with first trimester bleeding or abdominal pain, our preliminary results show some patients are not receiving this diagnostic modality nor POCUS during their index ED visit. Particularly in a setting, such as this ED, without rapid access to an early pregnancy clinic, patients should be counselled about their risk of ectopic pregnancy at the time of ED discharge.

Ectopic pregnancy outcomes in patients discharged from the emergency department

CJEM ◽  
2018 ◽  
Vol 21 (1) ◽  
pp. 71-74
Author(s):  
Krista Hawrylyshyn ◽  
Shelley L. McLeod ◽  
Jackie Thomas ◽  
Catherine Varner
Keyword(s):  
Emergency Department ◽  
Ectopic Pregnancy ◽  
Chart Review ◽  
Transvaginal Ultrasound ◽  
Tertiary Care ◽  
Expectant Management ◽  
Retrospective Chart Review ◽  
Missed Abortion ◽  
Ectopic Pregnancies ◽  
Rule Out

AbstractObjectiveThe objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the emergency department (ED) where ectopic pregnancy had not yet been excluded.MethodsThis was a retrospective chart review of pregnant (<12-week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule-out ectopic pregnancy, or pregnancy of unknown location over a 7-year period.ResultsOf the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes, and 71 (12.9%) had other outcomes that included therapeutic abortion, molar pregnancy, or resolution of βHCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal ultrasound during their index ED visit, and 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy.ConclusionThese results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.

Role of Serum β-HCG doubling in Diagnosis of Early Pregnancy and its Management Strategy

2020 ◽  
Vol 16 ◽  
Author(s):  
Divya Mirji ◽  
Shubha Rao ◽  
Akhila Vasudeva ◽  
Roopa P.S
Keyword(s):  
Ectopic Pregnancy ◽  
Early Pregnancy ◽  
Management Strategy ◽  
Transvaginal Ultrasound ◽  
Expectant Management ◽  
First Trimester ◽  
Intrauterine Pregnancy ◽  
Β Hcg ◽  
Pregnancy Of Unknown Location

Background: Pregnancy of unknown location (PUL) is defined as the absence of intrauterine or extrauterine sac and Beta Human Chorionic Gonadotropin levels (β-HCG) above the discriminatory zone of 1500 mIU/ml. It should be noted that PUL is not always an ectopic; however, by measuring the trends of serum β-HCG, we can determine the outcome of a PUL. Objective: This study aims to identify the various trends β-HCG levels in early pregnancy and evaluate the role of β-HCG in the management strategy. Methods: We conducted a prospective observational study of pregnant women suspected with early pregnancy. Cases were classified as having a pregnancy of unknown location (PUL) by transvaginal ultrasound and ß-HCG greater than 1000 mIU/ml. Expectant management was done until there was a definite outcome. All the collected data were analyzed by employing the chi-square test using SPSS version 20. Results: Among 1200 women who had early first trimester scans, 70 women who fulfilled our criteria of PUL and ß-HCG > 1000 mIU/ml were recruited in this study. In our study, the mean age of the participants was 30±5.6yrs, and the overall mean serum ß-HCG was 3030±522 mIU/ml. The most common outcome observed was an ectopic pregnancy, 47% in our study. We also found the rate of failing pregnancy was 27%, and that of intrauterine pregnancy (IUP) was 25%. Overall, in PUL patients diagnosed with ectopic pregnancy, 9% behaved like IUP, and 4% had an atypical trend in their ß-HCG. Those who had an IUP, 11% had a suboptimal increase in ß-HCG. Conclusion: PUL rate in our unit was 6%. Majority of the outcome of PUL was ectopic in our study. Every case of PUL should be managed based on the initial ß-HCG values, clinical assessments and upon the consent of the patient.

scholarly journals Acute pelvic pain following miscarriage heterotopic pregnancy must be excluded: case report

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Udit Thakur ◽  
Kiran Atmuri ◽  
Angelika Borozdina
Keyword(s):  
Ectopic Pregnancy ◽  
Pelvic Pain ◽  
Point Of Care ◽  
Transvaginal Ultrasound ◽  
Heterotopic Pregnancy ◽  
Point Of Care Ultrasound ◽  
Pelvic Ultrasound ◽  
Intrauterine Pregnancy ◽  
Tubal Ectopic Pregnancy ◽  
Acute Pelvic Pain

Abstract Background Heterotopic pregnancies are increasing in prevalence and this case highlights the importance of excluding the diagnosis in patients with pelvic pain following miscarriage. A known pre-existing intrauterine pregnancy can be falsely reassuring and delay the diagnosis of a potentially life-threatening concurrent ectopic pregnancy. Case presentation In this report, we describe a case of spontaneous heterotopic pregnancy in a woman who had initially presented with pelvic pain and vaginal bleeding, and was diagnosed on pelvic ultrasound with a missed miscarriage; a non-viable intrauterine pregnancy. She re-presented 7 days later with worsening pelvic pain and bleeding, and a repeat pelvic ultrasound identified a ruptured tubal ectopic pregnancy in addition to an incomplete miscarriage of the previously identified intrauterine pregnancy. She underwent an emergency laparoscopy where a ruptured tubal ectopic pregnancy was confirmed. Conclusion Being a time critical diagnosis with the potential for an adverse outcome, it is important that the emergency physician considers heterotopic pregnancy as a differential diagnosis in patients presenting with pelvic pain following a recent miscarriage. The same principle should apply to pelvic pain in the context of a known viable intrauterine pregnancy or recent termination of pregnancy. A combination of clinical assessment, beta human chorionic gonadotropin levels, point of care ultrasound and formal transvaginal ultrasound must be utilized together in these situations to explicitly exclude heterotopic pregnancy.

scholarly journals Pitfalls in Emergency Department Focused Bedside Sonography of First Trimester Pregnancy

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
Kerri Layman ◽  
Michael Antonis ◽  
Jonathan E. Davis
Keyword(s):  
Emergency Department ◽  
Clinical Decision Making ◽  
Case Reports ◽  
Clinical Decision ◽  
First Trimester ◽  
Intrauterine Pregnancy ◽  
Diagnostic Modality ◽  
First Trimester Pregnancy ◽  
Trimester Pregnancy ◽  
First Trimester Of Pregnancy

Background. Bedside sonography performed by emergency physicians is frequently utilized for real-time clinical decision-making in the emergency department (ED) setting. This includes the sonographic evaluation of pain or bleeding in the first trimester of pregnancy. The detection of intrauterine pregnancy (IUP) or life-threatening conditions, including ectopic pregnancy, is critical.Objectives. This paper will review several important pearls and avoidable pitfalls of this diagnostic modality by brief presentation of illustrative cases followed by discussion of key principles.Case Reports. Three patients evaluated in the ED for bleeding or pain occurring during the first trimester of pregnancy will be presented.Conclusions. When conducting emergency bedside ultrasound for the evaluation of first trimester pregnancy, it is important to avoid common pitfalls that can place your patient at risk.

scholarly journals P107: Does the use of bedside ultrasound to identify intrauterine pregnancy in the emergency department shorten the length of stay of patients presenting with 1st trimester vaginal bleeding or pelvic pain?

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S114-S114
Author(s):  
M. Ravichandiran ◽  
S. Ramkissoon
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Point Of Care ◽  
First Trimester ◽  
Control Group ◽  
Point Of Care Ultrasound ◽  
Intrauterine Pregnancy ◽  
First Trimester Pregnancy ◽  
Trimester Pregnancy ◽  
Experimental Group

Introduction: The use of point of care ultrasound (POCUS) has increased rapidly in the emergency department (ED) over the last 10 years. This study seeks to determine whether the use of POCUS to identify intrauterine pregnancy in the ED shortens the length of stay of patients presenting with first trimester pregnancy-related complaints at The Scarborough Hospital (TSH). Methods: A prospective chart review of women seen at TSH ED for first trimester pregnancy-related complaints was conducted from March 1, 2014 to December 30, 2014. ED physicians were asked to record the names of patients assessed using POCUS in the ED along with their findings during the study period (experimental group). Health Records data was used to find all patients seen in the emergency department during the study period with the chief triage complaint of “Pregnancy Issues < 20 weeks” (control group). Results: A total of 378 patients were identified in the control group and 61 patients were recorded in the experimental group. The outliers were removed from both groups. The POCUS identified an intra-uterine pregnancy (POS IUP) in 47.5% and no definite intrauterine pregnancy (NDIUP) in 52.5%.In the control group, 82.0% proceeded to obtain a formal ultrasound (FUS) after the POCUS. Patients found to have a POS IUP on the POCUS spent 141.48±100.95 minutes in hospital, while patients found to have NDIUP spent 197.10±132.48 minutes in hospital (p=0.07). The POS IUP group spent statistically significantly less time in hospital when compared to the control group (p=0.001). In the POCUS group, patients seen between 1700 and 0800 (i.e. when FUS is not available) spent significantly less time (p=0.02) in hospital (113.13±118.07 minutes, n=24) when compared to patients seen between 0800 and 1700 (208.28±106.35 minutes, n=36). Conclusion: For first-trimester pregnancy-related complaints, POCUS has been shown to be effective in reducing the time that patients spend in hospital at TSH. This difference was especially apparent when POCUS was used at times when FUS was not available. Despite the apparent reluctance of many ED physicians to discharge patients without a FUS, even after identifying a POS IUP on the POCUS, it was evident that this technology was saving time for both physicians and patients.

scholarly journals Role of Maternal Serum Glycodelin as Predictor of Ectopic Pregnancy in First Trimester

2018 ◽  
Vol 7 (4) ◽  
pp. 467-470
Author(s):  
Wasan Wajdi Ibrahim ◽  
Afraa Mahjoob Al-Naddawi ◽  
Hayder A. Fawzi
Keyword(s):  
Ectopic Pregnancy ◽  
Predictive Value ◽  
First Trimester ◽  
Maternal Serum ◽  
Intrauterine Pregnancy ◽  
Receiver Operator Curve Analysis ◽  
Medical City ◽  
First Trimester Of Pregnancy ◽  
Control Study

Objectives: Assessment of glycodelin (GD) as a marker for unruptured ectopic pregnancy (EP) in the first trimester of pregnancy. Materials and Methods: This case-control study was conducted during June 2016 to May 2017 in the Obstetrics and Gynecological Department of Baghdad University at Baghdad teaching hospital/medical city complex. In this study, 100 pregnant women in their first trimester of pregnancy were included after clinical and ultrasonic findings. Results: Based on the results, GD levels in EP were significantly lower than those with normal intrauterine pregnancy (1.58 ± 1.18 vs. 30.1 ± 11.9). In addition, using receiver operator curve analysis, the cut-off GD level of 9.5 and less had acceptable validity results (100% sensitivity, 100% specificity, 95% positive predictive value, 100% negative predictive value, and accuracy 100%) to predict EP. Conclusions: In general, serum GD is considered as an excellent predictor of unruptured EP.

scholarly journals Female with Vaginal Bleeding

2020 ◽  
Vol 4 (4) ◽  
pp. 636-637
Author(s):  
Mark Quilon ◽  
Alec Glucksman ◽  
Gregory Emmanuel ◽  
Josh Greenstein ◽  
Barry Hahn
Keyword(s):  
Emergency Department ◽  
Emergency Physician ◽  
Vaginal Bleeding ◽  
Point Of Care ◽  
First Trimester ◽  
Yolk Sac ◽  
Pregnant Female ◽  
Point Of Care Ultrasound ◽  
Fetal Demise ◽  
Case Presentation

Case Presentation: A 24-year-old pregnant female presented to the emergency department with lower abdominal cramping and vaginal bleeding. A point-of-care ultrasound demonstrated a calcified yolk sac. Discussion: When identified, calcification of the yolk sac in the first trimester is a sign of fetal demise. It is important for an emergency physician to be aware of the various signs and findings on point-of-care ultrasound and be familiar with the management of these pathologies.

Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy

2018 ◽  
Vol 37 (8) ◽  
pp. 1965-1975 ◽  
Author(s):  
Nova Panebianco ◽  
Frances Shofer ◽  
Katie O'Conor ◽  
Tristan Wihbey ◽  
Lakeisha Mulugeta ◽  
...  
Keyword(s):  
Emergency Department ◽  
Transvaginal Ultrasound ◽  
Emergency Department Patient ◽  
First Trimester ◽  
Patient Perceptions ◽  
First Trimester Pregnancy ◽  
Trimester Pregnancy

scholarly journals Ruptured Ectopic Pregnancy in the Presence of an Intrauterine Device

2019 ◽  
Vol 3 (1) ◽  
pp. 51-54 ◽  
Author(s):  
Matthew Neth ◽  
Maxwell Thompson ◽  
Courtney Gibson ◽  
John Gullett ◽  
David Pigott
Keyword(s):  
Abdominal Pain ◽  
Maternal Mortality ◽  
Ectopic Pregnancy ◽  
Female Patient ◽  
Vaginal Bleeding ◽  
Intrauterine Device ◽  
First Trimester ◽  
Equal Protection ◽  
Intrauterine Pregnancy

Ruptured ectopic pregnancy is the leading cause of first trimester maternal mortality. The diagnosis of ectopic pregnancy should always be suspected in patients with abdominal pain, vaginal bleeding or syncope. While the use of an intrauterine device (IUD) markedly reduces the incidence of intrauterine pregnancy, it does not confer equal protection from the risk of ectopic pregnancy. In this report we discuss the case of a female patient who presented with a ruptured ectopic pregnancy and hemoperitoneum despite a correctly positioned IUD.

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