scholarly journals P024: Obtaining consensus on optimal management and follow-up of patients presenting to the emergency department with early pregnancy complications – a modified Delphi study

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S71-S72
Author(s):  
A. Cornelis ◽  
R. Clouston ◽  
P. Atkinson
Keyword(s):  
Emergency Department ◽  
Family Medicine ◽  
Nurse Practitioners ◽  
Early Pregnancy ◽  
Pregnancy Complications ◽  
Delphi Study ◽  
Pregnancy Loss ◽  
Early Pregnancy Loss ◽  
Modified Delphi

Introduction: Complications in early pregnancy are common and have many physical and emotional consequences. Locally, there is no early pregnancy loss clinic or standardized guide in the emergency department (ED) for referral and follow-up decisions, and both initial management of patients and follow up can be inconsistent. This study aimed to obtain consensus on the best approach to initial work-up, management, and follow up for patients who present to the ED with early pregnancy complications, with the goal of using this consensus to produce a standardized guide for emergency provider use. Methods: A literature review was completed to produce evidence-based recommendations which were used to initiate a modified Delphi consensus process. A survey was distributed, with three rounds completed. Participants included emergency providers, obstetrician-gynecologists, a radiologist, a sample of family medicine physicians including some involved in primary care obstetrics, and nurse practitioners. An obstetric specialist from outside the local region was also involved. Results: Consensus was reached on several key recommendations, however some areas remained without clear accepted best practice. There was consensus that physical components of early pregnancy complications are addressed well, but that we could improve on patient flow and more consistent follow up. Important investigations to be done for patients were identified. The timing of formal ultrasound, necessity and timing of obstetrician consultation, and safety of discharge was addressed for various patient scenarios including stable and unstable patients, with and without adnexal pain, with intrauterine pregnancy of uncertain viability, and with pregnancy of unknown location. Management of confirmed early pregnancy loss in the ED and family medicine clinics was addressed. Barriers to an early pregnancy loss clinic included lack of funding, space, and staffing as well as lack of resources and uncertain patient volumes. A feasible alternative to an early pregnancy loss clinic was for willing providers to keep appointment times available to facilitate confirmation of follow-up prior to discharge. Other suggested alternatives included an early pregnancy loss clinic, a nurse educator, and having a standardized guideline in the ED. Conclusion: Through a consensus approach, several recommendations were agreed upon for improving care for patients presenting to the ED with early pregnancy complications.

scholarly journals LO40: Services for emergency department patients experiencing early pregnancy complications: a survey of Ontario hospitals

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S21-S22
Author(s):  
R. Glicksman ◽  
S. McLeod ◽  
J. Thomas ◽  
C. Varner
Keyword(s):  
Emergency Department ◽  
Early Pregnancy ◽  
Pregnancy Complications ◽  
Pregnancy Loss ◽  
Transvaginal Ultrasound ◽  
Point Of Care Ultrasound ◽  
Early Pregnancy Loss ◽  
Online Questionnaire ◽  
Follow Up Care

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. These hospitals constitute greater than 85% of the annual ED visits in Ontario, creating a sample reflective of the services available to most women older than 18 years old seeking care for early pregnancy complications in the province. Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications including pregnancy of unknown location and threatened abortion. Respondents also stated that radiologist-interpreted ultrasound was only available to 22 (34.9%) of hospital sites 24 hours a day, 7 days per week for women with early pregnancy complications. Of hospital site respondents, 55 (87.3%) reported point-of-care ultrasound (POCUS) use in the ED for patients with early pregnancy complications, and 27 (49.1%) reported the ED had access to transvaginal ultrasound probes for POCUS assessment by emergency physicians. Additionally, the proportion of ED physicians who were certified as Canadian Emergency Ultrasound independent practitioners ranged from 10% to 100%. Conclusion: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.

Services for emergency department patients experiencing early pregnancy complications: A survey of Ontario hospitals

CJEM ◽  
2019 ◽  
Vol 21 (5) ◽  
pp. 653-658 ◽  
Author(s):  
Robin Glicksman ◽  
Shelley L McLeod ◽  
Jackie Thomas ◽  
Catherine Varner
Keyword(s):  
Emergency Department ◽  
Early Pregnancy ◽  
Pregnancy Complications ◽  
Pregnancy Loss ◽  
Primary Objective ◽  
Early Pregnancy Loss ◽  
Online Questionnaire ◽  
Follow Up Care ◽  
Emergency Department Patients

ABSTRACTObjectivesWomen experiencing complications of early pregnancy frequently seek care in the emergency department (ED), because most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals.MethodsThe emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology.ResultsRespondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported that they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications, including pregnancy of unknown location and threatened abortion. Respondents also stated that a radiologist-interpreted ultrasound was available to only 22 (34.9%) of hospital sites for 24 hours, 7 days per week for women with early pregnancy complications.ConclusionsThe results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.

scholarly journals P074: Emergency department utilization and outcomes for patients with early pregnancy complications

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S91-S91
Author(s):  
R. Glicksman ◽  
D. Little ◽  
C. Thompson ◽  
S. McLeod ◽  
C. Varner
Keyword(s):  
Emergency Department ◽  
Ectopic Pregnancy ◽  
Early Pregnancy ◽  
Pregnancy Complications ◽  
Pregnancy Loss ◽  
Hospital Admissions ◽  
Emergency Department Utilization ◽  
Early Pregnancy Loss ◽  
Surgical Interventions ◽  
Ed Visits

Introduction: Affecting roughly 1 in 5 pregnancies, early pregnancy loss is a common experience for reproductive-aged women. In Canada, most women do not establish care with an obstetrical provider until the second trimester of pregnancy. Consequently, pregnant patients experiencing symptoms of early pregnancy loss frequently access care in the emergency department (ED). The objective of this study was to describe the resource utilization and outcomes of women presenting to two Ontario EDs for early pregnancy loss or threatened early pregnancy loss. Methods: This was a retrospective cohort study of pregnant (≤20 weeks), adult (≥18 years) women in two EDs (one community hospital with 110,000 annual ED visits; one academic hospital with 65,000 annual ED visits) between January 2010 and December 2017. Patients were identified by diagnostic codes indicating early pregnancy loss or threatened early pregnancy loss. Results: A total of 16,091 patients were included, with a mean (SD) age of 32.8 (5.6) years. Patients had a total of 22,410 ED visits for early pregnancy complications, accounting for 1.6% of the EDs’ combined visits during the study period. Threatened abortion (n = 11,265, 50.3%) was the most common ED diagnosis, followed by spontaneous abortion (n = 5,652, 25.2%), ectopic pregnancy (n = 3,242, 14.5%), missed abortion (n = 1,541, 6.9%), and other diagnoses (n = 710, 3.2%). 8,000 (44.8%) patients had a radiologist-interpreted ultrasound performed during the initial ED visit. Median (IQR) ED length of stay was 3.4 (2.3 to 5.1) hours. There were 4,561 (25.6%) return ED visits within 30 days, of which 2,317 (50.8%) occurred less than 24 hours of index visit, and 481 (10.6%) were for scheduled, next day ultrasound. The total number of hospital admissions was 1,793 (8.0%), and the majority were for ectopic pregnancy (n = 1,052, 58.7%). Of admitted patients, 1,320 (73.6%) underwent surgical interventions related to early pregnancy. There were 474 (10.4%) patients admitted to hospital during return ED visits. Conclusion: Pregnant patients experiencing symptoms of early pregnancy loss in the ED frequently had radiologist-interpreted US and low rates of hospital admission, yet had high rates of return ED visits. This study highlights the heavy reliance on Ontario EDs to care for patients experiencing complications of early pregnancy.

scholarly journals Early pregnancy loss in the emergency department, 2006–2016

2021 ◽  
Vol 2 (6) ◽  
Author(s):  
Lyndsey S. Benson ◽  
Sara L. Magnusson ◽  
Kristen E. Gray ◽  
Kelly Quinley ◽  
Larry Kessler ◽  
...  
Keyword(s):  
Emergency Department ◽  
Early Pregnancy ◽  
Pregnancy Loss ◽  
Early Pregnancy Loss

Early versus delayed follow-up after misoprostol treatment for early pregnancy loss

2019 ◽  
Vol 39 (1) ◽  
pp. 155-160 ◽  
Author(s):  
Yossi Mizrachi ◽  
Liliya Tamayev ◽  
Ofer Shemer ◽  
Ilia Kleiner ◽  
Jacob Bar ◽  
...  
Keyword(s):  
Early Pregnancy ◽  
Pregnancy Loss ◽  
Early Pregnancy Loss

scholarly journals LO45: Women's perspectives on early pregnancy complications and supportive care needs: a qualitative multi-site study

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S23-S23
Author(s):  
K. Dainty ◽  
B. Seaton ◽  
V. Rojas-Luengas ◽  
S. McLeod ◽  
M. Tunde-Byass ◽  
...  
Keyword(s):  
Supportive Care ◽  
Early Pregnancy ◽  
Pregnancy Complications ◽  
Pregnancy Loss ◽  
Supportive Care Needs ◽  
Point Of Care Ultrasound ◽  
Care Hospital ◽  
Early Pregnancy Loss ◽  
Care Needs ◽  
The Impact

Introduction: Women experiencing early pregnancy loss or threatened loss frequently seek care in emergency departments (ED) or early pregnancy clinics (EPC). The dearth of existing qualitative studies has left understudied questions about how these women perceive their healthcare and which strategies best meet their supportive care needs, particularly in the Canadian context. The objective of this study was to deepen our understanding of these women's experiences and gain insight into how clinicians and healthcare services can lessen the impact of this traumatic event on patients and their families. Methods: We conducted a descriptive qualitative study of women who presented to the ED or EPC at an urban tertiary care hospital and an urban community hospital for early pregnancy loss or threatened loss. Purposive sampling was used to recruit patients for in-depth, one-on-one telephone interviews conducted 4-6 weeks after the index visit. Data collection and analysis were concurrent and continued until thematic saturation had occurred. Data analysis was led by two qualitative researchers with support from a multi-disciplinary research team following standard thematic analysis techniques. Results: Interviews were completed with 59 women between July 2018 and August 2019. Participants ranged in age from 22 to 47 years and reflect the diversity of the multicultural city where the study occurred. Our analysis revealed that the medicalization and normalization of early pregnancy complications among ED and EPC clinicians is at odds with women's general lack of knowledge about the frequency, personal risk, causation, duration, and physical intensity of the miscarriage experience. Women identified the value of rapid access to appointments, point of care ultrasound, detailed care plans, and knowledgeable advice as key to lessening the physical and emotional trauma related to early pregnancy loss. Conclusion: This research highlights the physical, emotional, and psychological complexity of a medical situation frequently minimized within the current healthcare system. The results impart important knowledge about which aspects of ED and EPC care are most valued by women experiencing early pregnancy loss or threatened loss and demonstrate the clear need for women and their families to be provided with more education about the totality of the early pregnancy experience, including the possibility of pregnancy complications and loss.

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