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ACEP clinical policy: complications of early pregnancy . sigrid hahn, MD MPH mount sinai school of medicine, NY NY. disclosures none. 2012 update. applies to stable patients in the first trimester with abdominal pain or vaginal bleeding.

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acep clinical policy complications of early pregnancy
ACEP clinical policy:complications of early pregnancy

sigrid hahn, MD MPH

mount sinai school of medicine, NY NY

applies to stable patients in the first trimester with abdominal pain or vaginal bleeding
applies tostable patients in the first trimester withabdominal pain or vaginal bleeding
slide5

does not apply topatients with vital sign instability, infertility treatment (at high risk for heterotopic pregnancy), other presenting complaints

slide7

27 y/o F G1P0 LMP 5 weeks ago

β hCG 1950 mIU/mL

no IUP seen on bedside pelvic US

a) repeat bedside US and attempt to visualize adnexa

b) get a stat comprehensive US

c) get a comprehensive US ASAP

c) consult OB

d) d/c with 48 hour follow up

slide8

27 y/o F G1P0 LMP 5 weeks ago

β hCG 950 mIU/mL

no IUP seen on bedside pelvic US

a) repeat bedside US and attempt to visualize adnexa

b) get a stat comprehensive US

c) get a comprehensive US ASAP

c) consult OB

d) d/c with 48 hour follow up

slide9

classic “rule out” ectopic algorithm

β hCG >1500mIU/mL

β hCG <1500mIU/mL

Condous. BJOG. 112: 827-29. 2005

slide10

classic algorithm grew out of the

concept of the

discriminatory zone

sensitivity of pelvic US for IUP nears100%

β hCG 1000 - 2000 mIU/mL

IUP may be present but not yet visible

slide15

Wang. Ann Emerg Med. 2011; 58:12-20

positive LR 0.8 (95CI 0.5 to 1.4)

negative LR 1.1 (95CI 0.8 to 1.5)

slide16

Wang. Ann Emerg Med. 2011; 58:12-20

IUPs that would be misdiagnosed as abnormal or ectopic pregnancies

slide18

classic “rule out” ectopic algorithm

β hCG >1500mIU/mL

β hCG <1500mIU/mL

Condous. BJOG. 112: 827-29. 2005

slide20

about 50% of IUPs will be diagnosed when the β hCG < 1000 mIu/mL

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32886

slide21

about 50% of ectopics will have a suggestive or diagnostic US when the β hCG < 1000 mIu/mL

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32886

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32886

slide22
Isn’t it unlikely that the patient will have an ectopic with a bhCG below the discriminatory zone, anyway?
ectopics often have lower hcgs than iups
ectopics often have lower β hCGs than IUPs

mean EP

1886 mIU/mL

mean IUP

30,512 mIU/mL

Kohn. Academic Emergency Medicine. 2003. 10(2)

rupture has been reported at 10 miu ml and 189 720 miu ml
rupture has been reportedat 10 mIU/mL and 189,720 mIU/mL

Barnhart. Obstetrics and Gynecology. 1994. 84(6)

slide28

classic “rule out”algorithm

>1500 mIU/mL

< 1500 mIU/mL

Condous. BJOG. 112: 827-29. 2005

no high quality studies have looked at harm
no high quality studies have looked at harm
  • 37 patients had no deaths or hemodynamic instability despite d/c and median wait of 14 hours for US *
  • 69 patients had a mean delay of 5.2 days to diagnosis of ectopic with no deaths **

* Hendry JN, Naidoo Y. Emerg Med. 2001;13:338-343.

** Barnhart et al. Obstet Gynecol. 1994;84:1010-1015.

slide31

ACEP clinical policy 2012

Should the emergency physician obtain a pelvic ultrasound in a clinically stable pregnant patient who presents to the ED with pelvic pain and/or vaginal bleeding and a β-hCG below any discriminatory threshold?Level C recommendation: Perform or obtain a pelvic ultrasound for symptomatic pregnant patients with a β-hCG below any discriminatory threshold

slide33

modern “rule out” ectopic algorithm

β hCG pending

normal or abnormal

IUP,

molar

suggestive or diagnositic of ectopic

indeterminate

Condous. BJOG. 112: 827-29. 2005

slide36

what do you do with an

indeterminate US,

or a

pregnancy of unknown location?

slide37

ACEP clinical policy 2012

In patients who have an indeterminate transvaginal ultrasound, what is the diagnostic utility of β-hCG for identifying possible ectopic pregnancy?

slide39

ACEP clinical policy 2012

In patients who have an indeterminate transvaginal ultrasound, what is the diagnostic utility of β-hCG for identifying possible ectopic pregnancy?Answer: Diagnostic utility is poorLevel C recommendation: Obtain specialty consultation or arrange close outpatient follow up for all patients with an indeterminate pelvic ultrasound

what other ways can we risk stratify patients with indeterminate us regardless of hcg
what other ways can we risk stratify patients with indeterminate US (regardless of β hcG)?

excluded IUP: yolk sac or fetal pole

excluded EP: ectopic gestational sac, complex mass discrete from ovary, any echogenic fluid, moderate anechoic fluid

Dart and Howard. Acad Emerg Med. 1998. 5:313-319.

slide41

excluded IUP: yolk sac or fetal pole

excluded EP: ectopic gestational sac, complex mass discrete from ovary, any echogenic fluid, moderate anechoic fluid

Dart and Howard. Acad Emerg Med. 1998. 5:313-319.

spectrogram of diagnostic certainty
spectrogram of diagnostic certainty

Small to moderate anechoic free fluid or

non-specific adnexal mass

non-specific intrauterine debris/sac,

no adnexal mass

nothing in the uterus or adnexa

non-specific intrauterine debris/sac

ectopic pregnancy

nothing in the uterus

IUP

Indeterminate US

slide43

evaluation and disposition ends up being determined by your gestalt based on patient’s clinical (and social) state, hospital and clinic system

slide44

patient was sent home, and returns 2 days later…

I passed a lot of tissue at home

β hCG 1140 mIU/mL

slide45

I think she completed. She passed POC at home and there’s just echogenic material in the uterus on ultrasound.

slide46

6% of patients with a suspected

“complete miscarriage” had an ectopic pregnancy

152 patients

with clinically suspected “complete miscarriage”

US with

empty uterus

Mean β hCG

of 524 mIU/ml

94% complete

6% ectopic

It’s not complete until the βhCG is 0

Condous. BJOG. 112: 827-29. 2005

rhogam
Rhogam

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32886

slide48

90% of alloimmunization occurs at deliveryACOG concluded that alloimmunization is exceedingly rare after threatened ABs in first trimesterHigher rates of fetomaternal hemorrhage with complete AB compared with threatened AB

rhogam1
Rhogam

http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32886

slide50
In patients receiving methotrexate for confirmed or suspected ectopic pregnancy, what are the implications for ED management?
  • MTX is relatively contraindicated in patients with an ectopic gestational sac larger than 3.5 cm or with embryonic cardiac motion seen on US
  • Treatment success rates are lower in patients who have a β-hCG of 5,000 mIU/L or more
  • Often need repeat dosing until β-hCG is decreasing
  • Best estimates of failure rates appx 10%
  • Rupture reported to range from 0.5 – 19%, probably < 5%
slide51
In patients receiving methotrexate for confirmed or suspected ectopic pregnancy, what are the implications for ED management?
  • Arrange outpatient follow-up for patients who receive methotrexate therapy in the ED for a confirmed or suspected ectopic pregnancy

 (2) Strongly consider ruptured ectopic pregnancy in the differential diagnosis of patients who have received methotrexate and present with concerning signs or symptoms

slide52

don’t consider low β hCG low risk

  • consider a pelvic US for patients with any β hCG
  • your approach to the patient with a low β hCG will be determined by your US skills, comprehensive US availability, department protocol, clinical risk factors and findings
  • your approach to the patient with a PUL will also be determined by US skills, hospital protocols and resources, clinical risk factors and findings
  • a miscarriage is not complete until it’s complete
  • you probably don’t need to give rhogam for threatened AB
  • consider rupture in symptomatic patients s/p MTX