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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. 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

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  1. ACEP clinical policy:complications of early pregnancy sigrid hahn, MD MPH mount sinai school of medicine, NY NY

  2. disclosuresnone

  3. 2012 update

  4. applies tostable patients in the first trimester withabdominal pain or vaginal bleeding

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

  6. what is your “rule out ectopic” algorithm?

  7. 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

  8. 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

  9. classic “rule out” ectopic algorithm β hCG >1500mIU/mL β hCG <1500mIU/mL Condous. BJOG. 112: 827-29. 2005

  10. 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

  11. classic algorithm is based on several false assumptions

  12. The beta and the discriminatory zone should help guide your evaluation and disposition

  13. The beta and the discriminatory zone should help guide your evaluation and disposition

  14. the very concept of the discriminatory zone has been challenged

  15. 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)

  16. Wang. Ann Emerg Med. 2011; 58:12-20 IUPs that would be misdiagnosed as abnormal or ectopic pregnancies

  17. Doubliet. J Ultrasound Med 2011; 30:1637–1642

  18. classic “rule out” ectopic algorithm β hCG >1500mIU/mL β hCG <1500mIU/mL Condous. BJOG. 112: 827-29. 2005

  19. You’re unlikely to see something if the bhCG is low anyway

  20. about 50% of IUPs will be diagnosed when the β hCG < 1000 mIu/mL http://www.acep.org/WorkArea/DownloadAsset.aspx?id=32886

  21. 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

  22. Isn’t it unlikely that the patient will have an ectopic with a bhCG below the discriminatory zone, anyway?

  23. no

  24. 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)

  25. Well, isn’t the risk of rupture of an ectopic pregnancy low if the bhCG is low?

  26. no

  27. rupture has been reportedat 10 mIU/mL and 189,720 mIU/mL Barnhart. Obstetrics and Gynecology. 1994. 84(6)

  28. classic “rule out”algorithm >1500 mIU/mL < 1500 mIU/mL Condous. BJOG. 112: 827-29. 2005

  29. are there studies showing harm with the deferred ultrasound approach?

  30. 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.

  31. 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

  32. back to the case

  33. 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

  34. what if you saw this?

  35. or this?

  36. what do you do with an indeterminate US, or a pregnancy of unknown location?

  37. 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?

  38. risk of ectopic pregnancy with indeterminate US

  39. 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

  40. 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.

  41. 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.

  42. 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

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

  44. patient was sent home, and returns 2 days later… I passed a lot of tissue at home β hCG 1140 mIU/mL

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

  46. 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

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

  48. 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

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

  50. 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%

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