ACEP clinical policy: complications of early pregnancy

1
ACEP clinical policycomplications 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 ß 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 ß 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
ß hCG gt1500 mIU/mL
ß hCG lt1500 mIU/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
ß 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
positive LR 0.8 (95CI 0.5 to 1.4) negative LR 1.1
(95CI 0.8 to 1.5)

• Wang. Ann Emerg Med. 2011 5812-20

16
IUPs that would be misdiagnosed as abnormal or
ectopic pregnancies

• Wang. Ann Emerg Med. 2011 5812-20

17
ß hCG (mIU/mL) patients with empty uterus on comprehensive US and final diagnosis of IUP
1000 - 1499 19
1500 -1999 12
gt 2000 9
Doubliet. J Ultrasound Med 2011 3016371642
18
classic rule out ectopic algorithm
ß hCG gt1500 mIU/mL
ß hCG lt1500 mIU/mL
Condous. BJOG. 112 827-29. 2005
19
Youre unlikely to see something if the bhCG is
low anyway
20
about 50 of IUPs will be diagnosed when the ß
hCG lt 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 ß hCG lt 1000 mIu/mL
http//www.acep.org/WorkArea/DownloadAsset.aspx?id
32886
http//www.acep.org/WorkArea/DownloadAsset.aspx?id
32886
22
Isnt it unlikely that the patient will have an
ectopic with a bhCG below the discriminatory
zone, anyway?
23
no
24
ectopics often have lower ß hCGs than IUPs
mean EP 1886 mIU/mL
mean IUP 30,512 mIU/mL
Kohn. Academic Emergency Medicine. 2003. 10(2)
25
Well, isnt 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
gt1500 mIU/mL
lt 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.
200113338-343. Barnhart et al. Obstet
Gynecol. 1994841010-1015.
31
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 ß-hCG below any
discriminatory threshold?Level C
recommendation Perform or obtain a pelvic
ultrasound for symptomatic pregnant patients with
a ß-hCG below any discriminatory threshold
ACEP clinical policy 2012
32
back to the case
33
modern rule out ectopic algorithm
ß 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 ß-hCG for identifying possible ectopic
pregnancy?
38
risk of ectopic pregnancy with indeterminate US
39
In patients who have an indeterminate
transvaginal ultrasound, what is the diagnostic
utility of ß-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
ACEP clinical policy 2012
40
what other ways can we risk stratify patients
with indeterminate US (regardless of ß 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. 5313-319.
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. 5313-319.
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 patients
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
ß hCG 1140 mIU/mL
45
I think she completed. She passed POC at home and
theres 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 ß hCG of 524 mIU/ml
94 complete

6 ectopic
Its not complete until the ßhCG 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 ß-hCG of 5,000 mIU/L or more
• Often need repeat dosing until ß-hCG is
  decreasing
• Best estimates of failure rates appx 10
• Rupture reported to range from 0.5 19,
  probably lt 5

51
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

52

• dont consider low ß hCG low risk
• consider a pelvic US for patients with any ß hCG
  
• your approach to the patient with a low ß 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 its complete
• you probably dont need to give rhogam for
  threatened AB
• consider rupture in symptomatic patients s/p MTX