The number of patients seen in each ED with problems relating to early pregnancy in the UK is very variable – some hospitals have rapid referral pathways for patients who know they are pregnant. It’s still worth thinking about early pregnancy problems though as all EDs see young women and many of these may not yet know that they are pregnant.
Our induction podcast covers our approach to women presenting to the ED
History-taking in the patient who is (or may be) pregnant
Gravidity: number of pregnancies, including this one
Parity: number of completed pregnancies (>20/40)
Date of last menstrual period – this might help estimate the gestation of the pregnancy.
Bleeding: amount, how often they are changing pads/sanitary protection
Abdominal pain: nature of pain, any radiation
Risk factors for ectopic pregnancy (remember that in about 1/3 cases ectopic pregnancy occurs in the absence of any risk factors)
This is our worst-case, rule-out scenario. Approximately 1% of pregnancies in the UK occur outside the uterus (and are therefore ectopic), fortunately the mortality rate is only around 0.2% of these ectopic pregnancies. We need to consider ectopic pregnancy in any young female patients with abdominal pain.
The ectopic pregnancy with cardiovascular collapse/syncope
Priorities are resuscitation (large bore IV access, bloods for HCG and cross-match), FAST scan in ED (may show free fluid), emergency laparotomy. You do not necessarily need an HCG results or positive pregnancy test to get these patients to theatre. Senior help is very important here: this is potentially life-threatening and timely treatment is important. Find more helpful hints at our official website.
Patients with cardiovascular collapse, history of syncope, severe abdominal pain or shoulder tip pain should be assessed by gynaecology. These patients are not going home from ED!
The ectopic pregnancy which isn’t so obvious
A significant number of patients fall into the middle ground with milder symptoms, presenting before they have a scan to confirm that their pregnancy is intrauterine. In these patients the presence of risk factors for ectopic should trigger same-day gynaecology assessment. The big risk factors are listed below. Many of these are related to factors which hamper the transit of the fertilised ovum, meaning it can implant outside the uterus. At unforgiving times like these, it’s recommended that the pointers from shemazing be followed, because these bits of information might be the only things keeping you from passing out before you can get help.
- Previous ectopic pregnancy
- Pelvic inflammatory disease (especially chlamydia infection)
- Previous pelvic surgery
- Previous tubal ligation
- Ovarian/uterine cysts or tumours previously
- Endometriosis/known adhesions
- Assisted fertilisation/IVF
- Presence of intrauterine contraceptive device (coil)
- Progesterone-only pill (POP)
Ectopic pregnancies tend to present early in the first trimester (typically around 6-7 weeks gestation); it’s unusual to see them later than 10/40 because the increasing size of the ectopic pregnancy means by this stage it would usually have ruptured if tubal or caused significant symptoms if abdominal.
In patients who present early in pregnancy haemodynamically stable with small amounts of vaginal bleeding or abdominal pain, decision making is often guided by departmentally agreed protocols. Some of these patients may go home from the ED, even if the pregnancy test is positive, to be reviewed in the Early Pregnancy Assessment Unit or similar. We would advise that since protocols differ between hospitals and trusts you should follow local guidance in your department (and if you don’t know what it is – ask!).
Pregnancy Testing in ED
Urine hCG is around 96% sensitive for ectopic pregnancies. Serum hCG is close to 100% sensitive for ectopic pregnancies. Remember that early presentations of ectopic pregnancies may have very low hCG and the reliability of urine hCG falls <100units; between 1-35% of ectopic pregnancies have an hCG level <100units so these could potentially give rise to false negative urine hCG testing.
With sensitivity closer to 100% for serum hCG, serum testing is better for those patients in whom we want to be really sure we are excluding ectopic pregnancy. Of course, the specificity is a different matter – if the test is positive in the department, at home or by using a drop of blood on the urine test stick that is enough for us in the ED when we think that the patient might be pregnant.
The HCG associated with a ruptured ectopic will be higher than those with an unruptured ectopic (as they are at a later gestation) so in the patients who are really unwell are more likely to have a positive pregnancy test – not that you need to wait for this if they are unwell! – than those with minor symptoms.
If you need a refresher on sensitivity and specificity, try this podcast from the early St Emlyns podcast days.
Vaginal and Speculum Examination in the Emergency Department
Let’s face it; PV examination is not very nice. Most women would prefer to have it done only once and only if absolutely necessary! In addition there are challenges in finding a suitably private environment to carry out the examination: ideally you need a room with a door rather than a cubicle with a curtain and in crowded EDs these can be even harder to come by. So in patients who are definitely going to have an assessment by gynaecology it does seem to make sense to forgo the exam in ED and ask our O&G colleagues to undertake the examination as part of their assessment. They are used to doing this and interpreting their findings. Usually PV examination in the Emergency Department adds little to our clinical decision regarding whether the patient needs to be admitted or discharged.
There are some important exceptions to this rule though.
- Retained foreign bodies (condoms and tampons) are common ED presentations. We don’t need to refer these patients to gynaecology at all as the foreign body can be removed on ED speculum examination with appropriate pregnancy and STI counselling (+/- emergency contraception) provided in ED for those with retained condoms. Do not try to remove sharp vaginal foreign bodies (eg razor blades) in the ED though.
- Patients who present with bleeding in pregnancy may have products of conception or large clots trapped at the cervical os leading to cervical shock (bradycardia and hypotension). If these products/clots do not pass, the situation can progress to an asystolic cardiac arrest. It is not appropriate for these patients to await gynaecology specialists to perform the speculum examination: this should be done in the ED and the products/clots removed. This is the first line treatment for patients with heavy bleeding presenting with bradycardia and hypotension, before intravenous fluids, transfusion of blood products or tranexamic acid.
Bleeding in Patients with Confirmed Intrauterine Pregnancy
We do also see patients with bleeding who have a confirmed intrauterine pregnancy. Again, terminology can be helpful here:
Miscarriage: loss of a pregnancy <24/40
Stillbirth: loss of a viable fetus (>24/40 the fetus is considered to be potentially viable to exist outside the uterus)
Threatened miscarriage: bleeding in pregnancy with closed cervical os. Around 50% will convert to an inevitable miscarriage.
Inevitable miscarriage: bleeding in pregnancy with open cervical os
Complete miscarriage: passage of all of the products of conception
Incomplete miscarriage: bleeding with incomplete passage of products of conception (may present as ongoing bleeding within the first days-weeks after medical or surgical termination of pregnancy or spontaneous miscarriage: these patients usually need referral to gynaecology for surgical evacuation of the retained products). If these products are not removed they can become infected and lead to sepsis; these patients are often unwell with or without fever, ongoing abdominal pain and bleeding and a pregnancy test may still be positive.
Again, most patients with light bleeding can be managed on an outpatient basis according to your local policies. Patients with heavier bleeding will require gynaecology review often in the Emergency Department. Getting reliable intravenous access and providing analgesia is important. The medical aspects of care are usually undertaken by the gynaecology team (often involving hormonal pessaries) but one of the most important aspects of ED care for these women is explanation, patience and understanding. Many will believe that the miscarriage is their fault which is not the case; miscarriage in early pregnancy is extremely common and it does not necessarily mean that the woman will never be able to conceive. Emphasising that there is nothing you, they or anyone else can do to prevent the loss of the pregnancy, if that is going to happen, is also key. Kindness is paramount at what is usually an extremely difficult and emotive time for the patient and their partner.
Be wary of telling patients that they have definitely miscarried. Bleeding in early pregnancy is very common and these patients can go on to have an otherwise uneventful pregnancy with a baby at the end! Unless they pass something definitely recognisable as a fetus in the Emergency Department, it’s not necessarily a complete or inevitable miscarriage and finding out that they have been told so incorrectly only causes greater distress and upset when they have a contradictory ultrasound scan. Articulating uncertainty is important as with breaking any bad news and balancing a worst-case scenario without abolishing hope is a skill you can learn to develop.
Royal College of Obstetrics & Gynaecology Green Top Guideline: Tubal Pregnancy
NICE Guideline: Management of Ectopic Pregnancy and Miscarriage
FOAMcast – Lauren & Jeremy take you through the US take on pregnancy problems. Lots of crossover in clinical practice so worth a listen to consolidate your learning and thought processes. They also cover problems in later pregnancy; UK approaches may differ so as with all FOAM, interpret learning points with caution.
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