1. Approach to the First Trimester Patient with Vaginal Bleeding or Pelvic Pain Eric R. Swanson, MD, FACEP Associate Professor, Division of Emergency Medicine Medical Director, AirMed University of Utah Health Sciences Center AirMed

2. Objectives Provide and evidence based approach to the ED patient with vaginal bleeding and abdominal or pelvic pain Discuss the diagnostic role of technology (hormonal assays and US) Provide a guideline algorithm for managing these patients

3. Case Study HPI: 28 yo female presents to the ED with vaginal bleeding and cramping lower abdominal pain. Onset of pain was gradual & bleeding started as spotting yesterday and became heavy today. LMP 5 weeks ago. ROS: + Nausea, No fever, chills or urinary symptoms Exam: BP 128/80 HR 76 RR 16 T 37.5 Abdomen is soft with bilateral lower quadrant and suprapubic tenderness. No CVAT. Pelvic - Os closed, blood is coming from the uterus What information would be useful to you now?

4. ß-HCG The nurse informs you that a ß-HCG was not obtained because…. –The pt had her “tubes tied” –The pt was “not sexually active” –The pt was “on her period”

5. ß-HCG Every female patient of reproductive age with abdominal pain or vaginal bleeding needs to have a pregnancy test. Pittsburgh study –Unrecognized Pregnancy in ED patients 6.3% Overall 13% in women with abd or pelvic complaints 2.5% with other complaints What are you worried about in this patient?

6. Ectopic pregnancy Spontaneous abortion

7. Ectopic Pregnancy Incidence –Historically 4.5/1000, Current incidence is 20/1000 –Mortality has decreased 90% but still the leading cause of first trimester mortality Risk Factors –Infertility, history of PID, previous tubal surgeries, previous ectopic and IUD use. Risk factors are present in less than 50% of patients. Clinical Presentation (Variable) –Abdominal pain - 10% have no pain –Vaginal bleeding - 30% have no bleeding Exam (25% "normal" pelvic) –Abdominal and adnexal tenderness - 50% –Adnexal mass - 10% –Varying uterine size

8. Spontaneous Abortion Incidence –15 -20 % of all known pregnancies Causes –genetic abnormalities > 50 % Clinical presentation –Most before 8 or 9 weeks, can occur up to 20 weeks –Spotting proceeding to heavy bleeding with clots or tissue –Pain is usually midline and cramping Exam –Midline suprapubic tenderness –Os closed –Os open

9. Should a quantitative ß-HCG level influence the decision to perform pelvic ultrasound? You order a pelvic ultrasound but the radiologist requests a quantitative ß-HCG first. Or… Radiologist asks if the ultrasound can be done as an outpatient the next day or so

10. Should a quantitative ß-HCG level influence the decision to perform pelvic ultrasound? Perspective: –Vaginal bleeding, abdominal pain, or both in the first Trimester will result in: 60% Normal pregnancy 10% Ectopic 30% Miscarriage –50% of ectopic pregnancies that present to an emergency department are not diagnosed at the first visit, yet 70% to 80% are detectable using a combination of transvaginal ultrasound and quantitative ßHCG

11. Discriminatory level of ß-HCG ß- HCG = 2,000 Sensitivity 100%, Specificity 98% PPV 98%, NPV 100% Radiologist asks why you are getting the US if the ß- HCG is less than 2,000.

12. Literature Barnhart, Obstet Gynecol 1994: –59% of ectopics never exceed ß-HCG > 1,500 Brennan, Acad Emerg Med 1995: –15% of ectopics will rupture prior to missed menses. –83% of ectopics will never exceed ß-HCG of 2,000 (range 50,000). –36% to 50% will have a lower ß-HCG on serial testing

13. Literature Kaplan, Ann Emerg Med 1996: –Subgroup of patients with ß-HCG < 1,000 had 4X risk of ectopic. –One third of this subgroup were already ruptured. –Initial ED work-up was diagnostic in 79% of patients overall, and 70% of ectopics. Dart, Ann Emerg Med 1997: –17% of all patients with ß-HCG < 1,000 have diagnostic US. –40% of patients with an ectopic and ß-HCG < 1,000 have diagnostic initial US.

14. Clinical Prediction Rule Buckley, Ann Emerg Med 1999 –Prospective, 915 patients –FHT’s or tissue in os: Never had an ectopic –High Risk: Peritoneal signs, definite CMT 29% had ectopic –Intermediate Risk: Non-midline pain or tenderness, no FHT’s, no tissue in os. 7% had ectopic (most patients in this group - 70% of total) –Low Risk: All others 0.5% (1 of 196 patients) had ectopic (only 20% of total were low risk)

15. Retrospective, 730 ED pts, Quant ß-HCG & formal US ß-HCG < 1,500 more than doubled the odds of ectopic ß-HCG < 1,500 more than 5 times risk of abnormal pregnancy 158 (22%) had ß-HCG < 1,500, –25% had ectopic –16% had normal IUP

16. So……. High incidence of ectopic in symptomatic first trimester pts in the ED (around 10%) Exam is generally not helpful –Exceptions are peritoneal signs (ectopic) or presence of tissue (SAB) or FHT’s (Live IUP) Low ß-HCG doesn’t mean low risk –In fact ß-HCG < 1,500 is 2-4 times risk for ectopic

17. In the Era of ED Ultrasound

18. Prospective, 1,490 1st trimester ED US –IUP 1,037 (70%) –Demise 127 (8%) –Definite ectopic 24 (2%) –Molar Pregnancy (<1%) –Indeterminate 300 (20%)

19. 300 Indeterminate Ultrasounds –Demise 158 (53%) –IUP 88 (29%) –Ectopic 44 (15%)

27. American Journal of Emergency Medicine (2007) 25, 591 – 596

31. Controversy: Does evidence of IUP on ultrasound eliminate the possibility of an ectopic pregnancy? In general this is true. General population: The risk of heterotopic pregnancy is 1:30,000 ( 1948 ), Now 1:2600 to 1:8000. Assisted reproduction: The risk is 1:100 to 1:500 –Ultrasound is misleading due to concurrent IUP. –Quantitative ß-HCG is not helpful due to normal fetus making the hormone. –Expectant management is not indicated.

32. Controversy: Does evidence of IUP on ultrasound eliminate the possibility of an ectopic pregnancy? Point: Use extreme care and involve obstetrics in any pregnant patient with lower abdominal pain or vaginal bleeding and assisted reproduction.

37. Ectopic Pregnancy: Treatment Unstable –Oxygen –Volume resuscitation –FAST Exam –Type specific blood –OB/GYN –Laparotomy (possibly Laparoscopy) Stable –Laparoscopy –Methotrexate –Expectant

38. Ectopic Pregnancy: Treatment ACADEMIC EMERGENCY MEDICINE 2007; 14:755–758

40. Ectopic Pregnancy: Summary Incidence has increased 4 fold since 1970. 7% to 13% of pregnant patients presenting to ED’s with abdominal pain or bleeding have an ectopic pregnancy.

41. Ectopic Pregnancy: Summary History and physical can be misleading in ectopic pregnancy: –10% no pain30% no bleeding –50% no risk factors90% no adnexal mass –25% "normal" pelvic50% misdiagnosed initially No single test is extremely reliable. An algorithm utilizing physical exam, early transvaginal ultrasound and quantitative ß-HCG seems to be the best.

42. Ultasound Images in Early Pregnancy In this transvaginal view, a 4.0 week size gestational sac is clearly seen (arrow). The uterus is outlined with arrowheads.

43. Ultasound Images in Early Pregnancy Gestational Sac

44. Ultasound Images in Early Pregnancy 4 to 4.5 weeks Double sac sign, with the decidua capsularis (DC) and decidua parietalis (DP).

45. Ultasound Images in Early Pregnancy 4-5 weeks Yolk Sac

46. Ultasound Images in Early Pregnancy 5 - 6 weeks Fetal Cardiac Activity Initially slow (110 bpm), then to 160 at 8 wks, then decreases through rest of first trimester

47. Ultasound Images in Early Pregnancy 5.5 - 6.5 weeks Embryo elongation into fetal pole

48. ED US Pitfalls Pseudogestational sac is seen in 20-50% of ectopic pregnancies. Can be confused with double decidual sign.

49. ED US Pitfalls Pseudogestational sac

50. ED US Pitfalls Pseudogestational sac

51. ED US Pitfalls Twin gestation 7 weeks

52. ED US Pitfalls Threatened SAB with Clot

53. ED US Pitfalls Inevitable abortion In this case the endometrial cavity (En) at the fundus is empty because the gestational sac (arrowheads) has been pushed into the cervix (Cx).

54. Further Reading

55. Summary All women of reproductive age with GI or GU complaints need a ß-HCG 7% to 13% of pregnant patients presenting to ED’s with abdominal pain or bleeding have an ectopic pregnancy. History and physical can be misleading in ectopic pregnancy. No single test is extremely reliable. An algorithm utilizing physical exam, early transvaginal ultrasound and quantitative ß-HCG seems to be the best.

56. Questions?