First trimester bleeding evaluation

First trimester bleeding is a common presentation in the emergency room. Ultrasound evaluation of patients with first trimester bleeding is the mainstay of the examination. The important causes of first trimester bleeding include spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease; 50% to 70% of spontaneous abortions are due to genetic abnormalities. In normal pregnancy, the serum beta hCG doubles or increases by at least 66% in 48 hours. The intrauterine GS should be visualized by TVUS with beta hCG levels between 1000 to 2000 mIU/mL IRP. Visualization of the yolk sac within the gestational sac is definitive evidence of intrauterine pregnancy. Embryonic cardiac activity can be identified with CRL of >5 mm. A GS with a mean sac diameter (MSD) of 8 mm or more without a yolk sac and a GS with an MSD of 16 mm or more without an embryo, are important predictors of a nonviable gestation. A GS with a mean sac diameter of 16 mm or more (TVUS) without an embryo is a sonographic sign of anembryonic gestation. A difference of <5 mm between the mean sac diameter and the CRL carries an 80% risk of spontaneous abortion. Approximately 20% of women with first trimester bleeding have a subchorionic hematoma. The presence of an extra ovarian adnexal mass is the most common sonographic finding in ectopic pregnancy. Other findings include the tubal ring sign and hemorrhage. About 26% of ectopic pregnancies have normal pelvic sonograms on TVUS. Complete hydatidiform mole presents with a complex intrauterine mass with multiple anechoic areas of varying sizes (Snowstorm appearance). Twenty-five percent to 65% of molar pregnancies have associated theca-leutin cysts. Arteriovenous malformation of the uterus is a rare but life-threatening cause of vaginal bleeding in the first trimester. The sonographic findings in a patient with first trimester bleeding should be correlated with serum beta hCG levels to arrive at an appropriate clinical diagnosis.     

Overview of common obstetric bleeding disorders

Most bleeding occurring early in pregnancy is benign; occasionally, however, it can represent an abnormally developing fetus. Vaginal spotting occurs in about 25% of early pregnancies. Other common causes of bleeding during the first trimester of pregnancy are spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease. Second-trimester bleeding is usually related to an incompetent cervix. Third-trimester bleeding is most likely a sign of placental abnormalities. Most cases of bleeding after the first trimester need prompt referral. This article provides information to help clinicians diagnose, assess, and manage obstetric bleeding. Accurate diagnosis and prompt intervention are crucial in reducing the impact on maternal and perinatal morbidity and mortality.     

异常早期妊娠的超声诊断

目的探讨超声在诊断异常早期妊娠中的应用价值。方法对2010例早孕期出现阴道流血，下腹隐痛或急性下腹疼痛伴晕厥、休克的患的超声检查进行结果回顾性分析，并经临床、手术病理证实。结果B超诊断宫腔内无异常早孕229例，异常早期妊娠1781例(早期妊娠死胎380例，先兆流产817例，难免流产115例，不全流产225例，葡萄胎13例，异位妊娠231例)，均具有较典型的声像图特征。结论超声在诊断与鉴别诊断异常早期妊娠中具有非常重要的价值。对受孕时间短，孕卵发育小，声像图表现不典型，结合血β-HCG化验进行B超动态观察便可明确诊断。     

Ultrasound availability in the evaluation of ectopic pregnancy in the ED: comparison of quality and cost-effectiveness with different approaches

The liberal use of ultrasonography has been advocated in patients with first trimester cramping or bleeding to avoid misdiagnosis of ectopic pregnancy in the emergency department (ED). The cost-effectiveness of different approaches to ultrasound availability has not been previously reported. In this study, we investigated measures of quality and cost-effectiveness in detecting ectopic pregnancy in the ED over a 6-year period, divided into three approximately equal epochs with three distinct approaches to ultrasound availability. The study retrospectively identified 120 cases of ectopic pregnancy seen in the ED over 6 years. There was significant improvement in the percentage of patients with ectopic pregnancy who were documented to have absence of intrauterine pregnancy (IUP) at the first visit from 76% during Epoch 1, when there was limited availability of ultrasound through medical imaging (MI Sono), to 88% in Epoch 2, when MI Sono was readily available, to 96% in Epoch 3, when both MI Sono and ultrasound by emergency physicians (ED Sono) were readily available (P = .02). The estimated number of MI Sonos ordered by emergency physicians in patients at risk for ectopic pregnancy increased from 5.2 per ectopic pregnancy in Epoch 1 to 11.8 per ectopic pregnancy in Epoch 2, and declined to 5.5 per ectopic pregnancy in Epoch 3, when 19.9 ED Sonos per ectopic pregnancy were also done. The cost of ED Sono in Epoch 3 was more than offset by savings from avoiding calling in ultrasound technicians after regular medical imaging department hours. The specificity of ED Sono in ruling in an IUP was 100% (95% CI 98.3 to 100%), but analysis of secondary quality indicators reflecting times from first ED visit to treatment in Epoch 3 raised the possibility that an adnexal mass or signs of tubal rupture may have been missed on some ED Sonos. We conclude that increased availability of ultrasonography leads to improved quality in the detection of ectopic pregnancy in the ED, but at the expense of a disproportionate increase in the number of ultrasound studies done per ectopic pregnancy detected. Our study suggests that the most cost-effective strategy is for emergency physicians to screen all patients with first trimester cramping and bleeding with ED Sonos, and to obtain MI Sonos at the time of the initial ED visit in all cases in which the ED Sono is indeterminate or shows no IUP.     

尿液hCGRP和i-hCG比值监测对异位妊娠诊断的意义

目的探讨hCGRP/i-hCG比值在评估异位妊娠的临床意义。方法 200例可疑异位妊娠的门诊患者均作尿妊娠试验、伊耐思试剂盒检测hCGRP/i-hCG和B型超声检查。并通过血-βhCG、诊断性刮宫、腹腔镜或者开腹手术确定诊断。结果正常宫内孕、宫内孕流产和异位妊娠三组之间,i-hCG水平有明显差异(P0.001)。ROC曲线分析异位妊娠,hCGRP/i-hCG比值曲线下面积为0.703,B型超声为0.877。hCGRP/i-hCG比值检测异位妊娠的灵敏度、特异度、阳性预测值和异性预测值分别为:93.8%,51.4%,75.5%和82.2%;B型超声分别为:74.1%,74.3%,83.7%和64.2%。结论用伊耐思试剂盒检测hCGRP/i-hCG比值鉴别异位妊娠,方便经济,有较高的灵敏度及阴性预测值,是筛查异位妊娠的一种有效手段。     

Fetal outcomes in first trimester pregnancies with an indeterminate ultrasound

Background

Pregnant women commonly present to the Emergency Department (ED) for evaluation during their first trimester. These women have many concerns, one of which is the viability of their pregnancy and the probability of miscarriage.

Study Objectives

We sought to determine fetal outcomes of women with an indeterminate ultrasound who present to the ED during the first trimester of pregnancy.

Methods

A retrospective analysis of consecutive ED patient encounters from December 2005 to September 2006 was performed to identify patients who were pregnant and who had an indeterminate transvaginal ultrasound performed by an emergency physician or through the Radiology Department during their ED visit. Demographic data, obstetric/gynecologic history, and presenting symptoms were recorded onto a standardized patient chart template designed to be used for any first trimester pregnancy. Outcomes (spontaneous abortion, ectopic pregnancy, and 20-week gestation) were determined via computerized medical records.

Results

During the study timeframe, a total of 1164 patients were evaluated in the ED during the first trimester of their pregnancy; 359 patients (30.8%) met inclusion criteria and had a diagnosis of indeterminate ultrasound. Outcome data were obtained for 293 patients. Carrying the pregnancy to ≥20 weeks occurred in 70 patients (23.9%). Spontaneous abortion occurred in 193 women (65.9%), and 30 women (10.2%) were treated for an ectopic pregnancy. Total fetal loss incidence was 89.2% in patients presenting with any vaginal bleeding, compared to 34.7% in patients with pain only.

Conclusion

Indeterminate ultrasounds in the setting of first trimester symptomatic pregnancy are indicative of poor fetal outcomes. Vaginal bleeding increased the risk of fetal loss. These data will assist emergency physicians in counseling women in the ED who are found to have an indeterminate ultrasound.     

Cervical ectopic pregnancy case report: findings for the bedside sonographer

The evaluation of first trimester vaginal bleeding or pelvic pain is an important task for the emergency physician. The early identification of an ectopic pregnancy can help prevent significant morbidity and mortality for patients seeking emergency care. The increased use of bedside sonography by the emergency physician in the evaluation of these patients requires an increased knowledge about the variants and their appearance on sonogram. We present the case of a patient found to have a cervical ectopic pregnancy. A discussion of the diagnosis and management, as well as the findings on bedside sonogram are presented.     

Ectopic pregnancy

Ectopic pregnancy is a high-risk diagnosis that is increasing in frequency and is still commonly missed in the emergency department. The emergency physician needs a high index of suspicion and must understand that the history, physical examination, and a single quantitative beta-hCG level cannot reliably rule out an ectopic pregnancy. Most pregnant patients who present to the emergency department during the first trimester with abdominal or pelvic pain, regardless of the presence of vaginal bleeding, should undergo further evaluation with ultrasonography. Ultrasound findings in conjunction with quantitative beta-hCG levels guide the management of the patient.     

ECTOPIC PREGNANCY: EPIDEMIOLOGY,ADVANCES IN DIAGNOSIS AND MANAGEMENT

Ectopic pregnancy was first clearly described by Abulcasis, a famous Arabic writer on surgical topics.¹ Although maternal deaths from ectopic pregnancy have declined, it is still the leading cause of death in the first trimester and accounts for 6–11% of all maternal deaths. From 1982 to 1984, 14 women died in England and Wales from this condition.² The presence of ectopic pregnancy subjects women to the uncertainties of intra-abdominal bleeding, laparotomy, extended hospital stay and fetal loss. Furthermore, they could face reduced future fertility.³     

Diagnosis and management of ectopic pregnancy

Ectopic pregnancy is a high-risk condition that occurs in 1.9 percent of reported pregnancies. The condition is the leading cause of pregnancy-related death in the first trimester. If a woman of reproductive age presents with abdominal pain, vaginal bleeding, syncope, or hypotension, the physician should perform a pregnancy test. If the patient is pregnant, the physician should perform a work-up to detect possible ectopic or ruptured ectopic pregnancy. Prompt ultrasound evaluation is key in diagnosing ectopic pregnancy. Equivocal ultrasound results should be combined with quantitative beta subunit of human chorionic gonadotropin levels. If a patient has a beta subunit of human chorionic gonadotropin level of 1,500 mIU per mL or greater, but the transvaginal ultrasonography does not show an intrauterine gestational sac, ectopic pregnancy should be suspected. Diagnostic uterine curettage may be appropriate in patients who are hemodynamically stable and whose beta subunit of human chorionic gonadotropin levels are not increasing as expected. Appropriate treatment for patients with nonruptured ectopic pregnancy may include expectant management, medical management with methotrexate, or surgery. Expectant management is appropriate only when beta subunit of human chorionic gonadotropin levels are low and declining. Initial levels determine the success of medical treatment. Surgical treatment is appropriate if ruptured ectopic pregnancy is suspected and if the patient is hemodynamically unstable.     

Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin?

OBJECTIVE: To examine whether literature supports the use of Rh immune globulin in Rh-negative women with first trimester spontaneous abortions to prevent maternal sensitization to the fetal Rh antigen and subsequent fetal morbidity and mortality. METHODS: We searched MEDLINE (1966-2005), the Cochrane Central Register of Controlled Trials, EMBASE (1990 to 2005), and the reference sections of the articles found. The search is considered updated to December of 2005. Search terms included vaginal bleeding, Rh negative, Rh immune globulin, RhoGAM, isoimmunization, sensitization, first trimester pregnancy, threatened, and spontaneous abortion. RESULTS: The evidence to support the use of Rh immune globulin for a diagnosis of first trimester spontaneous abortion is minimal. There is a paucity of well-designed research that examines maternal sensitization or hemolytic disease of the newborn as an outcome in patients receiving, versus not receiving, Rh immune globulin in first trimester bleeding. There is significant evidence to demonstrate fetomaternal hemorrhage in first trimester spontaneous abortions; yet, no studies demonstrate subsequent maternal sensitization or development hemolytic disease in the fetus as a result of this hemorrhage. CONCLUSION: In summary, there is minimal evidence that administering Rh immune globulin for first trimester vaginal bleeding prevents maternal sensitization or development of hemolytic disease of the newborn. The practice of administering Rh immune globulin to Rh-negative women with a first trimester spontaneous abortion is based on expert opinion and extrapolation from experience with fetomaternal hemorrhage in late pregnancy. Its use for first trimester bleeding is not evidence-based.     

Current treatment of ectopic pregnancy.

The incidence of ectopic pregnancy showed a sharp increase in the industrialized countries in the late 1970s. This resulted in an epidemic of ectopic pregnancy in the 1980s. At present the incidence of ectopic pregnancy has levelled off or even decreased. In the meantime the diagnosis of ectopic pregnancy has improved markedly, which means that the detection of this disease can take place very early in the first trimester of pregnancy. This has led to the use of more conservative treatment modalities and to a better prognosis for further pregnancies. Medical treatment, especially with methotrexate, has largely replaced the radical surgical option, and the treatment of ectopic pregnancy is most obviously moving to the direction of these conservative, medical approaches.     

An Early Pregnancy Unit in the United States: An Effective Method for Evaluating First‐Trimester Pregnancy Complications

In the United Kingdom, early pregnancy assessment clinics have existed since the early 1990s and have become the reference standard for evaluating and treating women with first‐trimester pregnancy complications. These units have now been established in many countries and have been found to be effective and efficient, saving money and unnecessary emergency department visits and hospital admissions. To our knowledge, no such model has been described in the United States. A PubMed search using a combination of “early pregnancy unit,” “early pregnancy assessment clinic,” and “United States,” “U.S.,” and “America” on May 14, 2017, yielded no results. Denver Health, a safety net hospital in Denver, Colorado, has established the first known early pregnancy unit in the United States. Patients with positive urine pregnancy test results who are in their first trimester by best estimation, have not had a prior ultrasound examination, and present to their primary care providers with pain, bleeding, history of an ectopic pregnancy, history of a tubal ligation, or conception with an intrauterine device in place are eligible to be evaluated in the early pregnancy unit. This article describes our clinical setup, methods, and findings in the first 2 years of the unit's inception with the intention of serving as a model for the establishment of more early pregnancy units throughout the United States.     

Learning Curve of Emergency Physicians Using Emergency Bedside Sonography for Symptomatic First‐Trimester Pregnancy

Objective. The purpose of this study was to prospectively assess the learning curve of emergency physician training in emergency bedside sonography (EBS) for first‐trimester pregnancy complications. Methods. This was a prospective study at an urban academic emergency department from August 1999 through July 2006. Patients with first‐trimester vaginal bleeding or pain underwent EBS followed by pelvic sonography (PS) by the Department of Radiology. Results of EBS were compared with those of PS using a predesigned standardized data sheet. Results. A total of 670 patients underwent EBS for first‐trimester pregnancy complications by 1 of 25 physicians who would go on to perform at least 25 examinations. The sensitivity and specificity of EBS for an intrauterine pregnancy increased from 80% (95% confidence interval [CI], 71%–87%) and 86% (95% CI, 76%–93%), respectively, for a physician's first 10 examinations to 100% (95% CI, 73%–100%) and 100% (95% CI, 63%–100%) for those performed after 40 examinations. Likewise, the sensitivity and specificity for an adnexal mass or ectopic pregnancy changed from 43% (95% CI, 28%–64%) and 94% (95% CI, 89%–97%) to 75% (95% CI, 22%–99%) and 89% (95% CI, 65%–98%), whereas the sensitivity and specificity for a molar pregnancy changed from 71% (95% CI, 30%–95%) and 98% (95% CI, 94%–99%) to 100% (95% CI, 20%–100%) and 100% (95% CI, 81%–100%). Although detection of an intrauterine or a molar pregnancy improved with training, even with experience including 40 examinations, the sensitivity of EBS for an adnexal mass or ectopic pregnancy was less than 90%. Conclusions. There is an appreciable learning curve among physicians learning to perform EBS for first‐trimester pregnancy complications that persists past 40 examinations.     

Beta-Human Chorionic Gonadotropin Levels and the Likelihood of Ectopic Pregnancy in Emergency Department Patients with Abdominal Pain or Vaginal Bleeding

Strategies for diagnosing ectopic pregnancy that defer endovaginal ultrasound in women with suggestive symptoms and serum beta-human chorionic gonadotropin (beta-hCG) levels less than 1500 mIU/mL ignore the increased risk of ectopic pregnancy in these patients. OBJECTIVE: To quantify this increased risk by establishing and comparing the beta-hCG distributions of symptomatic women with ectopic pregnancies, abnormal intrauterine pregnancies, and normal intrauterine pregnancies. METHODS: The authors reviewed the records of a cohort of women who visited an urban emergency department (ED) during a 34-month period with abdominal pain or vaginal bleeding and non-zero quantitative beta-hCG levels. Explicit criteria were used to determine whether the pregnancy ultimately turned out to be intrauterine and normal, intrauterine and abnormal, or ectopic. Probability distributions were compared using frequency distributions, receiver operating characteristic (ROC) curves, and likelihood ratios. RESULTS: Of 730 ED patients included in the analysis, 96 (13%) had ectopic pregnancies, 253 (35%) had abnormal intrauterine pregnancies, and 381 (52%) had normal intrauterine pregnancies. The beta-hCG distributions of patients with ectopic pregnancies and abnormal intrauterine pregnancies were similar and much lower than the beta-hCG distribution of patients with normal intrauterine pregnancies. A beta-hCG level less than 1500 mIU/mL more than doubled the odds of ectopic pregnancy (likelihood ratio = 2.24). Of the 158 patients with beta-hCG below 1500 mIU/mL, 40 (25%; 95% confidence interval [CI] = 19% to 32%) had ectopic pregnancies, and only 25 (16%; CI = 11% to 22%) had normal intrauterine pregnancies. CONCLUSIONS: In women with pain or bleeding and serum beta-hCG levels less than 1500 mIU/mL, the risk of ectopic pregnancy is substantially increased, while the likelihood of normal intrauterine pregnancy is low.     

Ectopic uterine scar pregnancy: A case report

IntroductionImplantation of a gestational sac in a previous Caesarean section scar of the lower uterine segment is a rare form of ectopic pregnancy.Case reportWe report a case of Caesarean scar ectopic pregnancy in a 25-year-old female, diagnosed by ultrasonography and confirmed by magnetic resonance imaging. We present the clinical details, imaging findings, and management of the patient.DiscussionImaging plays an important role in the diagnosis of ectopic pregnancy and ultrasonography is the modality of choice. Ultrasonography features of scar ectopic pregnancy include empty uterus and cervix with normal endometrium and endocervical canal, gestational sac (with embryo and/or yolk sac) in the anterior part of the lower uterine segment in the region of the Caesarean scar with a thin myometrial layer between the bladder wall and gestational sac. Magnetic resonance imaging may be used as an adjunct imaging modality in cases with inconclusive or equivocal sonographic findings. Termination of pregnancy in the first trimester should be considered and treatment options should be individualized as there is no universal agreement on the best or most preferred treatment modality.ConclusionAwareness of specific ultrasound features of scar ectopic pregnancy is crucial for early recognition, correct diagnosis, and initiating prompt management to prevent complications.     

Emergency Gynecologic Imaging

Acute pelvic pain in the female patient can have myriad presentations and, depending on the diagnosis, profound consequences. In the pregnant patient with pelvic pain or bleeding, an ectopic pregnancy must be first excluded. Ultrasound is important in determining the size and location of the ectopic pregnancy, and presence of bleeding, which in turn helps guide treatment decisions. Subchorionic or subplacental bleeds in an intrauterine pregnancy may also present with vaginal bleeding with consequences dependent on gestational age and size of bleed. In the postpartum female suspected to have retained products of conception, sonographic findings may vary from a thickened endometrial stripe to an echogenic mass with associated marked vascularity, often mimicking an arterial-venous malformation. In the nonpregnant patient, early diagnosis and treatment of ovarian torsion can preserve ovarian function. Other causes of peritoneal irritation may also cause acute pelvic pain including a ruptured hemorrhagic cyst or ruptured endometrioma. When pelvic inflammatory disease is suspected, imaging is used to evaluate for serious associated complications including the presence of a tuboovarian abscess or peritonitis. While leiomyomas of the uterus are largely asymptomatic, a leiomyoma that undergoes necrosis, torsion or prolapse through the cervix may be associated with acute severe pain or bleeding. The imaging features of these and other important clinical entities in the female pelvis will be presented.     

The conservative management of early pregnancy complications: a review of the literature.

Early pregnancy complications include miscarriage, ectopic pregnancies, adnexal masses and pregnancies of unknown location. In this review, we evaluate the role of conservative management in these complications. We also evaluate the role of transvaginal sonography for diagnosis, treatment and follow up.When managing women with early pregnancy complications, it is important to recognise the normal sonographic milestones in the first trimester. Understanding the pattern of serum human chorionic gonadotropin change in early normal pregnancy and the correlation between low serum progesterone levels and the spontaneous resolution of a pregnancy are also important concepts.Guidelines for assessing suitability for conservative management should be strictly governed by evidence based protocols. Women can then be offered expectant or medical treatment as appropriate.     

Doppler ultrasonographic evaluation of abnormal pregnancies in the first trimester

Doppler examination of uteroplacental vessels was performed in the first trimester of pregnancy in 111 women with a normal pregnancy outcome and in 10 women with pregnancies that had or subsequently failed due to anembryonic pregnancy (N = 4), missed abortion (N = 1), subsequent spontaneous abortion of live fetus (N = 2), and ectopic pregnancy (N = 3). Flow velocity waveforms (FVWs) were obtained three times by the same observer from subplacental vessels just within the myometrium. The Resistance Index (RI) of the FVWs was compared with the values obtained from 73 uncomplicated pregnancies and 38 women with threatened miscarriage and normal outcome. There was no apparent difference in the values for RI in the 10 patients whose pregnancies had failed, although the 3 live ectopic pregnancies studied had higher values. Although these studies may improve our understanding of the pathophysiology of early placentation, they are unlikely to be of value in the diagnosis of early pregnancy failure.     

The problematic first-trimester pregnancy

The first-trimester obstetric patient who is experiencing pain or bleeding may have a normal intrauterine pregnancy, a threatened miscarriage, an ectopic pregnancy, a blighted ovum or trophoblastic disease. Correlation of clinical findings, quantitative human chorionic gonadotropin levels and diagnostic ultrasound findings can maximize the efficiency of the work-up, provide a definitive prognosis and identify early ectopic pregnancy.