Outcome Analysis of a Protocol Including Bedside Endovaginal Sonography in Patients at Risk for Ectopic Pregnancy

doi:10.1016/S0196-0644(96)70260-3

Annals of Emergency Medicine

Volume 27, Issue 3, March 1996, Pages 283-289

Presented at the Society for Academic Emergency Medicine Annual Meeting, Washington DC, May 1994.

https://doi.org/10.1016/S0196-0644(96)70260-3 Get rights and content

Abstract

Study objectives: To determine whether bedside endovaginal sonography (EVS) performed by emergency physicians reduces complications associated with ectopic pregnancy (EP) including missed EP and EP rupture. Methods: Our setting was an urban trauma center emergency department. We assembled a prospective convenience sample (n=314) with a historical EP control group (n=56) of women 18 years or older with a positive pregnancy test and any signs, symptoms, or risk factors for EP. Bedside EVS for all subjects and immediate quantitative serum human chorionic gonadotropin determination for patients with no definite intrauterine pregnancy by EVS. Results: Retrospective chart review identified 56 EP patients in the historical control group who had had no bedside EVS. Twenty-four of these patients (43%; 95% confidence interval [CI], 30% to 56%) were discharged from the ED, 12 of whom (50%; 95% CI, 30% to 70%) were later categorized as having ruptured EP. During the prospective study period, 40 patients were diagnosed as having EP; 11 (28%; 95% CI, 14% to 42%) were discharged from the ED (P=NS), and only 1 (9%; 95% CI, 0% to 26%) of the discharged patients was later determined to have a ruptured EP (P<.05). Conclusion: An EP protocol incorporating bedside EVS performed by emergency physicians significantly reduced the incidence of discharged patients with subsequent EP rupture, compared with historical controls. [Mateer JR, Valley VT, Aiman EJ, Phelan MB, Thoma ME, Kefer MP: Outcome analysis of a protocol including bedside endovaginal sonography in patients at risk for ectopic pregnancy. Ann Emerg Med March 1996;27:283-289.]

Section snippets

INTRODUCTION

The accurate diagnosis of ectopic pregnancy (EP) is a considerable challenge for clinicians. Abbott et al¹ demonstrated that emergency medicine residents and faculty miss this diagnosis during the initial emergency department visit in 43% of cases. Stovall et al² reported that, before implementation of their ectopic screening program, 45% of patients with EP, who were evaluated primarily by residents in obstetrics and gynecology (Ob/Gyn) in an ED setting, had a delayed diagnosis, and 79% of EP

METHODS

The study was conducted during a 36-month period from May 1991 to May 1994. All females 18 years of age or older presenting to the ED were candidates for the study if they had a positive pregnancy test and also had, either alone or in combination, pelvic or abdominal pain, vaginal bleeding, orthostasis, adnexal mass or tenderness, or any risk factors for EP (ie, history of pelvic inflammatory disease, tubal ligation, abdominal or pelvic surgery, two or more elective abortions, infertility,

RESULTS

During the 3-year period, 314 patients were enrolled in the study. Of these, 14 patients were excluded from analysis because of incomplete data collection or follow-up. The initial EVS diagnoses (Table 1) included definite IUP, 169 (56%); probable abnormal IUP, 31 (10%); definite EP, 5 (2%); and no definite IUP, 95 (32%). Of the patients with no definite IUP on initial EVS, 28 (29%) were found to have an hCG concentration higher than 2,000 mIU/mL (IRP), and 67 (71%) had an hCG level lower than

DISCUSSION

In 1990, a publication of the Centers for Disease Control emphasized that "until risk factors that lead to ectopic pregnancy are established and controlled, early detection will be the most effective means of reducing morbidity and mortality associated with this condition." The important role of emergency physicians in the recognition of patients at risk for this disease was specifically identified.⁹ Rottem and Timor-Tritsch¹⁰ concluded that the "early diagnosis and treatment of ectopic

Acknowledgements

The authors wish to thank Michael Brown, MD, Steve Jameson, MD, and Steve Meldon, MD, who also participated as sonologists for the study, and Laura Zirzow for her assistance in manuscript preparation.

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There are more references available in the full text version of this article.

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Emergency physicians (EP) can accurately rule out ectopic pregnancy with pelvic point of care ultrasound (PPOCUS). Multiple studies have suggested that PPOCUS may decrease length of stay (LOS) for emergency department (ED) patients presenting with early symptomatic pregnancy compared to comprehensive ultrasound (CUS). This systematic review and meta-analysis examines the association between the use of PPOCUS vs CUS and ED LOS.
A systematic review of the literature was performed. Patients with symptomatic early pregnancy receiving EP-performed PPOCUS were compared to patients receiving CUS without PPOCUS. Keywords and search terms were generated for PPOCUS, ED LOS and CUS. Two independent reviewers screened abstracts for inclusion. A third reviewer was used when conflicts arose to gain consensus. Formal bias assessment was performed on included studies. Meta-analysis was carried out, pooling the mean differences between studies using a random-effects model.
2980 initial articles were screened, 32 articles underwent detailed review, 8 underwent bias assessment, and 6 were included in the final meta-analysis. There were 836 patients in the study group and 1514 in the control group. All studies showed a decreased LOS in the PPOCUS group with a mean decrease of 73.8 min (95% CI 49.1, 98.6). Two studies not included in the meta-analysis also showed significantly decreased LOS with PPOCUS.
Use of PPOCUS in the evaluation of patients with symptomatic early pregnancy is associated with decreased LOS in patients ultimately diagnosed with intrauterine pregnancy. This review suggests that this finding is generalizable to a variety of practice settings.
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In resource-limited settings, where a general surgeon is frequently the only surgical provider, emergency obstetrical care is a cornerstone of surgical practice. Ultrasound has been shown to be associated with faster recognition of ectopic pregnancy in the United States, accurate diagnosis of intrauterine growth retardation (IUGR) in Egypt, and prompt evaluation of fetal heart rate and fetal positioning in Tanzania.17-19 Acute diarrhea accounts for 17% of pediatric deaths worldwide, mainly due to severe dehydration.20
Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of critically ill patients, particularly in resource-limited settings where access to diagnostic imaging may be constrained. We aimed to develop a novel POCUS training curriculum for surgical practice in the United States and in resource-limited settings in low- and middle-income countries and to determine its effect on surgical resident self-assessments of efficacy and confidence.
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After a POCUS course designed specifically for surgeons, surgical residents had improved self-efficacy and confidence levels across a broad range of skills.
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This was a prospective, observational study of female patients of reproductive age who required either an EPPU or RPPU for their ED evaluation. We hypothesized that patients receiving EPPU would have a length of stay reduction greater than or equal to 60 minutes, as compared with RPPU. Statistical analyses included an independent-samples t test and multivariate regression modeling to control for factors associated with ED LOS.
Eighteen resident physicians performed EPPU, with 15 attending physicians supervising. Forty-eight patients received only EPPU, and 84 patients received only RPPU. In univariate analysis, those who received EPPU had an ED LOS 162 minutes less than those who received RPPU (95% confidence interval, 106-209 minutes). In multivariate analysis controlling for gynecologist consultation, disposition, and pregnancy status, patients who received EPPU had an ED LOS reduction of 108 minutes when compared with RPPU (95% confidence interval, 38-166 minutes). Five patients (10%) who had received EPPU and were discharged from the ED returned to the ED within 2 weeks, but none had alternative diagnoses.
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In a 50-year-old woman with vaginal bleeding, a transabdominal view using the curvilinear transducer is likely sufficient to evaluate for the presence of obvious causes of her dysfunctional uterine bleeding. In general, the endocavitary transducer should be used for performing ultrasonography in the first trimester of pregnancy and for evaluation of ovarian or fallopian tube disease.2–4 The low-frequency, curvilinear transducer can be used for evaluation of second-trimester or third-trimester fetuses, and larger uterine and ovarian diseases, such as fibroids, large ovarian cysts, and so forth.5

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^☆: From the Departments of Emergency Medicine* and Obstetrics and Gynecology^‡, Medical College of Wisconsin, Milwaukee, Wisconsin; and Mt Sinai Hospital, Cleveland, Ohio.^§

^☆☆: Address for reprints: James R Mateer, MD, RDMS, Medical College of Wisconsin, Department of Emergency Medicine, 8700 West Wisconsin Avenue, Milwaukee, Wisconsin 53226, 414-257-5576, Fax 414-257-8040

^★: Reprint no. 47/1/69438

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Outcome Analysis of a Protocol Including Bedside Endovaginal Sonography in Patients at Risk for Ectopic Pregnancy☆,☆☆,★

Abstract

Section snippets

INTRODUCTION

METHODS

RESULTS

DISCUSSION

Acknowledgements

Am J Emerg Med

Ann Emerg Med

Am J Obstet Gynecol

Diagnosis of ectopic pregnancy: Endovaginal vs. transabdominal sonography

AJR Am J Roentgenol

Ultrasound evaluation of ectopic pregnancy by emergency physicians

Acad Emerg Med

The double sac sign of early intrauterine pregnancy: Use in exclusion of ectopic pregnancy

Radiology