Ep 34 - Intro to EM: Problems in Early Pregnancy

Managing Early Pregnancy Problems in the Emergency Department Welcome to the St. Emelene's induction podcast. I'm Iain Beardsell, and I'm Natalie May. Today, we're discussing the management of early pregnancy problems in female patients presenting to the emergency department (ED). Some of you may rarely encounter these cases, while others may see them frequently. This podcast aims to provide a detailed guide on how to manage these patients effectively, optimizing our approach for better patient outcomes. Understanding Early Pregnancy Problems Early pregnancy problems can range from minor concerns to life-threatening emergencies. As emergency physicians, our primary goal is to identify and manage the worst-case scenarios promptly. In this post, we'll cover the following topics: Worst-case scenarios and initial steps History and physical examination Risk factors for ectopic pregnancy Diagnostic testing: urine vs. serum HCG Per vaginal (PV) examination: when to perform Management of threatened miscarriage Patient communication and support Worst-case Scenarios and Initial Steps In emergency medicine, we often think about the worst-case scenarios first. For early pregnancy problems, the most critical concern is an ectopic pregnancy. Ectopic pregnancies occur in about 1 in 100 pregnancies in the UK and can be life-threatening if not identified and treated promptly. Initial Steps When a young female patient presents with lower abdominal pain or spotting and is potentially pregnant, our first steps should include: Confirming pregnancy status: Use a urine pregnancy test initially. Assessing vital signs: Look for signs of hemodynamic instability, such as hypotension or tachycardia, which could indicate a ruptured ectopic pregnancy. Taking a detailed history: Understand the patient's symptoms, last menstrual period, and any previous gynecological issues. History and Physical Examination A thorough history and physical examination are crucial in managing early pregnancy problems. Here's what you need to focus on: History Last Menstrual Period (LMP): Helps estimate the gestational age. Symptoms: Type and location of pain, nature of bleeding, and presence of other symptoms like dizziness or shoulder pain. Previous Pregnancies: Gravida (number of pregnancies) and Para (number of completed pregnancies). Risk Factors: Previous ectopic pregnancy, pelvic inflammatory disease, and any surgeries or procedures involving the reproductive organs. Physical Examination Abdominal Examination: Look for tenderness, guarding, or rebound tenderness. Vital Signs: Monitor for signs of shock or hemodynamic instability. Pelvic Examination: In specific cases, to assess for cervical motion tenderness, adnexal tenderness, or masses. Risk Factors for Ectopic Pregnancy Understanding the risk factors for ectopic pregnancy can help identify patients who need urgent evaluation. Risk factors include: History of pelvic inflammatory disease (PID) Previous pelvic or abdominal surgery Use of intrauterine devices (IUDs) Previous ectopic pregnancy Assisted reproductive techniques like IVF Anatomical abnormalities of the fallopian tubes or uterus Endometriosis Use of the progesterone-only pill Diagnostic Testing: Urine vs. Serum HCG Determining the pregnancy status and ruling out ectopic pregnancy requires accurate diagnostic testing. Here's a comparison between urine and serum HCG tests: Urine HCG Test Sensitivity: About 96%, particularly when HCG levels are above 100. Specificity: High, meaning a positive result is reliable. Limitations: May give false negatives if HCG levels are very low, as seen in some ectopic pregnancies. Serum HCG Test Sensitivity and Specificity: Both close to 100%, making it the preferred test for confirming pregnancy and assessing HCG levels. Usage: Particularly useful when urine tests are negative but clinical suspicion remains high. When to Perform a Per Vaginal (PV) Examination The necessity of PV examinations in the ED can be debated.