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:

1. Worst-case scenarios and initial steps
2. History and physical examination
3. Risk factors for ectopic pregnancy
4. Diagnostic testing: urine vs. serum HCG
5. Per vaginal (PV) examination: when to perform
6. Management of threatened miscarriage
7. 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

1. Last Menstrual Period (LMP): Helps estimate the gestational age.
2. Symptoms: Type and location of pain, nature of bleeding, and presence of other symptoms like dizziness or shoulder pain.
3. Previous Pregnancies: Gravida (number of pregnancies) and Para (number of completed pregnancies).
4. Risk Factors: Previous ectopic pregnancy, pelvic inflammatory disease, and any surgeries or procedures involving the reproductive organs.

Physical Examination

1. Abdominal Examination: Look for tenderness, guarding, or rebound tenderness.
2. Vital Signs: Monitor for signs of shock or hemodynamic instability.
3. 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. However, they are essential in specific situations:

1. Retained Foreign Bodies: Such as condoms or tampons.
2. Significant Vaginal Bleeding: Particularly in cases of suspected cervical shock due to retained products of conception.

For other scenarios, PV examinations are best left to gynecology specialists who have the expertise and appropriate setting to perform these exams with the required sensitivity and specificity.

Management of Threatened Miscarriage

A threatened miscarriage involves vaginal bleeding in a pregnancy less than 24 weeks, with a closed cervical os. It is a common issue that can cause significant anxiety for patients. Here's how to manage these cases:

Terminology

1. Threatened Miscarriage: Vaginal bleeding with a closed cervical os.
2. Inevitable Miscarriage: Open cervical os, indicating that miscarriage is likely to proceed.
3. Complete Miscarriage: All products of conception have passed.
4. Incomplete Miscarriage: Some products remain, requiring further management.

Approach

1. Assess Bleeding: Light bleeding can often be managed on an outpatient basis. Heavy bleeding requires immediate gynecological consultation.
2. Provide Reassurance: Explain that early pregnancy bleeding is common and not necessarily indicative of a miscarriage.
3. Pain Management: Offer analgesia, such as paracetamol or cocodamol, to manage discomfort.
4. Follow-up: Arrange for follow-up with an early pregnancy assessment unit (EPAU) within 48 hours.

Patient Communication and Support

Dealing with early pregnancy problems can be distressing for patients. Effective communication and support are crucial.

Tips for Communication

1. Be Empathetic: Understand that this might be a significant and emotionally charged situation for the patient.
2. Explain Clearly: Provide information about what is happening and what the next steps are.
3. Avoid Definitive Statements: Unless certain, avoid saying that the patient has definitely miscarried.
4. Offer Reassurance: Reiterate that early pregnancy complications are common and often not due to anything the patient did wrong.

Psychological Support

1. Acknowledge Emotions: Recognize the patient's feelings and provide support.
2. Encourage Support Systems: Suggest involving family or friends for emotional support.
3. Professional Help: Refer to counseling services if needed.

Conclusion

Managing early pregnancy problems in the ED requires a systematic approach, starting with identifying worst-case scenarios and performing appropriate diagnostic tests. Understanding the risk factors for ectopic pregnancy and knowing when to perform a PV examination are crucial. Providing compassionate care and clear communication can help support patients through what can be a distressing time.

By optimizing our approach, we can ensure better outcomes for our patients and provide the best possible care in these challenging situations. Always consult senior colleagues when in doubt and follow local guidelines to ensure consistency and quality of care.