Obstetrics (July 2015)
Review: Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy **Only read pages 1-8**
Review: Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy **Only read pages 1-8**
9 comments
Kline et al:
Very interesting and possibly myth debunking study that pregnant patients are at higher risk of VTE. However, we have to keep in mind they looked at only patients who were worked up for VTE.
These findings may be due to low threshold to test for VTE by clinicians as demonstrated by this study.
So, in light of this information, do YOU think we can safely exclude pregnant patients using existing decision rules, threshold-adjusted D-dimer, or initial bilateral compression dopplers?
How has reading the article changed your practice?
I think it makes me think differently about VTE in the pregnant patient. Before reading this article, I thought they had similar VTE risk as cancer patients, when in fact that is not true. I will have a higher threshold to investigate VTE now.
What information had you believed in previously that were debunked by reading this article?
See above. Also, I didn’t believe it previously but it’s always helpful to remember that the PERC rule was not created or validated in the pregnant population.
What new information did you learn from reading this article?
D-dimers are uniformly elevated in the 3rd trimester of pregnancy.
What are current areas of uncertainty on this topic that can be potential areas for research? There is a need for rational decision rules and algorithms in the pregnant patient with suspected VTE.
Clinical Policy paper
How has reading the article changed your practice?
It really didn’t change my practice. It was helpful to learn what our governing body considers standards of care.
What information had you believed in previously that were debunked by reading this article?
This article reaffirmed the practice of NOT using the quant bHCG to r/o ectopic pregnancy and that in the pregnant patient with vaginal bleeding or abdominal pain, you must get a TVUS if there is no documented IUP.
What new information did you learn from reading this article?
ACEP hates giving level A recommendations! Also, one study looking @ bHCG cutoffs found that even at a bHCG of 25,000, only 88% of IUPs were identified. That’s way higher than the “discriminatory zone” of 1500. I also didn’t know that MTX was frequently unsuccessful after the first dose and most patients require repeat administrations.
What are current areas of uncertainty on this topic that can be potential areas for research?
Similar to the kidney stone literature I’d like to see a comparison b/w ED-based TVUS vs. radiology-based TVUS. We don’t do it at BMC but I think it’s something that could be useful own the line (esp if you work at a place with no overnight ultrasound!).
How has reading the article changed your practice?
I don’t think this article will drastically change my practice, because I would hope that I would not order imaging on a pregnant patient unless I really suspected a VTE in them anyway. But I think it may help me feel more confident in not imaging a patient that doesn’t have a great story for VTE, rather than being afraid of every pregnant woman with shortness of breath or tachycardia.
What information had you believed in previously that were debunked by reading this article?
I definitely believed that pregnant women had a much higher rate of VTE than nonpregnant women, which this article is arguing is a complete myth.
What new information did you learn from reading this article?
I knew that the majorities of PEs that occur around pregnancy actually occur postpartum, but found it interesting that the number was as high as 70%
What are current areas of uncertainty on this topic that can be potential areas for research?
I agree with Travis that the development of a clinical decision tool that included pregnant women would be enormously helpful for stratification of risk for VTE.
Clinical Policy paper
How has reading the article changed your practice?
I would use the ACEP guidelines as a reference during the workup of first trimester pregnant patients.
What information had you believed in previously that were debunked by reading this article?
I had heard this in a podcast, but the article further reinforced that there is very limited evidence supporting the use of Rhogam, despite its widespread use. Their recommendations remain unchanged, but I found it interested that they did mention that they were based on theoretic construct and very limited studies.
What new information did you learn from reading this article?
I knew that frequently patients require a second dose of methotrexate, but I was not aware that the failure rate requiring surgery was as high as 20%. Along with all of the side effects and contraindications, this makes it seem like a drug with very limited applicability.
What are current areas of uncertainty on this topic that can be potential areas for research?
I think these recommendations are all Level B or C because they involve pregnant patients, which is an area that needs further research in all aspects (but ethically is very difficult to perform). Short of doing randomized controlled trials, I think some retrospective studies that help risk stratify patients suspected of ectopic pregnancy would be helpful to give some stronger evidence behind some of these guidelines.
How has reading the article changed your practice?
– Considering that my “practice” consists of just 2 pregnant patients I worked up for VTE (both were CTPA’d with negative findings), I don’t have much to rely on. What I will say is that this study kind of rids me of the PE boogey man when it comes to assigning percentages to your differential in a pregnant women with SOB. Prior to this article, I thought the risk of PE was incredibly high in pregnant women – making CTPA almost necessary (it sure does feel that way at times when talking to attendings/residents work up SOB in pregnant women). Reading this article will most likely result in a discussion with the attending – can a pregnant women fall under the PE clinical decision making rules (as suggested by the article)? Should we have a higher threshold for d-dimers? Lastly, it was also interesting to read that most PE-related episodes occur in the postpartum period. I had incorrectly assumed it was during 2nd or 3rd trimester.
What information had you believed in previously that were debunked by reading this article?
– See above – the PE boogey man (ie, SOB in pregnant women isn’t has highly correlated with PE as I would’ve thought)
What new information did you learn from reading this article?
– See above – lower incidence of VTE in pregnant patients vs postpartum patients.
What are current areas of uncertainty on this topic that can be potential areas for research?
– It would be interesting to see how including pregnancy in PE clinical decision rules pans out. Apparently Kline et al. attempted: http://www.aliem.com/when-perc-rule-fails/ – in summary, still unclear.
How has reading the article changed your practice?
– Not certain that this article has completely changed my practice (if I may call it that). I will say that I’m now more likely to order a TVUS even if a pt has a low beta-HCG. Barnhart’s study seems to suggest the ectopics don’t necessarily follow the rule when it comes to beta-HCG thresholds – and since TVUS carries less risk than CT, I’d be comfortable ordering in the TVUS even if the beta-HCG level is below the threshold. The authors were unable to state whether a delay in ectopic diagnosis had adverse effects…so I think I would err on the side of caution. I think I’d also more open to initiating methotrexate in ED after consultation with ob/gyn in a hemodynamically stable AND if appropriate follow up can be made. It’s something I thought was outside the scope of EM.
What information had you believed in previously that were debunked by reading this article?
– Interesting to learn about the high number (20-30%) of indeterminate pregnancies called via ultrasound during early pregnancy. I had thought the TVUS was much more sensitive/specific regarding the dx of IUP or abnormal pregnancy
What new information did you learn from reading this article?
– See above – Barnhart’s study suggesting that the relationship between ectopic pregnancies and beta-HCG doesn’t fit neatly into a box. I’d be curious to learn more about attending practice here – ED and ob/gyn – considering the prevalence of symptomatic ED patients with ectopic on the Ddx.
What are current areas of uncertainty on this topic that can be potential areas for research?
– It would be interesting to delve further into the notion of diagnosis delay with respect to ectopic pregnancies. The article kind of talks about it but evidence one way or the other would surely change practice, particularly regarding whether to the TVUS despite lower beta-HCGs.
Clinical Policy: Critical Issues in the Initial Eval and Management of Patients Presenting to the ED in Early Pregnancy
– How has reading this article changed my practice?
I hadn’t previously considered the administration of anti-D immunoglobulin in cases of minor trauma in Rh negative patients
– What previously held belief would you say has been debunked by reading this article?
I previously believed that low levels of HCG were reassuring that a ruptured ectopic was not present. This review noted that very low levels of HCG have been associated with a ruptured ectopic and that our current cutoffs may be arbitrary.
– What new information did I learn from this review?
I was not aware of the high failure/complication rate following administration of Methotrexate. I was unaware that 20% of patients who received Methotrexate go on to require operative intervention.
– What uncertainty exists in this review/What is an area of potential research?
It would be interesting to know if there has been any research into administration of higher levels of methotrexate and whether those levels improved outcomes in terms of management of ectopic pregnancy and whether higher doses were associated with increased side effects.
Systematic Review and Meta-analysis of Pregnant Patients Investigated for suspected PE in the ED
-How has this article changed my practice?
I’m not sure that this article would change my practice in the ED. If a pregnant woman presents with signs and symptoms suggestive of PE you simply cannot ignore it. If a patient presents with a very soft history you might feel more confident not fully investigating but generally, if there is any doubt I would err on the side of caution because missing a diagnosis could be devastating.
– What previously held belief would you say has been debunked by reading this article?
I echo other people’s comments. I had previously believed and been taught that women were at a higher risk of DVT/PE secondary to the procoagulant state during pregnancy and was surprised to learn that pregnant women presenting to the ED actually had a lower rate of VTE compared to other women of child-bearing age presenting to the ED.
– What new information did you learn from this review?
I hadn’t previously considered that your risk of VTE during pregnancy increases with maternal age although in retrospect this seems like it should be intuitive.
– What uncertainty exists in this review/what is an area of potential research?
It would be interesting to see if the rate of VTE in pregnant women equilibrates with women of childbearing age presenting to the ED if you could control for lifestyle somehow and screen out certain at risk populations: ie cancer, IVDU etc.