OBGYN/GI (July 2017)
Research: Goyal, Monika K. et al. “Underuse of Pregnancy Testing for Women Prescribed Teratogenic Medications in the Emergency Department.” Academic Emergency Medicine, 2015.
AIR: Gastroenterology
For a Review Article
- How has reading the article changed your practice?
- What information had you believed in previously that were debunked by reading this article?
- What new information did you learn from reading this article?
- What are current areas of uncertainty on this topic that can be potential areas for research?
For an Original Research Article
- What are some strengths of the study?
- What are the limitations?
- What are the main outcomes of the study?
- Does reading this article change your practice? If so, how?
13 comments
Lozeau – Ectopic pregnancy review
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I just wanted to clarify the summary statement at the beginning which states “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.”
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The bottom line is that HCG level doesn’t matter as long as it’s above 0. Because ruptured and unruptured ectopic pregnancies have been identified at beta hCG levels less than 100 mIU per mL (100 IU per L) and greater than 50,000 mIU per mL
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Just skip the physical examination part of the article. You aren’t going to feel a slightly more “gravid uterus” in the first trimester. Even the article states this: that there’s nothing sensitive or specific enough on exam to rule in or out ectopic except for abd pain WITH HD instability in female of child bearing age which obviously raises your suspicion.
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Focus a bit more on what patients should be considered for methotrexate vs. surgical tx since sometimes you have to make this decision in the community with only OB available over the phone.
Goyal et al.
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Interesting article. I must say I don’t always check urine preg when giving common meds like motrin. I know nurses ask frequently “any chance you could be pregnant?” as well as last LMP before giving meds, but not always.
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This study assumes that it’s the responsibility of the physician to know for sure if a patient is pregnant. It gives good public health reasons for doing so though the risks are often theoretical or at least overestimated.
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I compare this at times with x-rays in early pregnancy. Do I always check HCG in patients getting a CXR, or ankle x-ray for sprained ankle? The answer is no. The reason is that the risks is low, about the radiation exposure to a transcontinental flights. And women of childbearing age often fly without checking pregnancy test before doing so. While these potentially teratogenic meds may be more harmful, who’s responsibility is it to know? THe patient or the physician?
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Especially with benzos, I know OB’s who have significant experience in giving benzos in pregnant patients despite category D.
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The article makes it seem like it’s a piece of cake and everyone should get it, but we know there are barriers since getting that urine could be a lot more time consuming than these authors describe.
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Regardless, this article reminds me to check HCG more often for know teratogenic meds.
Goya et al
I did not see that they actually listed the prescribed medications by frequency?
Also, Annals has specific reporting requirements for large data sets that must address potential biases in coding based on prior work by Jay Schuur et al on pregnancy testing.
One wonders for example whether where macrobid is 1st line abx we would see different results here (and proportion of women with Udip UHCG in our ED). We don’t prescribe or rarely benzo or statins from the ED vs coded as ED in NHAMCS? Some of the meds (motrin as mentioned= pregnancy category: C) are OTC and don’t appear to require either HCG or continued HCG testing at the pharmacy.
In recent conversation in IRB policies for imaging (MRI in women of child bearing potential) the interesting point was made that there are gender disparities in screening. Asking a male patient if he has hardware in place vs requiring a female to have pregnancy testing even if she reports not pregnant. This is interesting to think about in a clinical setting that we assume female pt’s statement is false about not pregnant until objective HCG testing. Reasonable in setting of CxR to just aks/inform or routinely shield women of child bearing potential. A single UHCG is only snapshot in time, imperfect and could of course change soon p ED visit.
Finally given the interest in male preconception and risks, one could rethink ignoring male patient’s plans. One could start to consider exploring this and potential impact on ED prescribing.
jim
Huh! It’s really interesting that you brought up gender disparities in such line of questioning and screening in patient populations.
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Similarly, in terms of birth control, why aren’t there male OCP’s or hormonal contraceptives available? Why do we tend to put the onus on the female to do such things in most cases?
Lozeau
This article was an easy read and a good review- I found it applicable to our practice, especially in the community.
-I am more likely to be comfortable with treating a patient medically (with OBGYN input if at BMC)- high success rates if specific paramaters- bhcg<1000 and declining, ectopic 1000, success rates seem high. That being said, patients being treated medically must have good follow up and be reliable, which would be hard to coordinate through some EDs.
-Likelihood of ectopic is 39% in early pregnancy if pt has vaginal bleeding and abdominal pain w/ no other risk factors. This seems incredibly high- I thought this percentage would be lower.
-I learned that bHCG and transvaginal US combined is 96% sensitive and 97% specific for ectopic.
-Is there a relationship between time since treatment of ectopic pregnancy and infertility or recurrence of ectopic pregnancy?
Goyal
Interesting read! From this article, I take away how ED providers treat patients differently based on age, race, and geographical locations.
-Strengths: Large sample size and looked at geography, race, age, medication classification among other factors, stratified by triage level, also looked at pregnancy testing when prescribing drugs deemed safer in pregnancy
-Limitations: Cross-sectional study, no data on duration of treatment prescribed, did not narrow down to why medication was prescribed based other than general classification, did not stratify based on whether patient reported OCP/IUD/other birth control
-Outcomes: 22% were tested for pregnancy when being prescribed class D or X, associations between testing and demographic factors and type of drug being prescribed
-I think I will try to do a pregnancy test in all capable females who I am sending to the psych ED. If I cannot get a pregnancy test, I will make a point to mention this to the psych ED provider. I also want to become more familiar with which drugs are class D and X in pregnancy.
I think that the issues related to medical screening for women of child bearing potential are different. Here, the history is likely unreliable and knowing if a patient is a) pregnant or not and b) if yes, confirmed IUP and gestational age vs possible ectopic are very important to determine before sending a patient to Behavioral Health (as having completed medical screening exam). We had a serious AE when both pregnancy testing and ultrasound were not readily available. Could talk about that off line. Both here and if you work at a site where sending a patient, need to confirm HCG status unless known (e.g. s/p hysterectomy as example).
How has reading the article changed your practice?
-HCG number does not matter, reinforced this concept, as Alex and the article said ectopics have been noted in cases where HCG is 0 and 50,000
What information had you believed in previously that were debunked by reading this article?
-exam is useless, unless actively bleeding heavily, no indication for pelvic
What new information did you learn from reading this article?
-never had a pt undergo a uterine currettage to test for chorionic villi…interesting…better make sure not desired pregnancy and no gestational sac on US before poking around in there
-also we always use 1 dose MTX, didn’t realize there were protocols with higher success rates for multi dose MTX…why don’t we do this…increased risk of med side effects?
-also also risk of infertility was higher than I suspected in pts with prior ectopic
What are current areas of uncertainty on this topic that can be potential areas for research?
-?progesterone testing in ectopic but per article seems poorly sensitive and algorithms involving progesterone to evaluate for ectopic performed worse
Goyal
What are some strengths of the study?
Large study
What are the limitations?
Retrospective
What are the main outcomes of the study?
Turns out we don’t upreg a significant number of women receiving teratogenic meds, only 22% were screened per study
Does reading this article change your practice? If so, how?
There is definitely a notion to never trust anyone in ED including women. I feel I always get upreg even if woman reports a hx of a hysterectomy because…..lawyers. Simple enough and easy to do. Especially when prescribing benzos, abx
Ectopic article
1. Not much. As noted above, the beta hcg quantity doesn’t do much for me if no IUP is found. Despite the article suggesting you risk stratify based on beta hcg level of 1500, I treat it as an ectopic until it’s not.
2. I was unware of the difficulty in conceiving s/p ectopic pregnancy. I knew women were at higher risk of difficulty in conceiving, but didn’t think it was approximately a third. Definitely something to consider when providing counseling to a patient with a suspected ectopic. I also thought methotrexate works in 1-2 weeks; apparently it’s more like 7-8.
3. The article is a good reminder of who shouldn’t get methotrexate – people with liver/renal/pulmonary disease. Definitely something to consider in our patient population. Furthermore, up the 30% of patients with ectopic pregnancies have no vaginal bleeding! Thought the number was lower. Will need to have a higher index of suspicion.
4. Research questions to consider – methotrexate dosing probably needs more RTCs. Additionally, what pros/cons other therapeutic agents can have (eg, hyperosmolar glucose, prostaglandins, etc.). Better studies to evaluate role of progesterone. Prior to reading article, I wasn’t aware it played a potential role.
Goyal
1. Strengths? Great question – it really gets at a practice we should improve on as a profession. Also good that they used a large, national dataset.
2. Limitations? Cross-sectional study. Pregnancy testing may have been under-coded in the survey. Important data that could’ve potentially ruled out pregnancy was not asked.
3. Main outcomes? Low frequency of pregnancy testing when meds carry a teratogenic risk – 22%! Scary that 6% of US pregnancies are at risk for potential defects per the author.
4.Change in practice? I definitely could do a better job of obtaining the pregnancy status of patients prior to prescribing abx and AEDs a/w teratogenic effects.
Ectopic Article
1. Hasn’t changed much of my practice.
2. Physical exam really doesn’t help you much here unless someone is actively bleeding a lot or is in a lot of pain.
3. I learned more about why and how OBs choose to go for expectant vs medical vs surgical management. And also learned that thos with liver/renal/pulm disease are not candidates for MTX. Unfortunately, I rely too much on the obgyns here but actually having to think what treatments/who is a good candidate for them will be helpful in my future if I pursue community or am at a location without obgyn
4. I would actually like to see the different medical therapies for treating ectopics compared to one another. Only really know about methotrexate but not much on using hyperosmolar glucose or prostaglandins, not sure if our institution even uses these alternatives?
Goyal
1. Strengths: very large study using a large database
2. Limitations: cross sectional, but they also addressed the possibility to under coding the pregnancy tests. also, I wish they were able to breakdown in a little more detail the level of triage and number of patients receiving these meds (ie status epileptics and AEDs or agitations and BZDs)
3. Main Outcomes: we don’t do enough pregnancies tests when administering potentially teratogenic medications! However, I will say, statins were included as the third most common medication administered and I don’t see a lot of that happening in our ED. Wish they named other common class D and X medications
4. Change in practice: Makes me think twice now about getting upregs on my patients when I’m about to start a new medication.
Ectopic Article
1. Hasn’t changed much of my practice.
2. Physical exam really doesn’t help you much here unless someone is actively bleeding a lot or is in a lot of pain.
3. I learned more about why and how OBs choose to go for expectant vs medical vs surgical management. And also learned that thos with liver/renal/pulm disease are not candidates for MTX. Unfortunately, I rely too much on the obgyns here but actually having to think what treatments/who is a good candidate for them will be helpful in my future if I pursue community or am at a location without obgyn
4. I would actually like to see the different medical therapies for treating ectopics compared to one another. Only really know about methotrexate but not much on using hyperosmolar glucose or prostaglandins, not sure if our institution even uses these alternatives?
Goyal
1. Strengths: large study, able to use national database
2. Limitations: cross sectional, they also addressed that the number of pregnancy tests may be under coded
3. Main Outcomes: we don’t do enough pregnancy tests when starting our reproductive age females on new meds!
4. Change in practice: will now think twice about the category of medications and pregnancy testing in this group of patients