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Picture the scene…

Your next patient is a distraught 24 year old who recently found out she is pregnant and has starting having spots of blood a few hours ago. Her and her partner want to know if it’s going to be ok?….

Learning Objective

To learn about the management of the patient with problems in the early part of pregnancy in the Emergency Department.

Read this blogpost from RCEM Learning​1​. As with all patients presenting to the ED we want to be sure that they don’t have serious pathology: in this case that would be an ectopic pregnancy. Focus especially on the features in the history that make an ectopic pregnancy more likely.

Listen to this St Emlyn’s podcast with Nat and Iain, which will reenforce the learning from the RCEM article. Also read the accompanying blogpost if you have time​2​.

This part of the teaching session should be lead by an experienced clinician. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.

A 28 year old presents to the ED with some spotting (small amounts of PV bleeding) that she first noticed a few hours ago. She has been pregnant three times before and has one child who is 2 years old. Her last menstrual period was six weeks ago.

Gravida (from the Latin meaning “burdened” or “heavy”) is the number of times she has been pregnant. Para (from “Parity” – meaning “countable”) is the number of pregnancies that have gone beyond 20 weeks gestation.

This patient is Gravida 4 (including this pregnancy) and Para 1 – G4 P1

Ask about the bleeding: how much and how often they are changing pads/sanitary protection.

Do they have any abdominal pain? Is it localised or more generalised?

Try to confirm the date of the last menstrual period – was it “normal”? So patients can get a small “implantation bleed” that could be confused for a period.

Ask about risk factors for ectopic pregnancy (remember we are always looking to rule out the worst case senario first in the ED). These may increase the likelihood, but about 1/3 of ecoptic pregnancies will occur when no risk factors are present.

Risk factors include:

  • Previous ectopic pregnancy
  • Pelvic inflammatory disease (especially chlamydia infection)
  • Previous pelvic surgery
  • Previous tubal ligation
  • Ovarian/uterine cysts or tumours previously
  • Endometriosis/known adhesions
  • Assisted fertilisation/IVF
  • Presence of intrauterine contraceptive device (coil)
  • Progesterone-only pill (POP)

As with all ED patients start with an “ABC” assessment. Look out especially for tachycardia and hypotension. Later in pregnancy these may drop as part of the normal physiologicalchanges, but early on, in an otherwise well young patient even small changes mustn’t be ignored.

Ensure you confirm the pregnancy – Urine hCG is around 96% sensitive and serum hCG is close to 100% sensitive for pregnancies, ie if they are negative the patient is very unlikely to be pregnant and you need to look for other causes of her bleeding.

On physical examination feel the abdomen. Is there localised pain?

There really are very few indications for a PV examination in the Emergency Department. In this patient’s case it would add very little to the examination findings or alter the pre test probability (or what you do next at all).

This early in the pregnancy a POCUS (point of care ultrasound) is unlikely to be able to visualise the fetus, as it will still be deep in the pelvis.

If it is felt that an ectopic pregnancy is very low risk, then the patient could be managed as an outpatient depending on your local service (discuss with your facilitator). This may include a serial measurement of bHCG and a transvaginal ultrasound.

Anti D is given to patients who are Rhesus (RhD) negative, after sensitising events, to prevent haemolytic disease of the newborn. This can be given up to 72 hours after the event. In pregnancies of less than 12 weeks Anti D is only given following ectopic pregnancy, molar pregnancy, therapeutic termination of pregnancy, and in cases of uterine bleeding where this is repeated, heavy or associated with abdominal pain. 

In this patient none of these apply (yet) so she doesn’t need anti D in the ED

The University Hospital Southampton Guideline to administration of Anti D can be downloaded here

Firstly, remember that this will be a very distressing time for both the patient and their partner. Remember that although you may see this patient as a “quick hit” for her it may signal a life defining event.

Be wary of telling patients that they have definitely miscarried. Bleeding in early pregnancy is very common and these patients can go on to have an otherwise uneventful pregnancy with a baby at the end.

Take a few extra minutes to explain to her that there is nothing she can do to change whatever happens, and that it is most certainly not her “fault”. Ensure you give her a plan for follow up (likely an appointment at an “Early Pregnancy Clinic”) and advice about what to do if she has further bleeding or pain.

A 29 year old woman presents to the ED following a “faint”. She lost consciousness for approximately one minute and had a full recovery. She tells you that she had some really bad period pains just before she blacked out. She is on the mini pill and there is adament there is absolutely no way she could be pregnant.

In any young woman who is of child bearing age who has “fainted” we must consider that she has an ectopic prenancy until proven otherwise.

Before you do anything else move the patient to an area that she can be observed closely and intravenous access gained (likely your Resus Room). Tell your senior doctor about the patient.

You’ll remember the risk factors from the last question, but this is such an important diagnosis it does no harm to go through them again…

  • Previous ectopic pregnancy
  • Pelvic inflammatory disease (especially chlamydia infection)
  • Previous pelvic surgery
  • Previous tubal ligation
  • Ovarian/uterine cysts or tumours previously
  • Endometriosis/known adhesions
  • Assisted fertilisation/IVF
  • Presence of intrauterine contraceptive device (coil)
  • Progesterone-only pill (POP)

If this patient has already had a syncopal episode and she does have an ectopic, then she has already likely had significant bleeding. Check her vital signs and feel her abdomen.

This patient needs a POCUS in resus, looking for free fluid.

A bHCG will be important to confirm that she is prenant (either serum or urine). It may even be necessary to catheterise her to get the sample. Some​3​ would suggest trying a drop of blood on a usual pregnancy test.

Imagine this patient is a bleeding trauma patient (in a way they are). You need the most senior doctors from EM, O&G and Anaesthetics with her to plan for the next steps (likely the operating theatre if she is haemodynamically compromised).

Our patients tell us all sort of things, for all sorts of reasons! In the case of any potentially life threatening diagnosis we need objective evidence to say that the patient doesn’t have that problem.

In this session we have learned about the clinical assessment of the patient with problems in early pregnancy in the Emergency Department.

Remember: Any patient with child bearing potential, who has had a syncopal episode has an ectopic pregnancy until proven otherwise.

In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.

Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.

Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?

References and Further Reading

  1. 1
    Lawrence-Ball A. Induction Bleeding in Early Pregnancy. RCEM Learning. 2018; published online Feb 6. (accessed June 16, 2020).
  2. 2
    May N. Problems in Early Pregnancy. St Emlyns. 2015; published online Jan 14. (accessed June 16, 2020).
  3. 3
    Lin M. Trick of the Trade: Urine pregnancy test without urine. Academic Life in Emergency Medicine. 2012; published online April 10. (accessed June 16, 2020).