Early Pregnancy Loss in the Emergency Department: Lessons Learned as a Spouse, New Father, and Emergency Medicine Resident

Introduction: Complications in early pregnancy are common and have many physical and emotional consequences. Locally, there is no early pregnancy loss clinic or standardized guide in the emergency department (ED) for referral and follow-up decisions, and both initial management of patients and follow up can be inconsistent. This study aimed to obtain consensus on the best approach to initial work-up, management, and follow up for patients who present to the ED with early pregnancy complications, with the goal of using this consensus to produce a standardized guide for emergency provider use. Methods: A literature review was completed to produce evidence-based recommendations which were used to initiate a modified Delphi consensus process. A survey was distributed, with three rounds completed. Participants included emergency providers, obstetrician-gynecologists, a radiologist, a sample of family medicine physicians including some involved in primary care obstetrics, and nurse practitioners. An obstetric specialist from outside the local region was also involved. Results: Consensus was reached on several key recommendations, however some areas remained without clear accepted best practice. There was consensus that physical components of early pregnancy complications are addressed well, but that we could improve on patient flow and more consistent follow up. Important investigations to be done for patients were identified. The timing of formal ultrasound, necessity and timing of obstetrician consultation, and safety of discharge was addressed for various patient scenarios including stable and unstable patients, with and without adnexal pain, with intrauterine pregnancy of uncertain viability, and with pregnancy of unknown location. Management of confirmed early pregnancy loss in the ED and family medicine clinics was addressed. Barriers to an early pregnancy loss clinic included lack of funding, space, and staffing as well as lack of resources and uncertain patient volumes. A feasible alternative to an early pregnancy loss clinic was for willing providers to keep appointment times available to facilitate confirmation of follow-up prior to discharge. Other suggested alternatives included an early pregnancy loss clinic, a nurse educator, and having a standardized guideline in the ED. Conclusion: Through a consensus approach, several recommendations were agreed upon for improving care for patients presenting to the ED with early pregnancy complications.

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Emergency medicine resident wellness: Lessons learned from a national survey

CJEM ◽

10.1017/cem.2018.416 ◽

2018 ◽

Vol 20 (5) ◽

pp. 721-724 ◽

Cited By ~ 1

Author(s):

Ahmed Taher ◽

Alexander Hart ◽

Neil Dinesh Dattani ◽

Zafrina Poonja ◽

Christina Bova ◽

...

Keyword(s):

Emergency Medicine ◽

National Survey ◽

Lessons Learned ◽

Emergency Medicine Resident ◽

Medicine Resident ◽

Study Find ◽

Resident Wellness ◽

Physical Wellness

CLINICIAN’S CAPSULEWhat is known about the topic?Emergency medicine (EM) residents face many wellness challenges during residency.What did this study ask?What was the current landscape of Canadian EM resident wellness?What did this study find?Canadian EM residents face a multitude of psychosocial and physical wellness challenges, while supports may not be adequate.Why does this study matter to clinicians?Opportunities exist to further investigate resident wellness with validated tools, engage stakeholders, and advance the EM resident wellness agenda.

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LO40: Services for emergency department patients experiencing early pregnancy complications: a survey of Ontario hospitals

CJEM ◽

10.1017/cem.2019.83 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S21-S22

Author(s):

R. Glicksman ◽

S. McLeod ◽

J. Thomas ◽

C. Varner

Keyword(s):

Emergency Department ◽

Early Pregnancy ◽

Pregnancy Complications ◽

Pregnancy Loss ◽

Transvaginal Ultrasound ◽

Point Of Care Ultrasound ◽

Early Pregnancy Loss ◽

Online Questionnaire ◽

Follow Up Care

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. These hospitals constitute greater than 85% of the annual ED visits in Ontario, creating a sample reflective of the services available to most women older than 18 years old seeking care for early pregnancy complications in the province. Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications including pregnancy of unknown location and threatened abortion. Respondents also stated that radiologist-interpreted ultrasound was only available to 22 (34.9%) of hospital sites 24 hours a day, 7 days per week for women with early pregnancy complications. Of hospital site respondents, 55 (87.3%) reported point-of-care ultrasound (POCUS) use in the ED for patients with early pregnancy complications, and 27 (49.1%) reported the ED had access to transvaginal ultrasound probes for POCUS assessment by emergency physicians. Additionally, the proportion of ED physicians who were certified as Canadian Emergency Ultrasound independent practitioners ranged from 10% to 100%. Conclusion: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.

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P074: Emergency department utilization and outcomes for patients with early pregnancy complications

CJEM ◽

10.1017/cem.2020.280 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S91-S91

Author(s):

R. Glicksman ◽

D. Little ◽

C. Thompson ◽

S. McLeod ◽

C. Varner

Keyword(s):

Emergency Department ◽

Ectopic Pregnancy ◽

Early Pregnancy ◽

Pregnancy Complications ◽

Pregnancy Loss ◽

Hospital Admissions ◽

Emergency Department Utilization ◽

Early Pregnancy Loss ◽

Surgical Interventions ◽

Ed Visits

Introduction: Affecting roughly 1 in 5 pregnancies, early pregnancy loss is a common experience for reproductive-aged women. In Canada, most women do not establish care with an obstetrical provider until the second trimester of pregnancy. Consequently, pregnant patients experiencing symptoms of early pregnancy loss frequently access care in the emergency department (ED). The objective of this study was to describe the resource utilization and outcomes of women presenting to two Ontario EDs for early pregnancy loss or threatened early pregnancy loss. Methods: This was a retrospective cohort study of pregnant (≤20 weeks), adult (≥18 years) women in two EDs (one community hospital with 110,000 annual ED visits; one academic hospital with 65,000 annual ED visits) between January 2010 and December 2017. Patients were identified by diagnostic codes indicating early pregnancy loss or threatened early pregnancy loss. Results: A total of 16,091 patients were included, with a mean (SD) age of 32.8 (5.6) years. Patients had a total of 22,410 ED visits for early pregnancy complications, accounting for 1.6% of the EDs’ combined visits during the study period. Threatened abortion (n = 11,265, 50.3%) was the most common ED diagnosis, followed by spontaneous abortion (n = 5,652, 25.2%), ectopic pregnancy (n = 3,242, 14.5%), missed abortion (n = 1,541, 6.9%), and other diagnoses (n = 710, 3.2%). 8,000 (44.8%) patients had a radiologist-interpreted ultrasound performed during the initial ED visit. Median (IQR) ED length of stay was 3.4 (2.3 to 5.1) hours. There were 4,561 (25.6%) return ED visits within 30 days, of which 2,317 (50.8%) occurred less than 24 hours of index visit, and 481 (10.6%) were for scheduled, next day ultrasound. The total number of hospital admissions was 1,793 (8.0%), and the majority were for ectopic pregnancy (n = 1,052, 58.7%). Of admitted patients, 1,320 (73.6%) underwent surgical interventions related to early pregnancy. There were 474 (10.4%) patients admitted to hospital during return ED visits. Conclusion: Pregnant patients experiencing symptoms of early pregnancy loss in the ED frequently had radiologist-interpreted US and low rates of hospital admission, yet had high rates of return ED visits. This study highlights the heavy reliance on Ontario EDs to care for patients experiencing complications of early pregnancy.

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