Ectopic pregnancy outcomes in patients discharged from the emergency department

CJEM ◽  
2018 ◽  
Vol 21 (1) ◽  
pp. 71-74
Author(s):  
Krista Hawrylyshyn ◽  
Shelley L. McLeod ◽  
Jackie Thomas ◽  
Catherine Varner
Keyword(s):  
Emergency Department ◽  
Ectopic Pregnancy ◽  
Chart Review ◽  
Transvaginal Ultrasound ◽  
Tertiary Care ◽  
Expectant Management ◽  
Retrospective Chart Review ◽  
Missed Abortion ◽  
Ectopic Pregnancies ◽  
Rule Out

AbstractObjectiveThe objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the emergency department (ED) where ectopic pregnancy had not yet been excluded.MethodsThis was a retrospective chart review of pregnant (<12-week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule-out ectopic pregnancy, or pregnancy of unknown location over a 7-year period.ResultsOf the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes, and 71 (12.9%) had other outcomes that included therapeutic abortion, molar pregnancy, or resolution of βHCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal ultrasound during their index ED visit, and 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy.ConclusionThese results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.

scholarly journals P067: Ectopic pregnancy outcomes in patients discharged from the emergency department

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S80-S81
Author(s):  
K. Hawrylyshyn ◽  
S. McLeod ◽  
J. Thomas ◽  
C. Varner
Keyword(s):  
Ectopic Pregnancy ◽  
Chart Review ◽  
Surgical Intervention ◽  
Tertiary Care ◽  
Expectant Management ◽  
Retrospective Chart Review ◽  
Missed Abortion ◽  
Ectopic Pregnancies ◽  
Pregnancy Of Unknown Location ◽  
Rule Out

Introduction: The objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the ED where ectopic pregnancy had not yet been excluded. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes and 71 (12.9%) had other outcomes which included therapeutic abortion, molar pregnancy or resolution of HCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal US during their index ED visit, 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy. Conclusion: These results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.

scholarly journals P070: Excluding ectopic pregnancy in patients presenting to a community emergency department with first trimester bleeding

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S81-S82
Author(s):  
E. Hoe ◽  
C. Varner ◽  
M. Ivankovic
Keyword(s):  
Emergency Department ◽  
Ectopic Pregnancy ◽  
Community Hospital ◽  
Transvaginal Ultrasound ◽  
Retrospective Chart Review ◽  
First Trimester ◽  
Point Of Care Ultrasound ◽  
Intrauterine Pregnancy ◽  
Missed Abortion ◽  
Diagnostic Modality

Introduction: Current guidelines recommend patients with first trimester bleeding without previously documented intrauterine pregnancy undergo urgent transvaginal ultrasound (TVUS) to exclude ectopic pregnancy. However, in Canadian practice to receive urgent TVUS, particularly out of daytime hours is difficult, if not impossible. Thus, when TVUS is not available to exclude ectopic pregnancy, providers use point of care ultrasound (POCUS) or their best clinical judgment to determine if the patient can be safely discharged home while awaiting outpatient follow-up. The objective of this study was to determine what proportion of first trimester patients presenting to a community hospital emergency department (ED) with vaginal bleeding undergo either TVUS or POCUS to exclude ectopic pregnancy. Methods: This is an ongoing retrospective chart review of pregnant women gestational age (GA) less than 20 weeks presenting to a community hospital ED (103,000 visits/year) with a discharge diagnosis of vaginal bleed, first trimester bleed, threatened abortion, spontaneous abortion, missed abortion, rule out ectopic pregnancy, and ectopic pregnancy from January 2016 - January 2017. Patients are excluded if they are diagnosed with a ruptured ectopic pregnancy during their index ED visit. To date, 98 patient charts have been reviewed. Results: Of the 98 included patients, 13 (13.3%) had a viable pregnancy, 37 (37.8%) had a spontaneous or missed abortion, 4 (4.1%) had an ectopic pregnancy, and 45 (45.9%) had unknown outcomes. Of included patients, 4 (4.1%) only had POCUS, 66 (67.4%) only had a radiologist-interpreted TVUS, and 3 (3.1%) had both POCUS and radiologist-interpreted TVUS during their ED index visits. Thus, 73 (74.5%) had either a radiologist-interpreted TVUS or ED provider-performed POCUS during their index ED visit. After their index ED visits, 2 (2.0%) patients returned with ruptured ectopic pregnancies, 1 of whom had not undergone initial US investigations. Conclusion: Although TVUS is standard of care to exclude ectopic pregnancy in patients presenting with first trimester bleeding or abdominal pain, our preliminary results show some patients are not receiving this diagnostic modality nor POCUS during their index ED visit. Particularly in a setting, such as this ED, without rapid access to an early pregnancy clinic, patients should be counselled about their risk of ectopic pregnancy at the time of ED discharge.

scholarly journals Inappropriateness of Repeated Laboratory and Radiological Tests for Transferred Emergency Department Patients

2019 ◽  
Vol 8 (9) ◽  
pp. 1342 ◽  
Author(s):  
Jérôme Bertrand ◽  
Christophe Fehlmann ◽  
Olivier Grosgurin ◽  
François Sarasin ◽  
Omar Kherad
Keyword(s):  
Emergency Department ◽  
Logistic Regression ◽  
Regression Analysis ◽  
Laboratory Tests ◽  
Chart Review ◽  
Primary Outcome ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Emergency Department Patients ◽  
Radiological Procedures

Background: Laboratory and radiographic tests are often repeated during inter-hospital transfers from secondary to tertiary emergency departments (ED), despite available data from the sending structure. The aim of this study was to identify the proportion of repeated tests in patients transferred to a tertiary care ED, and to estimate their inappropriateness and their costs. Methods: A retrospective chart review of all adult patients transferred from one secondary care ED to a tertiary care ED during the year 2016 was carried out. The primary outcome was the redundancy (proportion of procedure repeated in the 8 h following the transfer, despite the availability of the previous results). Factors predicting the repetition of procedures were identified through a logistic regression analysis. Two authors independently assessed inappropriateness. Results: In 2016, 432 patients were transferred from the secondary to the tertiary ED, and 251 procedures were repeated: 179 patients (77.2%) had a repeated laboratory test, 34 (14.7%) a repeated radiological procedure and 19 (8.2%) both. Repeated procedures were judged as inappropriate for 197 (99.5%) laboratory tests and for 39 (73.6%) radiological procedures. Conclusion: Over half of the patients transferred from another emergency department had a repeated procedure. In most cases, these repeated procedures were considered inappropriate.

scholarly journals P063: Identification of emergency department patients for referral to rapid-access addiction services: A retrospective chart review

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S86
Author(s):  
J. Hann ◽  
H. Wu ◽  
A. Gauri ◽  
K. Dong ◽  
N. Lam ◽  
...  
Keyword(s):  
Emergency Department ◽  
Substance Use ◽  
Chart Review ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Care Team ◽  
Addiction Medicine ◽  
Multivariable Logistic Regression Model ◽  
Factors Associated ◽  
Extract Information

Introduction: Emergency Department (ED) visits related to substance use are rapidly increasing. Despite this, few Canadian EDs have immediate access to addiction medicine specialists or on-site addiction medicine clinics. This study characterized substance-related ED presentations to an urban tertiary care ED and assessed need for an on-site rapid-access addiction clinic (RAAC). Methods: This prospective enrollment, retrospective chart review was conducted from June to August 2018. Adult patients presenting to the ED with a known or suspected substance use disorder were enrolled by any member of their ED care team using a 1-page form. Retrospective chart review of the index ED visit was conducted and the Emergency Department Information System was used to extract information related to the visit. A multivariable logistic regression model was fit to examine factors associated with recommendation for referral to a hypothetical on-site RAAC.This prospective enrollment, retrospective chart review was conducted from June to August 2018. Adult patients presenting to the ED with a known or suspected substance use disorder were enrolled by any member of their ED care team using a 1-page form. Retrospective chart review of the index ED visit was conducted and the Emergency Department Information System was used to extract information related to the visit. A multivariable logistic regression model was fit to examine factors associated with recommendation for referral to a hypothetical on-site RAAC. Results: Of the 557 enrolment forms received, 458 were included in the analysis. 64% of included patients were male and 36% were female, with a median age of 35.0 years. Polysubstance use was seen in 23% of patients, and alcohol was the most common substance indicated (60%), followed by stimulants (32%) and opioids (16%). The median ED length of stay for included patients was 483 minutes, compared to 354 minutes for all-comers discharged from the ED during the study period. 28% of patients had a previous ED visit within 7 days of the index visit, and an additional 17% had a visit in the preceding 30 days. The ED care team indicated ‘Yes’ for RAAC referral from the ED for 66% of patients, for a mean of 4.3 patients referred per day during the study period. Multivariable analysis showed that all substances (except cannabis) correlated to a statistically significant increase in likelihood for indicating ‘Yes’ for RAAC referral from the ED (alcohol, stimulants, opioids, polysubstance; p &lt; 0.05). Patients presenting to the ED with a chief complaint related to substance use were also more likely to be referred (p = 0.01). Conclusion: This retrospective chart review characterized substance-related presentations at a Canadian urban tertiary care ED. Approximately four patients per day would have been referred to an on-site RAAC had one been available. The RAAC model has been implemented in other Canadian hospitals, and collaborating with these sites to begin developing this service would be an important next step.

Methotrexate for the treatment of unruptured tubal ectopic pregnancy

CJEM ◽  
2018 ◽  
Vol 21 (3) ◽  
pp. 391-394
Author(s):  
K Hawrylyshyn ◽  
SL McLeod ◽  
J Thomas ◽  
Catherine Varner
Keyword(s):  
Ectopic Pregnancy ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Line Treatment ◽  
First Line ◽  
Tubal Ectopic Pregnancy ◽  
Surgical Evaluation ◽  
Ectopic Pregnancies ◽  
Recommended Guidelines ◽  
First Line Treatment

ABSTRACTObjectiveThe objective of this study was to determine the outcomes of women who presented to the emergency department (ED) with suspected ectopic pregnancy and received methotrexate as first-line treatment.MethodsThis was a retrospective chart review of pregnant (< 12 week’ gestational age) women from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule-out ectopic pregnancy, or pregnancy of unknown location over a 7-year period.ResultsOf 612 patients with a suspected ectopic pregnancy at initial ED presentation, 326 (53.3%) had non-ectopic pregnancy outcomes, 30 (4.9%) were diagnosed with a ruptured ectopic pregnancy at the index ED visit, and 18 (2.9%) were diagnosed and managed as non-tubal ectopic pregnancies and excluded from further analyses; 238 patients were diagnosed with a tubal ectopic pregnancy, and 152 (63.9%) were treated with methotrexate at the index ED visit or in follow-up. Of patients treated with methotrexate, 27 (17.8%) went on to require surgical management, with 17 (11.2%) documented as having ruptured on surgical evaluation.ConclusionThe proportion of patients failing methotrexate as first-line treatment was higher than previously reported. Further investigation is needed to determine whether methotrexate failure was due to non-adherence to recommended guidelines.

scholarly journals Cesarean Scar Ectopic Pregnancy: Treatment Decision Algorithm and Success With Medical Treatment

2021 ◽  
Author(s):  
Lorena Sabonet Lorente ◽  
Ana I. Guzman Leon ◽  
Pilar Espejo Reina ◽  
José Ramón Anderica Herrero ◽  
Ernesto Gonzalez Mesa ◽  
...  
Keyword(s):  
Ectopic Pregnancy ◽  
Transvaginal Ultrasound ◽  
Treatment Options ◽  
Expectant Management ◽  
Treatment Decision ◽  
Maternal Condition ◽  
Decision Algorithm ◽  
Cesarean Scar ◽  
Future Fertility ◽  
Ectopic Pregnancies

Background Cesarean scar ectopic pregnancies are a rare form of extrauterine pregnancies, yet their incidence has increased along with the rise in the number of cesarean deliveries. As with other ectopic pregnancies, cesarean scar ectopic pregnancies pose a greater risk for maternal hemorrhage and ultimately maternal mortality. Case presentation We present a series of clinical cases of cesarean scar ectopic pregnancy diagnosed by transvaginal ultrasonography. Each patient received an individualized treatment: the rate of success depended on the particular maternal condition in each case. Due to the low frequency of this entity, there are no clear protocols for its treatment and thus there are numerous options for treatment and follow up: expectant management, medical therapy, surgical intervention, uterine artery embolization or a combined approach. Each method has different levels of success and is dependent on the surgeon&rsquo;s skill and patient presentation. The transvaginal ultrasound is necessary to obtain the fine details of the gestation sac and its relation to the scar and must be followed by a meticulous abdominal scan with a full bladder. Conclusion Herein, we present a rare pathological phenomenon whose frequency is on the rise, and for which transvaginal ultrasound and flow doppler provide high diagnostic accuracy. Early diagnosis of cesarean scar ectopic pregnancies offers treatment options to that may help avoid uterine rupture and bleeding, thus preserving the uterus and future fertility.

scholarly journals Cesarean Scar Ectopic Pregnancy—Case Series: Treatment Decision Algorithm and Success with Medical Treatment

Medicina ◽  
2021 ◽  
Vol 57 (4) ◽  
pp. 362
Author(s):  
Lorena Sabonet Morente ◽  
Ana I. Guzmán León ◽  
M. Pilar Espejo Reina ◽  
Jose R. Anderica Herrero ◽  
Ernesto González Mesa ◽  
...  
Keyword(s):  
Ectopic Pregnancy ◽  
Transvaginal Ultrasound ◽  
Treatment Options ◽  
Case Series ◽  
Expectant Management ◽  
Maternal Condition ◽  
Decision Algorithm ◽  
Cesarean Scar ◽  
Future Fertility ◽  
Ectopic Pregnancies

Background: Cesarean scar ectopic pregnancies are a rare form of extrauterine pregnancies, yet their incidence has increased along with the rise in the number of cesarean deliveries. As with other ectopic pregnancies, cesarean scar ectopic pregnancies pose a greater risk for maternal hemorrhage and ultimately maternal mortality. Case presentation: We present a series of clinical cases of cesarean scar ectopic pregnancy diagnosed by transvaginal ultrasonography. Each patient received an individualized treatment: the rate of success depended on the particular maternal condition in each case. Due to the low frequency of this entity, there are no clear protocols for its treatment and thus there are numerous options for treatment and follow-up: expectant management, medical therapy, surgical intervention, uterine artery embolization or a combined approach. Each method has different levels of success and is dependent on the surgeon’s skill and patient presentation. A transvaginal ultrasound is necessary to obtain the fine details of the gestation sac and its relation to the scar and must be followed by a meticulous abdominal scan with a full bladder. Conclusion: Herein, we present a rare pathological phenomenon whose frequency is on the rise, and for which transvaginal ultrasound and flow Doppler provide high diagnostic accuracy. Early diagnosis of cesarean scar ectopic pregnancies offers treatment options that may help avoid uterine rupture and bleeding, thus preserving the uterus and future fertility.

scholarly journals P066: Methotrexate in the management of suspected ectopic pregnancy

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S80-S80
Author(s):  
K. Hawrylyshyn ◽  
S. McLeod ◽  
J. Thomas ◽  
C. Varner
Keyword(s):  
Ectopic Pregnancy ◽  
Surgical Management ◽  
Gestational Age ◽  
Tertiary Care ◽  
Expectant Management ◽  
Retrospective Chart Review ◽  
Line Treatment ◽  
Success Rates ◽  
First Line ◽  
First Line Treatment

Introduction: Early detection of ectopic pregnancy and careful management is critical to prevent adverse clinical outcomes, including fallopian tube rupture and future decreased fertility, in patients presenting to the ED with symptoms suggestive of ectopic pregnancy. Methotrexate therapy is widely accepted as a first line treatment of ectopic pregnancy, with success rates greater than 90% if used according to published guidelines. This study aims to determine the outcomes of pregnant women who presented to the ED with suspected ectopic pregnancy whom received methotrexate as first line treatment. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of 612 included patients, 30 (4.9%) were diagnosed with a ruptured ectopic pregnancy at the index ED visit. Of the remaining 582 patients, 256 (44.0%) were diagnosed with an ectopic pregnancy at the index ED visit, the Early Pregnancy Clinic, or a subsequent ED visit. Of these patients diagnosed with ectopic pregnancy, their initial treatments at time of discharge from the index ED visit were as follows: 102 (39.8%%) received methotrexate, 132 (51.6%) underwent expectant management, and 22 (8.6%) underwent surgical management. Of the 132 patients discharged with an expectant management plan, only 42 (31.8%) had a final outcome of expectant management; the others went on to be treated surgically or with methotrexate. Of the 165 patients treated with methotrexate at index visit or in follow-up, 30 (18.2%) went on to require surgical management with 17 (10.3%) documented as having ruptured on surgical evaluation. Clinical characteristics of patients treated with methotrexate include the following: mean age 32.8 years (SD 5.7), gestational age of 6.2 weeks (SD 1.2) and serum beta human chorionic gonadotropin level of 2702 mIU/mL (SD 8800). Conclusion: The proportion of patients receiving methotrexate as first-line treatment that resulted in rupture or required further surgical management is higher than reported literature at this institution. Further investigation is needed to determine if there was a relationship between methotrexate failure and non-adherence to recommended guidelines. Given the risk of a possible rupture, patient education of these risks is critical on discharge from the ED.

scholarly journals Presentation of Primary Adrenal Insufficiency in Childhood

2011 ◽  
Vol 96 (6) ◽  
pp. E925-E928 ◽  
Author(s):  
Susan Hsieh ◽  
Perrin C. White
Keyword(s):  
Adrenal Insufficiency ◽  
Chart Review ◽  
Clinical Symptoms ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Signs And Symptoms ◽  
Primary Adrenal Insufficiency ◽  
Adrenal Hypoplasia ◽  
Glucocorticoid Deficiency ◽  
Rule Out

Context: Primary adrenal insufficiency is usually diagnosed in infancy or adulthood, and cases presenting in childhood have not been systematically reviewed. Objective: Our objective was to determine etiologies, signs, and symptoms of primary adrenal insufficiency presenting in childhood. Design and Setting: We conducted a retrospective chart review at a tertiary-care pediatric hospital. Patients: Patients were children with corticoadrenal insufficiency, glucocorticoid deficiency, or mineralocorticoid deficiency. Results: Seventy-seven cases were identified in 1999–2010. Thirty-five had congenital adrenal hyperplasia (CAH) and were not reviewed further. Forty-two patients (20 diagnosed at our institution) had primary adrenal insufficiency. These had etiologies as follows: autoimmune (18), autoimmune polyendocrinopathy syndrome (an additional five), ACTH resistance (four), adrenoleukodystrophy (three), adrenal hypoplasia congenita (two), adrenal hemorrhage (two), IMAGe syndrome (one), and idiopathic (two). Of 20 patients diagnosed at our institution, two were being monitored when adrenal insufficiency developed and were not included in the analysis of presenting signs and symptoms: 13 of 18 patients were hypotensive; 12 of 18 had documented hyperpigmentation. Hyponatremia (&lt;135 mEq/liter) occurred in 16 of 18. However, hyperkalemia (&gt;5.0 mEq/liter) was noted in only nine. Hypoglycemia and ketosis were documented in four of 15 and four of six patients in whom it was sought, respectively. Fifteen patients underwent cosyntropin stimulation testing with median baseline and stimulated cortisol of 1.1 and 1.2 μg/dl, respectively. ACTH and renin were markedly elevated in all patients. Conclusions: Hyperkalemia is not a consistent presenting sign of primary adrenal insufficiency in childhood, and its absence cannot rule out this condition. A combination of chronic or subacute clinical symptoms, hypotension, and hyponatremia should raise suspicion of adrenal insufficiency.

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