Prospective Outcomes of Pregnant ED Patients with Documented Fetal Cardiac Activity on Ultrasound

Background

Vaginal bleeding is a common cause of presentation to the emergency department (ED), and is the leading cause of presentations to the ED among patients with first trimester pregnancy [1]. It is reported that up to 25% of pregnancies have some bleeding within the first trimester [2]. Based on previous data, bleeding in the first trimester represents an increased risk of spontaneous abortion (SAB), with up to 50% of women losing the pregnancy [3]. However, patients with first trimester bleeding and a documented intrauterine pregnancy (IUP)  with fetal heart tones (FHTs), represent a subset of first trimester bleeding patients with improved outcomes, with rates of SAB ranging from 11.1-16.4% [4-5]. These previous studies were performed in outpatient obstetrical clinics and no prospective data exists with respect to outcomes in this subset of patients presenting to the emergency department. 

Prospective Outcomes of Pregnant ED Patients with Documented Fetal Cardiac Activity on US

Clinical Question

What is the rate of SAB in pregnant women presenting to the ED with first trimester bleeding and a documented IUP with cardiac activity?

Methods & Study Design

  • Design
    • Prospective observational study
    • Convenience sample of pregnant patients presenting to the University of Utah ED from January 1, 2008 through April 30, 2010.
  • Population
    • Pregnant women presenting to the ED with abdominal pain and/or bleeding
  • Inclusion criteria
    • Ultrasound (performed by ED physician at bedside or formal radiology study) demonstrating an IUP with FHTs and whose pregnancy dates placed them in the first trimester (< 13 weeks)
  • Exclusion criteria
    • No specific criteria
  • Intervention
    • Ultrasound demonstrating IUP with FHTs
  • Outcomes
    • Rate of SAB at 30 days after ED visit
    • Patients were contacted by telephone at least 30 days after their ED visit and asked about the status of their pregnancy

Results

Strengths & Limitations

  • Strengths
    • Performed in ED based population
    • Majority of ultrasound examinations performed by ED physicians making this applicable to point-of-care ultrasound
  • Limitations
    • Performed at single academic center
    • Low patient enrollment leading to large CI for rate of SAB
    • 85.9% patient follow up rate
    • Patients only followed out to 30 days after ED visit

Authors Conclusion

"In this prospective study of ED patients with first trimester bleeding and/or pain, we found that patients who had an IUP and FHTs by ED US had a 14.8% rate of SAB at 30 days. These findings may help to better define risk of SAB after first-trimester bleeding and allow us to provide more accurate counseling and prognostic information to pregnant ED patients presenting with these symptoms.”

Our Conclusion

This is an excellent paper that helps provide emergency medicine providers with prognostic information  regarding women presenting to the ED during first trimester pregnancy with vaginal bleeding and a documented IUP with FHTs. Often in emergency medicine we are focused on ruling out the life threatening diagnoses, in the above scenario, ectopic pregnancy, and it can be easy to lose sight of other important aspects of patient care. This paper helps refocus our attention and gives us important data to be able to provide an already anxious patient with some useful information on the potential expected course of their pregnancy. With this data, we are now able to better define the risk of SAB after first trimester bleeding and provide improved counseling and prognostic information to these patients.

The Bottom Line

In ED patients with first trimester bleeding, those that have an IUP and FHTs by ED ultrasound have ~15% rate of SAB at 30 days. 

Authors

This post was written by Michael Macias, MD, Ultrasound Fellow at UCSD.

References

    1. Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester bleeding. J Clin Ultrasound 2008;36(6):352-66.
    2. Hasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Ann Epidemiol 2010;20(7):524-31.
    3. Dideriksen KL, Lidegaard O, Langhoff-Roos J. First trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol 2010;115(5):935-44.
    4. Poulose T, Richardson R, Ewings P, Fox R. Probability of early pregnancy loss in women with vaginal bleeding and a singleton live fetus at ultrasound scan. J Obstet Gynaecol 2006;26(8):782-4.
    5. Siddiqi TA, Caligaris JT, Miodovnik M, Holroyde JC, Mimouni F.Rate of spontaneous abortion after first trimester sonographic demonstration of fetal cardiac activity. Am J Perinatol 1988;5(1):1-4.
    6. Mallin M, e. (2018). Prospective outcomes of pregnant ED patients with documented fetal cardiac activity on ultrasound. - PubMed - NCBI . Ncbi.nlm.nih.gov. Retrieved 26 January 2018, from https://www.ncbi.nlm.nih.gov/pubmed/21334156