Asynchrony EM: First Trimester Bleeding and Complications of Abortion

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM, with digital content curated into topic modules following our curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM professional community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

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Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

This week in Asynchrony EM, we continue in the OB/Gyn block with core content knowledge on vaginal bleeding in early pregnancy, as well as a look at something not often covered in didactics: complications of elective abortion. 

We do have a (sad) theme song this week: Beyonce, with a simple song about miscarriage called "Heartbeat."

 *Sigh.* Ok, let's work it through together.

1)  FIRST TRIMESTER BLEEDING

a) A place to start: from EM in 5, Vaginal Bleeding in 1st TM Pregnancy (Nov 9, 2015). 

b) Now a little deeper.  Some interesting points on the utility of β-hCG levels, and note the reference to the landmark 2013 (sadly not #FOAMed) NEJM article.  (This is also a good US overview, but more on that coming next. )  Tips and Tricks from ACEP

b) Hot off the press! (It's lengthy; just skim, and know that this now exists.)

Approved on October 26, 2016 by the ACEP Board of Directors: New ACEP Current Clinical Policy on "Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. (If you are having trouble accessing the pdf from this site, here it is in my Evernote.

This new policy addresses two "critical questions": 

(a) Should the emergency physician obtain a pelvic ultrasound in a clinically stable pregnant patient who presents to the emergency department with abdominal pain and/or vaginal bleeding and a β-human chorionic gonadotropin (β-hCG) level below a discriminatory threshold? (My short answer: yes.)

(b) In patients who have an indeterminate transvaginal ultrasound result, what is the diagnostic utility of β-hCG for predicting possible ectopic pregnancy? (My short answer: it's not as helpful as you would like it to be.)

2) BEDSIDE ULTRASOUND

Bedside ultrasound is now an important EM skill in the management of patients with first trimester bleeding. 

a) FOR ULTRASOUND NOVICES: Pregnancy Ultrasound Part One from Ultrasound Podcast. Under 20 minutes if you forward through the puppet intro ad for the Cabo conference.  Watch this if only you feel you should start from scratch, but the main points are:

a) Trained emergency physicians are quite good at identifying IUP's and patients who are at risk for ectopic. A meta-analysis of 576 publications demonstrated a pooled sensitivity of over 99% (sensitivity being defined in this article as the proportion of patients who had ectopics that had no finding of IUP in the ED.) (NB: another earlier study cited in podcast #2 cites a specificity of over 99% and a sensitivity of 71% in regards to identifying IUP's. Still good: when we say there's an IUP, there is almost always an IUP--and if we don't see it, we're just going to take the conservative route and arrange follow up anyway, right?)

b) Another study suggests that for you to achieve above 99% sensitivity in accurately identifying IUP's, it takes the experience generated by doing about 40 exams.

c) ED US has been suggested to decrease length of stay by 21% in this specific scenario. 

d) In one study, free fluid in Morrison's pouch had a positive LR of 112 in predicting the need for operative intervention in suspected ectopic pregnancy.

e) Prognostic ability of finding an IUP with normal cardiac activity on US: 85% of these patients (the large majority) will NOT have miscarried by the 30 day mark. 

Of course, after all that, they then go on to describe a case in which an EP misdiagnoses an IUP and the ectopic subsequently ruptures, but don't let that freak you out too much! There was identifiable fluid in Morrison's pouch on bedside ultrasound when she returned...

Then they review basic ultrasound technique, the probes, the positions, and normal anatomy.  USEFUL review if you need it.

b) Move on to Pregnancy Ultrasound Part Two: also from Ultrasound Podcast. Start at 1:30 to skip the ads, and it lasts for 25 minutes after that. (The last few minutes are an ad for a more advanced podcast on myometrial measurements, interstitial ectopics, etc--watch if you are interested.) 

Shifting gears a little to a topic that is not often covered in EM Didactics.

3) COMPLICATIONS OF ABORTION

Regardless of how you feel about abortion rights, know that complications of elective abortions do occur, and that these patients WILL wind up in your ED, requiring knowledgeable and sensitive care. Induced abortion should cross your mind in the right clinical setting, and if it crosses your mind, you should ASK patients about recent abortions or abortion attempts--in a sensitive, non-judgmental way--because they might not volunteer it. In my experience, patients almost never tell the triage nurse, so it's our job to ASK. And kick everyone else out of the room when you do, or you probably won't get the truth. (I usually nicely ask everyone else to exit at physical exam time -- and ask all of my sensitive questions then.) Sometimes you won't get the truth, regardless.

Getting the history of the recent abortion is probably the most difficult part.  Once you have that, you'll have context for your ultrasound to look for retained POC (or, as I have seen, a still-living fetus), to consider infectious complications, to loop in your OB/Gyn consultants, and move forward.

a) Kudos to EM Docs for their recent #FOAMed post, "Recent Elective Abortion" (August 2016).

b) Updated 2016 information on pharmacologic termination of early pregnancy, from the FDA. Note the warning against internet-obtained mifepristone: there is a brisk internet market for mifepristone in the US and abroad, safe or not. (As another aside, for you international medicine folks, if you haven't heard of Women on Waves, from a global perspective it's very interesting--and of course, very controversial.)

c) Most of us have no idea how late term abortions are actually performed. So in the interest of best knowing how to treat their complications, read this JEM article (Aug 2013) (or here in Evernote).  No need to memorize everything (we'll do digoxin toxicity another day) but just be aware of the various techniques used and their potential complications. (The Journal of Emergency Medicine, Volume 45, Issue 2, August 2013, Pages 190–193)

d) Brief article on a complication of self-induced abortion, which we expect to see more of in areas where abortion access is increasingly limited. The take home point is that these patients are reluctant historians, and may wait until they are at death's door before presenting.

And now on to...

THE OPTIONAL EXTRAS

1) Need a primer on the basics of ALL types of vaginal bleeding? Check out Episode 34 of CrackCast on vaginal bleeding, covering bleeding in all age groups, pregnant and non-pregnant. (If you're not familiar with CrackCast, 'CRACK' stands for 'Core Rosen's and Clinical Knowledge'; it's a podcast project working on summarizing every chapter of Rosen's textbook in EM in order. Check it out, it's a great place to review core content.)

2) If you have more time and an EM:RAP subscription (and all EMRA members do, so activate it!) -- the September 2016 C3 Review was First Trimester Vaginal Bleeding.  Basic review, hits the highlights, lasts about an hour and a half.

3) So you can tell patients with miscarriage what to expect: Here is the American College of OB/Gyn's May 2015 Practice Bulletin on Early Pregnancy Loss.

4) A surprisingly touching depiction of pregnancy loss and its context in the larger lives of those we care for. If you haven't seen it, the opening scene of Disney's UP handles it beautifully, and without a single spoken word. 

THAT'S IT! (Brown EM residents, remember you have to complete the discussion section and quiz in Canvas in order to receive credit.)

Tell us in the comments:

• Any brief cases with teaching points on first trimester bleeding or complications of abortion?
• What advice can you give learners on how to handle situations in which you suspect patients are not being truthful about their presentation, as discussed in the section on complications of abortion and the internet market for abortifacients? 
• Any other #FOAMed resources on these topics that you think are helpful?

Click, engage, learn, comment, query, teach, share.  See you next time!