Deep Dive MW R2

EM Clerkship

Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD

Health & Fitness, Science, Education, Medicine, Life Sciences

4.9 • 816 Ratings

🗓️ 18 September 2022

⏱️ 16 minutes

🔗️ Recording | iTunes | RSS

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Summary

Summary of Key Points

1. You should consider ectopic pregnancy in every patient who is capable of bearing children

2. If a patient of child bearing age presents with severe abdominal pain or vaginal bleeding and is either hemodynamically unstable or very ill appearing, this is a ruptured ectopic pregnancy until proven otherwise and I would recommend performing a bedside FAST exam immediately.

3. Remember that the discriminatory zone for TVUS is approximately 1500.

4. Don’t forget your three ACEP clinical policies on this topic: just to remind you,

4a. It is a level B ACEP clinical policy to obtain a TVUS in every stable pregnant patient presenting with abdominal pain or vaginal bleeding, regardless of serum b-HCG level

4b. There is also a level B ACEP clinical policy stating that in patients with an indeterminate TVUS, you cannot use serum bHCG value to rule out ectopic pregnancy.

4c. It is a level C ACEP clinical policy to obtain specialty consultation or arrange close outpatient followup in all patients with an indeterminate TVUS result.

5. Although this isn’t an ACEP recommendation, ACOG recommends rhogam for all Rh negative women diagnosed with an ectopic pregnancy

6. Don’t forget to consider heterotopic pregnancy, especially if IVF was used to help conceive.

Further Reading:

ACEP Clinical Policy – Early Pregnancy

Transcript

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0:00.0	Hello, students. My name is Mike Estefan, and I thank you for joining me today on this month's deep dive episode on the EM Clerkship podcast.
0:11.8	Today's episode is going to be a quick deep dive into the ED management of ectopic pregnancy and a few other pregnancy-related topics.
0:20.5	Before we begin, just a quick word from our
0:23.1	sponsors over at Pearson Rabbit's. Pearson Rabbit's insurance is my personal disability insurance broker.
0:30.9	I cannot emphasize the importance of getting own occupation disability insurance while you are a resident. It is so important.
0:40.3	There are so many discounts to be had compared to obtaining this while you're in attending.
0:45.3	The underwriting process can take some time, so please don't wait until it's too late.
0:50.3	Get this done while you are young and healthy before significant coverage restrictions
0:55.4	get added to your policy. Check out Pearson Rabbits at www.personravitz.com and schedule an
1:03.7	appointment for consultation. Don't forget to mention EM Clerkship. Now, back to the episode.
1:10.7	Last week we had our first OB case. There was a lot to
1:14.3	unpack. Let's start by talking about ectopic pregnancy, and in doing so, we will cover a couple
1:20.1	other pregnancy-related pearls as well. So about 2% of all pregnancies in the U.S. are
1:25.9	ectopic pregnancies, and ectopic pregnancy
1:29.0	is the leading cause of first trimester mortality in pregnant individuals.
1:34.1	The biggest risk factor for an ectopic pregnancy is history of prior ectopic pregnancies.
1:40.6	However, previous GYN surgery, history of a sexually transmitted infection or pelvic
1:46.4	inflammatory disease, cigarette smoking, and use of assisted reproductive technologies such
1:53.2	as IVF or hormonal therapy also increase the risk of developing an ectopic pregnancy.
2:00.8	So patients who have an ectopic pregnancy can present in many different ways.
2:06.3	On one end of the spectrum, patients can present totally asymptomatic.
2:10.8	Maybe they just missed their period and is only in the ED for a pregnancy test.
	...

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