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Pregnancy [Early]

Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy (April 2012)

Complete Clinical Policy on Early Pregnancy  (PDF)

Scope of Application. This guideline is intended for physicians working in hospital-based EDs.

Inclusion Criteria. This guideline is intended for stable patients (with normal blood pressure and pulse rate) in the first trimester of pregnancy with abdominal pain or vaginal bleeding, without a previously confirmed intrauterine pregnancy.

Exclusion Criteria. This guideline is not intended to address the care of patients who are clinically unstable, have had abdominal trauma, or are at higher risk for heterotopic pregnancy such as those who are undergoing fertility treatments.

Critical Questions

1. Should the emergency physician obtain a pelvic ultrasound in a clinically stable pregnant patient who presents to the ED with abdominal pain and/or vaginal bleeding and a β-hCG level below a discriminatory threshold?

Level A recommendations. None specified.

Level B recommendations. None specified.

Level C recommendations. Perform or obtain a pelvic ultrasound for symptomatic pregnant patients with a β-hCG level below any discriminatory threshold.

2. In patients who have an indeterminate transvaginal ultrasound, what is the diagnostic utility of β-hCG for predicting possible ectopic pregnancy?

Level A recommendations. None specified.

Level B recommendations. Do not use the β-hCG value to exclude the diagnosis of ectopic pregnancy in patients who have an indeterminate ultrasound.

Level C recommendations. Obtain specialty consultation or arrange close outpatient follow-up for all patients with an indeterminate pelvic ultrasound.

3. In patients receiving methotrexate for confirmed or suspected ectopic pregnancy, what are the implications for ED management?

Level A recommendations. None specified.

Level B recommendations. (1) Arrange outpatient follow-up for patients who receive methotrexate therapy in the ED for a confirmed or suspected ectopic pregnancy. 
(2) Strongly consider ruptured ectopic pregnancy in the differential diagnosis of patients who have received methotrexate and present with concerning signs or symptoms.

Level C recommendations. None specified.

Purpose of ACEP’s Clinical Policies

Clinical Findings and Strength of Recommendations