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Early Pregnancy

Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy (2016)

Scope of Application

This guideline is intended for physicians working in hospital-based emergency departments.

Inclusion Criteria

This guideline is intended for stable patients (with normal blood pressure and pulse rate) in the first trimester of pregnancy who have 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.

Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician’s judgment and patient preferences.

Critical Questions

  • 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?

    Recommendations
    Level A Recommendations
    None specified.
    Level B Recommendations
    Perform or obtain a pelvic ultrasound for symptomatic pregnant patients with any β-hCG level.
    Level C Recommendations
    None specified.
    Level A Recommendations
    None specified.
    Level B Recommendations
    Perform or obtain a pelvic ultrasound for symptomatic pregnant patients with any β-hCG level.
    Level C Recommendations
    None specified.

  • In patients who have an indeterminate transvaginal ultrasound result, what is the diagnostic utility of β-human chorionic gonadotropin (β-hCG) for predicting possible ectopic pregnancy?

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

Download the Policy

PDF Icon CP-EarlyPregnancy-Doc.pdf April 2018

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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