CJEM Articles: ectopic pregnancy
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Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic reviewJuly 2009 11 4Andrew McRae, Heather Murray, Marcia Edmonds
Objective: Emergency department targeted ultrasonography (EDTU) offers the possibility of rapid exclusion of ectopic pregnancy in patients with first-trimester pelvic pain or bleeding. We sought to systematically review the evidence describing the diagnostic accuracy and clinical utility of EDTU in the first trimester of pregnancy, and to generate a pooled estimate of the sensitivity and specificity of EDTU for the detection of intrauterine pregnancy (IUP).
Methods: The literature search, abstract review and study selection were performed using predefined criteria. We abstracted the sensitivity and specificity of EDTU for IUP from included studies, and evaluated and summarized the evidence assessing the effect of EDTU use on time to diagnosis, time to treatment of ectopic pregnancy, emergency department (ED) length of stay and health care costs.
Results: The specificity of EDTU for IUP in most studies exceeds 98%. The sensitivity in most studies exceeds 90%. Pooled estimates were not calculated because of statistical heterogeneity between studies. Published evidence indicates that EDTU use reduces the frequency of missed ectopic pregnancies, decreases time to surgery for ectopic pregnancy, shortens the length of stay for patients with normal pregnancies and may be more cost-effective than diagnostic strategies requiring formal ultrasonography.
Conclusion: EDTU is highly specific for the identification of IUP. Patients who have an IUP identified with EDTU may be safely discharged from the ED with outpatient follow-up. The specificity of EDTU for IUP, along with the potential improvements in patient care that EDTU affords, justifies its adoption as routine ED care in evaluating first-trimester pain or bleeding.
Ultrasonography is a useful tool for the immediate evaluation of patients with suspected ruptured ectopic pregnancy, abdominal aortic aneurysm, traumatic intra-abdominal hemorrhage or cardiac tamponade. The 1999 Canadian Association of Emergency Physicians position statement states that bedside emergency department ultrasonography should be available 24 hours per day. This case study illustrates how emergency physicians properly trained in emergency bedside ultrasonography can use this tool effectively to dramatically impact patient care.