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Dehshahri A, Kumar A, Madamsetty VS, Uzieliene I, Tavakol S, Azedi F, Fekri HS, Zarrabi A, Mohammadinejad R, Thakur VK. New Horizons in Hydrogels for Methotrexate Delivery. Gels 2020; 7:2. [PMID: 33396629 PMCID: PMC7839000 DOI: 10.3390/gels7010002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/24/2022] Open
Abstract
Since its first clinical application, methotrexate (MTX) has been widely used for the treatment of human diseases. Despite great advantages, some properties such as poor absorption, short plasma half-life and unpredictable bioavailability have led researchers to seek novel delivery systems to improve its characteristics for parenteral and oral administration. Recently, great attention has been directed to hydrogels for the preparation of MTX formulations. This review describes the potential of hydrogels for the formulation of MTX to treat cancer, rheumatoid arthritis, psoriasis and central nervous system diseases. We will delineate the state-of-the-art and promising potential of hydrogels for systemic MTX delivery as well as transdermal delivery of the drug-using hydrogel-based formulations.
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Affiliation(s)
- Ali Dehshahri
- Center for Nanotechnology in Drug Delivery, Shiraz University of Medical Sciences, Shiraz 7146864685, Iran;
| | - Anuj Kumar
- School of Chemical Engineering, Yeungnam University, 280 Daehak-Ro, Gyeongsan 38541, Korea;
| | - Vijay Sagar Madamsetty
- Department of Biochemistry and Molecular Biology, Mayo Clinic College of Medicine and Science, Jacksonville, FL 32224, USA;
| | - Ilona Uzieliene
- Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Santariskiu 5, LT-08406 Vilnius, Lithuania;
| | - Shima Tavakol
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran 1449614525, Iran; (S.T.); (F.A.)
| | - Fereshteh Azedi
- Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran 1449614525, Iran; (S.T.); (F.A.)
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran 1449614535, Iran
| | - Hojjat Samareh Fekri
- Student Research Committee, Kerman University of Medical Sciences, Kerman 7619813159, Iran;
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman 7616911319, Iran
| | - Ali Zarrabi
- Sabanci University Nanotechnology Research and Application Center (SUNUM), Tuzla, Istanbul 34956, Turkey;
| | - Reza Mohammadinejad
- Research Center for Tropical and Infectious Diseases, Kerman University of Medical Sciences, Kerman 7618866749, Iran
| | - Vijay Kumar Thakur
- Biorefining and Advanced Materials Research Center, Scotland’s Rural College (SRUC), Kings Buildings, West Mains Road, Edinburgh EH9 3JG, UK
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Koźmiński P, Halik PK, Chesori R, Gniazdowska E. Overview of Dual-Acting Drug Methotrexate in Different Neurological Diseases, Autoimmune Pathologies and Cancers. Int J Mol Sci 2020; 21:ijms21103483. [PMID: 32423175 PMCID: PMC7279024 DOI: 10.3390/ijms21103483] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 02/07/2023] Open
Abstract
Methotrexate, a structural analogue of folic acid, is one of the most effective and extensively used drugs for treating many kinds of cancer or severe and resistant forms of autoimmune diseases. In this paper, we take an overview of the present state of knowledge with regards to complex mechanisms of methotrexate action and its applications as immunosuppressive drug or chemotherapeutic agent in oncological combination therapy. In addition, the issue of the potential benefits of methotrexate in the development of neurological disorders in Alzheimer’s disease or myasthenia gravis will be discussed.
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A Review of the Management of Loss of Pregnancy in the Emergency Department. J Emerg Nurs 2018; 44:146-155. [DOI: 10.1016/j.jen.2017.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 10/29/2017] [Accepted: 11/04/2017] [Indexed: 12/30/2022]
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Quinley KE, Chong D, Prager S, Wills CP, Nagdev A, Kennedy S. Manual Uterine Aspiration: Adding to the Emergency Physician Stabilization Toolkit. Ann Emerg Med 2017; 72:86-92. [PMID: 29248332 DOI: 10.1016/j.annemergmed.2017.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Indexed: 10/18/2022]
Affiliation(s)
- Kelly E Quinley
- Department of Emergency Medicine, Highland Hospital of Alameda Health System, Oakland, CA.
| | - Deborah Chong
- Department of Maternal and Child Health, Highland Hospital of Alameda Health System, Oakland, CA
| | - Sarah Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Charlotte P Wills
- Department of Emergency Medicine, Highland Hospital of Alameda Health System, Oakland, CA
| | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital of Alameda Health System, Oakland, CA
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Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2017; 69:241-250.e20. [DOI: 10.1016/j.annemergmed.2016.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times. ACTA ACUST UNITED AC 2016. [DOI: 10.1155/2016/7213625] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Emergency departments (EDs) throughout USA have improvised various processes to curb the “national epidemic” termed ED “crowding.” Standing orders (SOs), one such process, are medical orders approved by the medical director and entered by nurses when patients cannot be seen expeditiously, expediting medical decision-making and decreasing length of stay (LOS) and time to disposition. This retrospective cohort study evaluates the impact of SOs on ED LOS and disposition time at a large university ED. Results indicate that SOs significantly improve ED throughput by reducing disposition time by up to 16.9% (p=0.04), which is especially significant in busy ED settings. SOs by themselves are not sufficient for a complete diagnostic assessment. Strategies such as having a provider in the waiting area may help make key decisions earlier.
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Panebianco NL, Shofer F, Fields JM, Anderson K, Mangili A, Matsuura AC, Dean AJ. The utility of transvaginal ultrasound in the ED evaluation of complications of first trimester pregnancy. Am J Emerg Med 2015; 33:743-8. [PMID: 25817202 DOI: 10.1016/j.ajem.2015.02.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 02/05/2015] [Accepted: 02/06/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND For patients with early intrauterine pregnancy (IUP), the sonographic signs of the gestation may be below the resolution of transabdominal ultrasound (TAU); however, it may be identified by transvaginal ultrasound (TVU). We sought to determine how often TVU performed in the emergency department (ED) reveals a viable IUP after a nondiagnostic ED TAU and the impact of ED TVU on patient length of stay (LOS). METHODS This was a retrospective cohort study of women presenting to our ED with complications of early pregnancy from January 1, 2007 to February 28, 2009 in a single urban adult ED. Abstractors recorded clinical and imaging data in a database. Patient imaging modality and results were recorded and compared with respect to ultrasound (US) findings and LOS. RESULTS Of 2429 subjects identified, 795 required TVU as part of their care. Emergency department TVU was performed in 528 patients, and 267 went to radiology (RAD). Emergency department TVU identified a viable IUP in 261 patients (49.6%). Patients having initial ED US had shorter LOS than patients with initial RAD US (median 4.0 vs 6.0 hours; P < .001). Emergency department LOS was shorter for women who had ED TVU performed compared with those sent for RAD TVU regardless of the findings of the US (median 4.9 vs 6.7 hours; P < .001). There was no increased LOS for patients who needed further RAD US after an indeterminate ED TVU (7.0 vs 7.1 hours; P = .43). There was no difference in LOS for those who had a viable IUP confirmed on ED TAU vs ED (median 3.1 vs 3.2 hours, respectively; P < .32). CONCLUSION When an ED TVU was performed, a viable IUP was detected 49.6% of the time. Emergency department LOS was significantly shorter for women who received ED TVU after indeterminate ED TAU compared with those sent to RAD for TVU, with more marked time savings among those with live IUP diagnosed on ED TVU. For patients who do not receive a definitive diagnosis of IUP on ED TVU, this approach does not result in increased LOS.
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Affiliation(s)
- Nova L Panebianco
- Department of Emergency Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104.
| | - Frances Shofer
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - J Matthew Fields
- Department of Emergency Medicine, Jefferson University Hospital, Philadelphia, PA
| | - Kenton Anderson
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX
| | - Alessandro Mangili
- Department of Emergency Medicine, Legacy Good Samaritan Hospital, Portland, OR
| | | | - Anthony J Dean
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
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Evaluation of waiting times and sonographic findings in patients with first trimester vaginal bleeding at the university hospital of the west indies. Can emergency department ultrasound make a difference? W INDIAN MED J 2014; 63:247-51. [PMID: 25314282 DOI: 10.7727/wimj.2013.230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 11/26/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pregnant female patients with vaginal bleeding in the first trimester are seen commonly in the Emergency Department (ED) at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. The protocol for the management of these patients requires that they have a sonographic evaluation performed for the purpose of localizing the pregnancy where possible, to assist with determining the risk for an ectopic pregnancy. The ultrasound examinations are performed in the radiology department. OBJECTIVE This retrospective study was conducted to evaluate how long patients wait for a pelvic ultrasound. We also sought to establish how many patients had ultrasound findings that would have allowed safe discharge home. METHODS The records of 150 patients seen in the six-month period from January 1 to July 30, 2008 were examined. Data were extracted pertaining to age, time to see an emergency room doctor, time taken for ultrasound examination to be obtained from the radiology department and the ultrasound findings. RESULT Fifty-four per cent presented to the Emergency Department with a complaint of vaginal bleeding and abdominal pain, 29% with bleeding only, 16% with abdominal pain only and one with syncope. One hundred and sixteen of the patients enrolled had an ultrasound performed at UHWI. The average waiting time for an ultrasound was 3.8 ± 2.5 hours. The majority (66/116) of the patients had an intrauterine pregnancy (IUP) demonstrated on ultrasound. Twenty-nine had no IUP, free fluid or adnexal mass. These 95 patients would likely have been discharged home. Ten patients had an adnexal mass with or without free fluid, and ten had free fluid only on ultrasound. One patient was found to have a definite ectopic pregnancy. These 21 patients would have been referred for evaluation by the obstetrician on call for further management. CONCLUSION The majority of patients had sonographic findings that would have allowed safe and timely discharge from the Emergency Department had ultrasound been available at the point of care.
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Abstract
Ectopic pregnancy is a high-risk condition that occurs in 2% of reported pregnancies. This percentage is fivefold higher than that registered in the 1970s. Since 1970 there has been a two-fold increase in the ratio of ectopic pregnancies to all reported pregnancies in Hungary and in 2012 7.4 ectopic pregnancies per thousand registered pregnancies were reported. Recently, the majority (80%) of cases can be diagnosed in early stage, and the related mortality objectively decreased in the past few decades to 3.8/10,000 ectopic pregnancies. If a woman with positive pregnancy test has abdominal pain and/or vaginal bleeding the physician should perform a work-up to safely exclude the possibility of ectopic pregnancy. The basis of diagnosis is ultrasonography, especially vaginal ultrasound examination and measurement of the β-subunit of human chorionic gonadotropin. The ultrasound diagnosis is based on the visualization of an ectopic mass rather than the inability to visualize an intrauterine pregnancy. In some questionable cases the diagnostic uterine curettage or laparoscopy may be useful. The actuality of this topic is justified by practical difficulties in obtaining correct diagnosis, especially in the early gestational time.
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Affiliation(s)
- Zoran Belics
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet Szülészeti és Nőgyógyászati Osztály Budapest Köves u. 1. 1204
| | - Balázs Gérecz
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet Szülészeti és Nőgyógyászati Osztály Budapest Köves u. 1. 1204
| | - M György Csákány
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet Szülészeti és Nőgyógyászati Osztály Budapest Köves u. 1. 1204
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Murtaza UI, Ortmann MJ, Mando-Vandrick J, Lee ASD. Management of first-trimester complications in the emergency department. Am J Health Syst Pharm 2013; 70:99-111. [DOI: 10.2146/ajhp120069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Umbreen I. Murtaza
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Melinda J. Ortmann
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | | | - Amy S. D. Lee
- Department of Gynecology-Obstetrics, The Johns Hopkins Hospital, Baltimore
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
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Hahn SA, Lavonas EJ, Mace SE, Napoli AM, Fesmire FM. Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med 2012; 60:381-90.e28. [DOI: 10.1016/j.annemergmed.2012.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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12
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Warner A, Saxton A, Indig D, Fahy K, Horvat L. Women's experience of early pregnancy care in the emergency department: A qualitative study. ACTA ACUST UNITED AC 2012. [DOI: 10.1016/j.aenj.2012.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
OBJECTIVE Diagnostic imaging performed during pregnancy, particularly if it involves the use of ionizing radiation, can be a source of great anxiety for both health care providers and patients. Especially with the growing public awareness of the increasing radiation from medical imaging, including CT, it is important to have a contemporary policy for imaging evaluation in the pregnant or potentially pregnant patient. Implementation of such policies and guidelines would be useful for those developing or modifying policies for imaging pregnant or potentially pregnant patients; those developing regional or national guidelines or recommendations (i.e., professional specialty societies, including emergency medicine, radiology, and obstetrics and gynecology); and groups such as National Council on Radiation Protection, advocacy groups, and individuals writing research grants or articles. CONCLUSION To this end, a compendium of resources representing national organization guidelines would be useful. The purpose of this study is to review available resources for pertinent recommendations that can be used to develop or update policies for imaging during pregnancy, as well as to serve as a reference document for preparing reports, scientific articles, or other documents by individuals or organizations, including regulatory agencies.
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INDIG D, WARNER A, SAXTON A. Emergency department presentations for problems in early pregnancy. Aust N Z J Obstet Gynaecol 2011; 51:257-61. [DOI: 10.1111/j.1479-828x.2011.01301.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mol F, van den Boogaard E, van Mello NM, van der Veen F, Mol BW, Ankum WM, van Zonneveld P, Dijkman AB, Verhoeve HR, Mozes A, Goddijn M, Hajenius PJ. Guideline adherence in ectopic pregnancy management. Hum Reprod 2010; 26:307-15. [PMID: 21127354 DOI: 10.1093/humrep/deq329] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Evidence-based guidelines have been issued for ectopic pregnancy (EP), covering both diagnostic and therapeutic management. In general, guidelines aim to reduce practice variation and to improve quality of care. To assess the guideline adherence in the management of EP, we developed guideline-based quality indicators and measured patient care in various hospitals. METHODS A panel of experts and clinicians developed quality indicators based on recommendations from the Dutch guideline on EP management, using the systematic RAND-modified Delphi method. With these indicators, patient care was assessed in six Dutch hospitals between January 2003 and December 2005. For each quality indicator, a ratio for guideline adherence was calculated. Overall adherence was reported, as well as adherence per hospital type, i.e. academic, teaching and non-teaching hospitals. RESULTS Out of 30 guideline-based recommendations, 12 quality indicators were selected covering procedural, structural and outcome aspects of care. For 317 women surgically treated for EP, these aspects were assessed. Overall adherence to the guideline was 75%. The highest adherence (98%) was observed for performing transvaginal sonography during the diagnostic workup. The lowest adherence (21%) was observed for performing salpingotomy in case of contra-lateral tubal pathology. Wide variance in adherence (0-100%) existed between academic, teaching and non-teaching hospitals. CONCLUSIONS The overall guideline adherence was reasonable, with ample room for improvement in various aspects of care. Further research should focus on the barriers for guideline dissemination and adherence, to further improve the management of EP.
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Affiliation(s)
- F Mol
- Centre for Reproductive Medicine, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands.
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Abstract
Trauma is the leading cause of maternal death in the United States. Nurses must optimize the well-being of 2 patients in the pregnant trauma patient. Rapid assessment, initiating immediate interventions for life-threatening injuries, and transport to a trauma center are critical to optimize maternal and fetal outcome. Understanding these factors can facilitate an effective resuscitation and optimize the outcome for both mother and baby.
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Affiliation(s)
- Daria C Ruffolo
- Trauma/surgical critical care and acute care nurse practitioner at the Loyola University Medical Center Maywood, IL..
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Bacidore V, Warren N, Chaput C, Keough VA. A Collaborative Framework for Managing Pregnancy Loss in the Emergency Department. J Obstet Gynecol Neonatal Nurs 2009; 38:730-738. [DOI: 10.1111/j.1552-6909.2009.01075.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Bedside pediatric emergency evaluation through ultrasonography. Pediatr Radiol 2008; 38 Suppl 4:S679-84. [PMID: 18810417 DOI: 10.1007/s00247-008-0890-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2008] [Accepted: 04/23/2008] [Indexed: 10/21/2022]
Abstract
Bedside US has emerged as a valuable technology for the emergency department physician. It impacts clinical decision-making and the safety of procedures, and it decreases the time and increases the efficiency for completion of procedures. The portability, accuracy and noninvasive nature of US make it an ideal tool for the trained clinician. Bedside US can improve clinical decision-making for the pediatric patient by helping the clinician to identify critical pathology, direct therapeutic maneuvers and determine the futility of resuscitations. Many pediatric procedures, such as vascular access, lumbar puncture and bladder catheterization, are typically performed blindly. Bedside US enhances the success of procedures, minimizes complications and limits the number of attempts necessary to complete a procedure. Bedside US can be a valuable adjunct for complicated and time-sensitive disease processes such as ectopic pregnancy, testicular torsion and hypovolemia by providing information to guide diagnostic and therapeutic interventions that subsequently improve outcomes.
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Malvasi A, Tinelli A, Hudelist G, Tinelli R. Exocervical pregnancy in a patient with intrauterine device: a case report. J Minim Invasive Gynecol 2008; 15:758-60. [PMID: 18971144 DOI: 10.1016/j.jmig.2008.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 07/05/2008] [Accepted: 07/12/2008] [Indexed: 11/15/2022]
Abstract
Cervical pregnancy (CP) is a rare and life-threatening ectopic pregnancy characterized by implantation of the fertilized ovum into the cervix, whereas exocervical pregnancy is an extremely rare CP with implantation of the fertilized ovum on the exocervix. Possible causative factors of CP such as tubal dysfunction, impaired sperm motility, previous uterine surgery, or the use of intrauterine device were not clearly associated with the development of CP until now. Diagnosis of CP is usually established by ultrasonography and by beta-human chorionic gonadotropin serum tests, but definitive diagnosis is by histologic examination. Current treatment strategies of CP, which were described in some reports, involve: medical treatment with methotrexate, surgical removal of ectopic trophoblastic tissues, cervical cerclage and vaginal packing, ligation of descending branches of uterine arteries or hypogastric arteries, and unilateral internal iliac artery embolization. We report a case of exocervical pregnancy contemporary to intrauterine device normally inserted, diagnosed by colposcopy, beta-human chorionic gonadotropin, and histology, and treated by a local excision without using methotrexate chemotherapy.
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Affiliation(s)
- Antonio Malvasi
- Department of Obstetrics and Gynecology at Santa Maria Hospital, Bari, Italy
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Saul T. Ectopic pregnancy and tubo-ovarian abscess. J Emerg Med 2008; 39:499-500. [PMID: 18842382 DOI: 10.1016/j.jemermed.2008.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 03/20/2008] [Accepted: 04/04/2008] [Indexed: 11/15/2022]
Affiliation(s)
- Turandot Saul
- Department of Emergency Medicine, Emergency Ultrasound Division, St. Luke's/Roosevelt Hospital Center, New York, NY 10019, USA
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Abstract
The care of the pregnant trauma patient provides unique challenges and holds profound implications for both fetal and maternal outcomes. The management of these patients is influenced by unique anatomic and physiologic changes, increased concern for deleterious radiation and medication exposures, and the need for multidisciplinary care. This article reviews the critical features necessary in the assessment, diagnosis, treatment, and disposition of pregnant trauma patients with a focus on recent developments reported in the literature as pertinent to emergency management.
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Affiliation(s)
- Seric S Cusick
- Department of Emergency Medicine, UC Davis School of Medicine, PSSB, 4150 V Street, #2100, Sacramento, CA 95817, USA
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Adhikari S, Blaivas M, Lyon M. Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience. Am J Emerg Med 2007; 25:591-6. [PMID: 17606080 DOI: 10.1016/j.ajem.2006.11.020] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Revised: 10/31/2006] [Accepted: 11/12/2006] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The objective of this study was to describe diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasound (US) in an established emergency US program. METHODS This was a retrospective study on patients presenting over a 2-year period performed at a level I urban academic emergency department (ED). The ED sees 78,000 patients annually and has a residency and active US program. Patients were eligible for inclusion if they were pregnant, seen in the ED for a first-trimester complication, and underwent a bedside emergency US suggesting an ectopic pregnancy. Emergency department US logs were reviewed for findings suggestive of ectopic pregnancy. Medical records were reviewed for history, physical examination findings, laboratory results, additional diagnostic testing, management, hospital course, and a discharge diagnosis by the admitting obstetric service (OB). Patients with incomplete data were excluded from analysis. Statistical analysis consisted of descriptive statistics. RESULTS Seventy-four patients ranging in age from 16 to 39 years (mean, 25 years) were included in the study. Eight patients with incomplete data were excluded from analysis. Emergency-physician US diagnoses included definite ectopic pregnancy (6/74), probable ectopic pregnancy (28/74), and possible ectopic pregnancy (40/74). Forty-seven (64%) of these patients were eventually diagnosed with definite ectopic pregnancy by the OB. During initial consultation, the OB disagreed with the diagnosis of ectopic pregnancy in 15 (32%) of the 47 eventual patients with ectopic pregnancy, calling them miscarriages. Other eventual diagnoses included 9 (12%) patients with possible ectopic pregnancy, 11 (14%) patients with miscarriage, and 7 (9%) with intrauterine pregnancy. Emergency sonologists found tubal rings in 9 (19%) patients with eventual ectopic pregnancy, complex adnexal mass in 29 (61%) patients, and a large amount of echogenic fluid in the cul-de-sac in 10 (21%) patients. Six (13%) patients had live ectopic pregnancy. The OB ordered a radiology US in 10 cases but did not change the diagnosis or management. Beta-human chorionic gonadotropin (beta-hCG) levels ranged from 41 to 59846 mIU/mL (mean, 4602 mIU/mL), but for live ectopic pregnancy, the range was 2118 to 59,846 mIU/mL (mean, 36,341 mIU/mL). Seventeen (36%) patients had beta-hCG levels of lower than 1000 mIU/mL. Of 47 eventual ectopic pregnancies, 29 (62%) patients underwent operative intervention, 17 (36%) patients received methotrexate, and 1 patient left against medical advice. Five (11%) of these patients with definite ectopic pregnancy were initially managed by emergency physicians with follow-up ED visits and serial US examinations without OB consultation. CONCLUSION Our study demonstrates that with increased experience, emergency sonologists can accurately diagnose ectopic pregnancy. Furthermore, patients at risk for ectopic pregnancy should not be denied US examinations if their beta-hCG levels fall below an arbitrary discriminatory zone.
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Affiliation(s)
- Srikar Adhikari
- Section of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA
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Hodgson DT, Lotfipour S, Fox JC. Vaginal Bleeding Before 20 Weeks Gestation Due to Placental Abruption Leading to Disseminated Intravascular Coagulation and Fetal Loss After Appearing to Satisfy Criteria for Routine Threatened Abortion: A Case Report and Brief Review of the Literature. J Emerg Med 2007; 32:387-92. [PMID: 17499692 DOI: 10.1016/j.jemermed.2006.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 05/26/2006] [Accepted: 08/03/2006] [Indexed: 11/23/2022]
Abstract
We present a case of placental abruption with concomitant disseminated intravascular coagulation in a woman who presented with vaginal bleeding. A 32-year-old pregnant woman at 17 and 4/7 weeks gestation with a 1-month history of intermittent abdominal pain presented to our Emergency Department (ED) with 1 h of vaginal bleeding. Upon initial history, the patient reported that she was diagnosed with "blood behind the placenta" the day before and was discharged on pelvic precautions. An ED ultrasound confirmed the sub-amniotic hematoma with placental hematoma and a viable intrauterine fetus. A low fibrinogen level was suggested for disseminated intravascular coagulation and increasing hemorrhage necessitated dilation and evacuation and multiple units of blood products on an emergent basis. Only a few cases have been described in the literature demonstrating disseminated intravascular coagulation in patients at fewer than 20 weeks gestation with routine ultrasound findings of live intrauterine pregnancy and subchorionic hemorrhage.
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Affiliation(s)
- Danner T Hodgson
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Irvine, California, USA
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25
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Swing SR, Schneider S, Bizovi K, Chapman D, Graff LG, Hobgood C, Lukens T, Radford MJ, Sanders A, Smith-Coggins R, Spillane L, Hruska L, Wears RL. Using Patient Care Quality Measures to Assess Educational Outcomes. Acad Emerg Med 2007. [DOI: 10.1111/j.1553-2712.2007.tb01809.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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26
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Abstract
Physicians not used to caring for pregnant patients may feel uncomfortable dealing with the many routine problems that can occur during a pregnancy. Other than true obstetric emergencies, which are usually cared for by obstetricians and family physicians, and the common problems of pregnancy can often be cared for by any primary care physician. Given the litigious nature of our society, especially in the realm of obstetrics, it does behoove the physician caring for pregnant women to be aware of the standards of care. When in doubt, it would be prudent to consult with a physician that routinely provides care to pregnant women.
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Affiliation(s)
- Kevin S Ferentz
- Department of Family Medicine, University of Maryland School of Medicine, 29 South Paca Street, Baltimore, MD 21201, USA
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27
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Hamman AK, Wang NE, Chona S. The pregnant adolescent with vaginal bleeding: etiology, diagnosis, and management. Pediatr Emerg Care 2006; 22:761-7; quiz 768-9. [PMID: 17047481 DOI: 10.1097/01.pec.0000238740.06909.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alyssa K Hamman
- Department of Anesthesiology, Stanford University Hospital, Stanford, CA, USA
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28
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The Challenge of Ectopic Pregnancy. J Nurse Pract 2006. [DOI: 10.1016/j.nurpra.2006.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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29
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Abstract
Ultrasound represents the cornerstone of the emergent evaluation of pregnancy-related complaints. Knowledge of the potential and the limitations of this imaging modality, regardless of who performs it, is important for physicians who evaluate and manage these patients and their unborn children in the ED.
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Affiliation(s)
- Christopher Moore
- Section of Emergency Medicine, Yale University School of Medicine, PO Box 208062, Suite 260, New Haven, CT 06519, USA
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