ACEP Clinical Policies Committee and Clinical Policies Subcommittee on Early Pregnancy. American College of Emergency Physicians. Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy

New Horizons in Hydrogels for Methotrexate Delivery

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.

Overview of Dual-Acting Drug Methotrexate in Different Neurological Diseases, Autoimmune Pathologies and Cancers

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.

Implementing Triage Standing Orders in the Emergency Department Leads to Reduced Physician-to-Disposition Times

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.

The utility of transvaginal ultrasound in the ED evaluation of complications of first trimester pregnancy

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.

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?

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.

[Early diagnosis of ectopic pregnancy]

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.

Compendium of national guidelines for imaging the pregnant patient

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.

Guideline adherence in ectopic pregnancy management

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.

Trauma care and managing the injured pregnant patient

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.

Bedside pediatric emergency evaluation through ultrasonography

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.

Exocervical pregnancy in a patient with intrauterine device: a case report

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.

Trauma in pregnancy

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.

Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience

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.

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

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.

Common problems and emergencies in the obstetric patient

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.

Ultrasound in pregnancy

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.