Annals of Emergency Medicine
Volume 41, Issue 1 , Pages 123-133 , January 2003

Clinical policy: Critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy

  • ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Early Pregnancy

References 

  1. American College of Emergency Physicians . Clinical policy for the initial approach to patients presenting with a chief complaint of vaginal bleeding. Ann Emerg Med. March. 1997;29:435–458 [III]
  2. Centers for Disease Control and Prevention . Current trends in ectopic pregnancy—United States, 1990-1992. MMWR Morb Mortal Wkly Rep. 1995;44:46–48 [II]
  3. Saraiya M, Berg CJ, Shulman H, et al.  Estimates of the annual number of clinically recognized pregnancies in the United States, 1981-1991. Am J Epidemiol. 1999;149:1025–1029 [III]
  4. Strathy J, Coulam C, Marchbanks P, et al.  Incidence of ectopic pregnancy in Rochester Minnesota, 1950-1981. Obstet Gynecol. 1984;64:37–43 [II]
  5. Makinen JL. Increase of ectopic pregnancy in Finland—combination of time and cohort effects. Obstet Gynecol. 1989;73:21–24 [II]
  6. Makinen JL, Rantala M, Vanha-Kamppa O. A link between the epidemic of ectopic pregnancy and the “baby-boom” cohort. Am J Epidemiol. 1998;148:369–374 [II]
  7. Ankum W, Mol B, Van der Veen F, et al.  Risk factors for ectopic pregnancy: A meta-analysis. Fertil Steril. 1996;65:1093–1099 [II]
  8. Skjeldestad FE, Hadgu A, Eriksson N. Epidemiology of repeat ectopic pregnancy: A population-based prospective cohort study. Obstet Gynecol. 1998;91:129–135 [II]
  9. Pisarska MD, Carson SA, Buster JE. Ectopic pregnancy. Lancet. 1998;351:1115–1120 [III]
  10. Pisarska MD, Carson SA. Incidence and risk factors for ectopic pregnancy. Clin Obstet Gynecol. 1999;42:2–8 [III]
  11. Marcus S, Brinsden P. Analysis of the incidence and risk factors associated with ectopic pregnancy following in-vitro fertilization and embryo transfer. Hum Reprod. 1995;10:199–203 [II]
  12. Strandell A, Thorburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction. Fertil Steril. 1999;71:282–286 [II]
  13. Dubuisson J, Aubriot F, Mathieu L, et al.  Risk factors for ectopic pregnancy in 556 pregnancies after in vitro fertilization: Implications for preventive management. Fertil Steril. 1991;45:686–690 [II]
  14. Pyrgiotis E, Silton K, Neal G, et al.  Ectopic pregnancies after in vitro fertilization and embryo transfer. J Assisted Reprod Genet. 1994;11:79–84 [II]
  15. Rojansky N, Schenker JG. Heterotopic pregnancy and assisted reproduction—an update. J Assist Reprod Genet. 1996;13:594–601 [III]
  16. Schriger DL, Cantrill SV, Greene CS. The origins, benefits, harms and implications of emergency medicine clinical policies. Ann Emerg Med. 1993;22:597–602 [III]
  17. Bernaschek GR, Rudelstorfer R, Csaicsich P. Vaginal sonography versus serum human chorionic gonadotropin in early detection of pregnancy. Am J Obstet Gynecol. 1988;158:608–612 [II]
  18. Kadar NM, Bohrer M, Kemmann E, et al.  The discriminatory human chorionic gonadotropin zone for endovaginal sonography: A prospective, randomized study. Fertil Steril. 1994;61:1016–1020 [II]
  19. Nyberg DA, Mack LA, Laing FC, et al.  Early pregnancy complications: Endovaginal sonographic findings correlated with human chorionic gonadotropin levels. Radiology. 1988;167:619–622 [II]
  20. Shapiro BS, Escobar M, Makruch R, et al.  A model-based prediction for transvaginal ultrasonographic identification of early intrauterine pregnancy. Am J Obstet Gynecol. 1992;166:1495–1500 [II]
  21. Kaplan BC, Dart RG, Moskos M, et al.  Ectopic pregnancy: Prospective study with improved diagnostic accuracy. Ann Emerg Med. 1996;28:10–17 [I]
  22. Dart RG, Kaplan B, Cox C. Transvaginal ultrasound in patients with low β-human chorionic gonadotropin values: How often is the study diagnostic?. Ann Emerg Med. 1997;30:135–140 [II]
  23. Mol BWJ, Hajenius PJ, Engelsbel S, et al.  Serum human chorionic gonadotropin measurement in the diagnosis of ectopic pregnancy when transvaginal ultrasound is inconclusive. Fertil Steril. 1998;70:972–981 [II]
  24. Shepherd RW, Patton QI, Novy MJ, et al.  Serial beta-hCG measurements in the early detection of ectopic pregnancy. Obstet Gynecol. 1990;75:417–420 [II]
  25. Romero R, Kadar N, Copel J, et al.  The value of serial human chorionic gonadotropin testing as a diagnostic tool in ectopic pregnancy. Am J Obstet Gynecol. 1986;155:392–394 [III]
  26. Kadar NG, Caldwell BV, Romero R. A method of screening for ectopic pregnancy and its indications. Obstet Gynecol. 1981;58:162–165 [III]
  27. Goldstein SR, Snyder JR, Watson C, et al.  Very early pregnancy detection with endovaginal ultrasound. Obstet Gynecol. 1988;72:200–204 [II]
  28. Stitka CS, Anderson L, Fredericksen MC. Single dose methotrexate for the treatment of ectopic pregnancy: Northwestern Memorial Hospital three-year experience. Am J Obstet Gynecol. 1996;174:1846–1848 [II]
  29. Jimenez-Caballo A, Rodriguez-Donoso G. A 6-year clinical trial of methotrexate therapy in the treatment of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol. 1998;79:167–171 [I]
  30. Hajenius PJ, Engelsbel S, Mol BWJ, et al.  Randomized trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. Lancet. 1997;350:771–779 [I]
  31. American College of Obstetricians and Gynecologists . Medical management of tubal pregnancy. ACOG Practice Bulletin 3. Washington, DC: ACOG; 1998; [III]
  32. Stovall TG, Ling FW. Single-dose methotrexate: An expanded clinical trial. Am J Obstet Gynecol. 1993;168:1759–1765 [I]
  33. Fernandez H, Bourget P, Ville Y, et al.  Treatment of unruptured tubal pregnancy with methotrexate: Pharmokinetic analysis of local versus intramuscular administration. Fertil Steril. 1994;62:943–947 [II]
  34. Fernandez H, Capella-Allouc YVS, Pauthier S, et al.  Randomized trial of conservative laparoscopic treatment and methotrexate administration in ectopic pregnancy and subsequent fertility. Hum Reprod. 1998;13:3239–3243 [I]
  35. Yao M, Tulandi T, Falcone T. Treatment of ectopic pregnancy by systemic methotrexate, transvaginal methotrexate and operative laparoscopy. Int J Fertil. 1996;41:470–475 [II]
  36. Korhonen J, Stenman UH, Ylostalo O. Low-dose oral methotrexate with expectant management of ectopic pregnancy. Obstet Gynecol. 1996;88:775–778 [I]
  37. Lipscomb GH, Bran D, McCord ML, et al.  Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol. 1998;178:1354–1358 [I]
  38. Gross Z, Rodriguez J, Stalnaker BL. Ectopic pregnancy. Nonsurgical, outpatient evaluation and single-dose methotrexate treatment. J Reprod Med. 1995;40:371–374 [II]
  39. Pietrzak Z, Augustyniak T, Szram K, et al.  Efficacy of methotrexate in the treatment of nonruptured ectopic pregnancy. Acta Obstet Gynecol Scand. 1999;78:258–259 [II]
  40. Thoen LD, Creinin MD. Medical treatment of ectopic pregnancy with methotrexate. Fertil Steril. 1997;68:727–730 [II]
  41. Lipscomb GH, McCord ML, Stovall TG, et al.  Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med. 1999;341:1974–1978 [II]
  42. Hung TH, Shau WY, Hsieh TT, et al.  Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: A quantitative review. Hum Reprod. 1998;13:2636–2642 [II]
  43. Bergstrom H, Nilsson LA, Nilsson L, et al.  Demonstration of Rh antigens in a 38 day old fetus. Am J Obstet Gynecol. 1967;99:130–133 [III]
  44. Urbaniak SJ. The scientific basis of antenatal prophylaxis. Br J Obstet Gynaecol. 1998;105:11–18 [III]
  45. Hartwell EA. Use of Rh immune globulin. Am J Clin Path. 1998;110:281–292 [III]
  46. Cohen F, Gustafson PC, Evans NM. Mechanisms of isoimmunization; the transplacental passage of fetal erythrocytes in homospecific pregnancies. Blood. 1964;23:621; [II]
  47. Stern K, Goodman HS, Berger M. Experimental iso-immunization to hemo antigens in man. J Immunol. 1961;87:189–198 [I]
  48. Jakobovicz R, Williams L, Silberman D. Immunization of Rh negative volunteers with repeated injection of very small amounts of Rh positive blood. Vox Sang. 1972;23:376–381 [III]
  49. Contreras M. The prevention of Rh haemolytic disease of the fetus and newborn – general background. Brit J Obstet Gynaecol. 1998;105:7–10 [III]
  50. Bowman J. The prevention of Rh immunization. Transfus Med Rev. 1998;2:129–150 [III]
  51. Katz J, Marcus RG. The risk of isoimmunization in ruptured tubal pregnancy. BMJ. 1972;3:667–669 [II]
  52. Litwak O, Taswell HF, Banner EA, et al.  Fetal erythrocytes in maternal circulation after spontaneous abortion. JAMA. 1970;214:531–534 [II]
  53. Stewart FH, Burnhill MS, Bozorgi N. Reduced dose of Rh immunoglobulin following first trimester pregnancy termination. Obstet Gynecol. 1978;51:318–322 [II]
  54. Rose PG, Strohm PL, Zuspan FP. Fetomaternal hemorrhage following trauma. Am J Obstet Gynecol. 1985;153:844–847 [II]
  55. Hughes RG, Craig JIO, Murphy WG, et al.  Causes and clinical consequences of Rhesus D haemolytic disease of newborn: A study of a Scottish population, 1985-1990. Br J Obstet Gynaecol. 1994;101:297–300 [III]
  56. McSweeney E, Kirkham J, Vinall P, et al.  An audit of anti-D sensitization in Yorkshire. Br J Obstet Gynaecol. 1998;105:1091–1094 [III]
  57. Chown B, Duff AM, James J, et al.  Prevention of primary Rh immunization. First report of the western Canadian trial. Can Med Assoc J. 1969;100:1021–1024 [III]
  58. Prevention of Rh-haemolytic disease . Results of the clinical trial. A combined study from centres in England and Baltimore. BMJ. 1966;2:907–914 [II]
  59. Ghosh S, Murphy WG. Implementation of the rhesus prevention program: A prospective study. Scott Med J. 1994;39:147–149 [III]
  60. Thornton JG, Page C, Foote G, et al.  Efficacy and long term effects of antenatal prophylaxis with anti-D immunoglobulin. BMJ. 1989;298:1671–1673 [II]
  61. American College of Obstetricians and Gynecologists . Prevention of Rh D alloimmunization. ACOG Practice Bulletin 4. Washington, DC: ACOG; 1999; [III]
  62. Bowman JM. Controversies in Rh prophylaxis: Who needs Rh immune globulin and when should it be given?. Am J Obstet Gynecol. 1985;151:289–294 [III]
  63. Bowman JM, Pollock JM, Penston LE. Fetomaternal transplacental hemorrhage during pregnancy and after delivery. Vox Sang. 1986;51:117–121 [II]
  64. Von Stein GA, Munsick RA, Stiver K, et al.  Fetomaternal hemorrhage in threatened abortion. Obstet Gynecol. 1992;79:383–386 [II]
  65. Robson SC, Lee D, Urbaniak S. Anti-D immunoglobulin in RhD prophylaxis. Br J Obstet Gynaecol. 1998;105:129–134 [III]
  66. Aborjaily AN. Rh sensitization after tubal pregnancy. N Engl J Med. 1969;281:1076; [III]

☆ Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.

☆☆ This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Early Pregnancy. For a complete listing of subcommittee and committee members, please see page 131.

★ Approved by the ACEP Board of Directors, September 9, 2002.

PII: S0196-0644(02)84936-8

doi: 10.1067/mem.2003.13

Annals of Emergency Medicine
Volume 41, Issue 1 , Pages 123-133 , January 2003

Article Tools