Good points Jim, I suppose we do not see many of the low risk patients come back in extremis, so the system seems to be working. Increasingly early (<8 weeks) ectopics are being managed with oral methotrexate as an out patient. I certainly think next day follow up should be the norm...we can wait 4 days for a scan and appointment sometimes.

-----Original Message-----
From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Jim Connolly
Sent: 06 October 2010 10:05
To: [log in to unmask]
Subject: Re: First trimester bleeding

In the tradition of what we tell our juniors-  " there is no such thing as a stupid question" and at the risk of looking stupid, I have something to challenge the discussion with

am I the only one over the years who has questioned the nationally accepted strategy for first trimester bleeding management, namely

we are not sure it is an ectopic, but there is a chance it is...
you need to come back for diagnosis next working day....
if in the mean time you have significant bleeding come back

So would be grateful if anyone is aware of the figures we rely on with respect to natural history that say this current strategy is the best one  -

Seems to me ED has certain subgroups of patients

We know what it is  - unsafe to go home..
We know what it is  - safe to go home
We don't know what it is but its likely low risk so go home We don't know what it is but don't know the risk or the risks could be high so we admit


In other groups in which we reach this point of  "not sure but there 
are possible diagnoses that carry  risk"most of us may be tempted to 
admit.

So, hte challenge, should we

a) be developing better risk assessments in ED - combination of BHCG 
levels, even developing TV scanning by ED personnel as performed in USA 
or
b) push our colleagues,  as we have done for many other conditions,  to 
accept that patients don't just get ill 9-5 monday to friday but at 
night and weekends as well and push for departmental scans 24/7

I await my education and any ridicule

jim Connolly



-----Original Message-----
From: Jason Horan <[log in to unmask]>
To: [log in to unmask]
Sent: Tue, 5 Oct 2010 14:55
Subject: Re: First trimester bleeding

Jel, I think there are pros and cons to doing serum HCGs.  Inthe 
setting of being able to organise a same/next day Ob/Gyn assessment 
thereis probably no benefit in ordering the test.  If the ultrasound 
isinconclusive they can be either booked for a follow-up scan or serial 
HCGs, asappropriate.  So delaying their bloods by one day makes 
nodifference.  This is particularly relevant in my current Dept, where 
serumHCGs are a send-out and results take a week to come back and 
Ob/Gyn follow-upis also off-site.  They do their HCGs in-house, so our 
results would beignored anyway. Your situation is different, being in a 
rural area withoutsame-day specialist assessment.  If, as you say, 
there is a 3-4 day delayin Ob/Gyn assessment and ultrasound then having 
a repeat HCG on the day of thisassessment for comparison would be 
meaningful.  So depending on cost, labturn-around time and whether or 
not Ob/Gyn can access your initial result forcomparison, there may be 
some benefit in taking that initial serum HCG. Is your urgent 
ultrasound being done by in an EPAU setting or bya general 
sonographer?  In the last few months in Ireland we’ve hadinstances 
coming into the public domain of expectant mothers being told ontheir 
initial scan that their pregnancy was not viable, only to 
subsequentlytold otherwise.  A significant proportion of blame was put 
on equipment,training and re-scanning 
protocols.http://www.independent.ie/national-news/further-mistakes-emerge
-in-baby-scan-fiasco-2212400.htmlAs part of this, there is a review of 
all miscarriages in thepast 5 years.  So, maybe there is a role for 
serum HCGs after 
all......  Jason  ===========================================Please 
make a note of my new e-mail [log in to unmask]
 From: Accident and Emergency Academic 
List[mailto:[log in to unmask]] On Behalf Of Mandar Marathe
Sent: 05 October 2010 14:01
To: [log in to unmask]
Subject: Re: First trimester bleeding

 I have worked in departments where serumB-HCG was part of the standard 
EPAU referral pathway.

The rationale was that a scan at 6/40 might not give sufficient 
informationabout viability (the heart may not be visible). The patient 
will then needserial scans, typically a week apart.

However, serial B-HCGs are more useful - whether they are rising, 
doubling,falling, etc.

Having the 1st one done in ED therefore led to a quicker diagnosis. The 
1stscan can be interpreted in the context of paired serial B-HCGs.

Mandar.


&gt; &gt; Hi all
&gt; &gt;
&gt; &gt; A question to the wise assembled masses please :)
&gt; &gt;
&gt; &gt; G0P0
&gt; &gt;
&gt; &gt; 6+ weeks by dates, reg cycle. Slight painless brown
&gt; &gt;discharge for 2 days then slightly heavier on day seen.
&gt; &gt; No pain. Positive urine preg test.
&gt; &gt;
&gt; &gt; Perfectly well otherwise. No risk factors. No local
&gt; &gt;early preg assessment unit.
&gt; &gt;
&gt; &gt; USS booked urgently and will be in a few days.
&gt; &gt;
&gt; &gt; Should every patient like this have serum beta-hcg
&gt; &gt;measured?
&gt; &gt;
&gt; &gt; My practice has been no - I try to counsel them well,
&gt; &gt;advise of the possibilities, ensure that they know they
&gt; &gt;can come in any time (we cover the emerg too - rural
&gt; &gt;Canada) if heavier bleeding or pain.
&gt; &gt;
&gt; &gt; Someone suggested differently to me today, and I am
&gt; &gt;happy to eat humble pie if my understanding is off.
&gt; &gt;
&gt; &gt; Thoughts please?
&gt; &gt;
&gt; &gt; ....and thanks!
&gt; &gt;
&gt; &gt; --
&gt; &gt; Jel
&gt; &gt; Visit the OSCAR Canada Users Society
&gt; &gt; http://OSCARcanada.org
&gt; &gt; and learn about a world leading open-source Electronic
&gt; &gt;Medical Record