Biomedical subjects

R Dart

Publications and source records attributed to R Dart.

12 recordsLinked to original sources

PubMed2001

Emergency management of the nonviable intrauterine pregnancy.

Fetal death early in gestation is common. Patients in the first trimester of pregnancy with abdominal pain or vaginal bleeding often present to the emergency department for care. Over the past 20 years, the technology available to confirm or exclude the diagnosis of a nonviable pregnancy has improved dramatically. These improvements have altered the diagnostic approach to these patients and have lead to a change in the terminology used to categorize the pregnancy status. In addition, the therapeutic options available to manage patients with a confirmed nonviable pregnancy have expanded greatly. In this article, we re-evaluate the classification scheme used to categorize patients with first trimester pain or bleeding given the improved technology that is available to the emergency physician today. We discuss the role of ultrasound and biochemical markers in confirming or excluding the diagnosis of a nonviable pregnancy. Finally, we review the therapeutic options, including expectant, surgical as well as medical management that are available once the diagnosis of a nonviable intrauterine pregnancy has been confirmed.

Abdominal Pain↗

PubMed1999

Normal intrauterine pregnancy is unlikely in patients who have echogenic material identified within the endometrial cavity at transvaginal ultrasonography.

UNLABELLED: In first-trimester patients with abdominal pain or vaginal bleeding, pelvic ultrasonography (US) is often performed to assess the status of the pregnancy. Identification of echogenic material within the endometrial cavity in the absence of a gestational sac has been attributed to the presence of either retained products of conception or clotted blood. However, to the authors' knowledge, no study has directly addressed whether this finding reliably excludes the diagnosis of a normal intrauterine pregnancy (IUP). OBJECTIVE: To determine whether the identification of echogenic material within the endometrial cavity at transvaginal US excludes the diagnosis of a normal IUP. METHODS: Data were collected retrospectively from August 1991 to August 1997 on consecutive urban teaching hospital ED patients with abdominal pain or vaginal bleeding who had a transvaginal US performed during the ED visit that demonstrated echogenic material within the endometrial cavity. Patients were excluded if they had a dilatation and evacuation (D + E) procedure performed prior to the exclusion of a normal IUP by other means [open cervical os, falling quantitative beta--human chorionic gonadotropin (beta-hCG) values, a progesterone value < 5.0 ng/mL or beta-hCG > 3,000 mIU/mL] or if they were lost to follow-up. Patients were followed until a final diagnosis was ultimately determined. RESULTS: A total of 83 patients with echogenic material were identified. Of these, three patients were excluded because a D + E was performed prior to an IUP being excluded by other means, and two patients were lost to follow-up. Of the 78 enrolled patients, none had a final diagnosis of normal IUP. Ectopic pregnancy was confirmed in nine patients, five of whom had no adnexal or cul de sac findings to suggest this diagnosis. CONCLUSION: In symptomatic patients who have echogenic material but no gestational sac visualized within the endometrial cavity at US, the likelihood of a normal IUP is low.

Chorionic Gonadotropin, beta Subunit, Human↗

PubMed1999

The utility of a dilatation and evacuation procedure in patients with symptoms suggestive of ectopic pregnancy and indeterminate transvaginal ultrasonography.

OBJECTIVES: To ascertain the overall frequency of obtaining chorionic villi (CV) in patients with indeterminate transvaginal ultrasound (US) examinations who have had a dilatation and evacuation (D+E) procedure performed, to determine whether the frequency of obtaining CV is dependent on whether the endometrial cavity is empty at US, and to determine the likelihood of ectopic pregnancy in patients without CV after D+E and with or without an empty endometrial cavity at US. METHODS: A retrospective review was made of consecutive ED patients presenting to an urban teaching hospital from August 1991 through August 1997 with abdominal pain or vaginal bleeding and a positive beta-human chorionic gonatropin (beta-hCG) test. Patients who had a transvaginal US that was read as indeterminate (no extrauterine findings of ectopic pregnancy, and no intrauterine fetal pole or yolk sac) and who had a D+E performed within 48 hours of the ED visit were eligible. US exams were subdivided into two groups, those with empty endometrial cavities and those with endometrial cavities that contained fluid, echogenic material, or sac-like structures. The presence or absence of CV was based on the official pathology report. Patients were excluded if pathology results were not available. RESULTS: A total of 255 patients met eligibility criteria. Of these, pathology results were not available for five patients. Of the remaining patients, 177 of 250 (70.8%: 95% CI = 64.7% to 76.3%) had CV identified in the pathology specimen. The difference in the frequencies of obtaining CV in those with empty endometrial cavities (35/78; 44.9%: 95% CI = 34% to 56%) vs. those without empty endometrial cavities (142/172; 82.6%: 95% CI = 76% to 88%) was significant (p<0.001). Ectopic pregnancy was diagnosed in 17 of 42 (40.0%) with empty uteri at US and no CV at pathology vs 5 of 26 (19.2%) in whom the uterus was not empty and no CV were obtained (p = 0.07). CONCLUSION: In symptomatic patients with indeterminate transvaginal ultrasound exams, CV will be identified after D+E in approximately 70% of cases. Although CV were found with increased frequency when the endometrial cavity was not empty, still almost half of the patients with empty uteri had villi identified. Finally, although the frequency of ectopic pregnancy was higher in the patients with empty uteri and no CV at D+E, vs. those without an empty uterus and no CV, this difference did not reach statistical significance.

Abortion, Therapeutic↗

PubMed1998

The ability of a single serum progesterone value to identify abnormal pregnancies in patients with beta-human chorionic gonadotropin values less than 1,000 mIU/mL.

OBJECTIVE: To determine the test performance of a single serum progesterone value <5.0 ng/mL for detecting ectopic pregnancy or other abnormal pregnancies in symptomatic ED patients with beta-hCG levels <1,000 mIU/mL. METHODS: A prospective study of progesterone levels was performed in consecutive ED patients presenting to an urban teaching hospital from December 1995 to March 1997 with abdominal pain and/or vaginal bleeding, a positive qualitative beta-hCG, and a quantitative beta-hCG value <1,000 mIU/mL. Patients were excluded if they were status-post a dilatation and evacuation procedure, had insufficient serum to run the progesterone assays, or were lost to follow-up. Progesterone values were measured from the original beta-hCG sample. Final patient diagnosis was abstracted from hospital records. RESULTS: 127 patients met eligibility criteria. 39 patients were excluded, leaving a total of 88 enrolled patients. 76 patients with abnormal pregnancies were identified [9 ectopic pregnancies, 62 abnormal intrauterine pregnancies (IUPs), 5 abnormal IUPs vs ectopic pregnancies], 71 of whom had progesterone values <5.0 ng/mL [sensitivity 71/76 (94%), 95% CI 86-98%]. 12 patients with normal pregnancies were identified, all of whom had progesterone values > or =5.0 ng/mL [specificity 12/12 (100%), 95% CI 78-100%]. CONCLUSION: A single progesterone value <5.0 ng/mL has high sensitivity and specificity in detecting abnormal pregnancy in symptomatic ED patients with beta-hCG values <1,000 mIU/mL.

Biomarkers↗

PubMed1998

Subclassification of indeterminate pelvic ultrasonograms: stratifying the risk of ectopic pregnancy.

OBJECTIVE: To determine whether the subclassification of indeterminate ultrasound readings can identify patients who are at high, intermediate, or low risk for ectopic pregnancy. METHODS: A retrospective review was made of consecutive ED patients presenting to an urban teaching hospital from August 1991 to December 1994 with abdominal pain and/or vaginal bleeding and a positive beta-hCG. Patients who had transvaginal ultrasonograms obtained during the ED visit that were read as indeterminate (no extrauterine findings of ectopic pregnancy and no intrauterine fetal pole or yolk sac) were eligible. Ultrasonograms were subclassified into 5 groups (empty uterus, nonspecific intrauterine fluid, echogenic debris within endometrial cavity, abnormal sac, normal sac) based on predetermined criteria. Patients were excluded if the final diagnosis could not be definitively determined. RESULTS: 248 patients were identified. 20 patients were excluded because a final diagnosis could not be determined. Patients with an empty uterus [25/94 = 27% (95% CI 18-36%)] had the highest frequency of ectopic pregnancy. Patients with nonspecific intrauterine fluid collections [4/30 = 13% (95% CI 4-31%)] had the next highest frequency of ectopic pregnancy. Patients with intrauterine echogenic debris [2/39 = 5% (95% CI 1-11%)], abnormal sacs [1/36 = 3% (95% CI 1-9%)], or normal-appearing sacs [0/29 = 0% (95% CI 0-8%)] had low frequencies of ectopic pregnancy. CONCLUSION: Subclassification of indeterminate ultrasound readings identifies patients at high, intermediate, or low risk for ectopic pregnancy and should improve the diagnostic accuracy of ultrasonography in patients at risk for ectopic pregnancy.

Emergency Medical Services↗

PubMed1997

Normal intrauterine pregnancy is unlikely in emergency department patients with either menstrual days > 38 days or beta-hCG > 3,000 mIU/mL, but without a gestational sac on ultrasonography.

OBJECTIVE: To determine whether the absence of a gestational sac on transvaginal ultrasonography in patients with a quantitative beta-human chorionic gonadotropin (beta-hCG) > 3,000 mIU/mL and/or menstrual days > 38 excludes the diagnosis of a normal intrauterine pregnancy (IUP). METHODS: A retrospective analysis was performed of ED patients evaluated from August 1991 to December 1994 at an urban teaching hospital. Patients presented with abdominal pain and/or vaginal bleeding and had a positive serum beta-hCG test. Patients who had transvaginal ultrasonographies performed during the ED visit that were read as indeterminate were reviewed. Menstrual days were determined by subtracting the date of the last normal menstrual period (LMP) from the ED visit date. ED beta-hCGs were quantified. Patients were excluded if the LMP or quantitative beta-hCG result was not available or if the final diagnosis could not be definitively determined. RESULTS: 248 patients met eligibility criteria; of these, 54 were excluded. Therefore, 194 patients were enrolled. Menstrual days ranged from 5 to 151, with a median of 54 days. Of 143 patients with menstrual days > 38 and no gestational sac by ultrasonography, only 4 (2.8%) had a final diagnosis of normal IUP. The menstrual days for the 4 normal IUPs were 39, 41, 42, and 59 days. beta-hCGs ranged from 19 to 151,926 mIU/mL, with a median of 2,410 mIU/mL. None of the 74 patients with a beta-hCG > 3,000 mIU/mL and no gestational sac by ultrasonography had a final diagnosis of normal IUP. CONCLUSION: In patients with either a beta-hCG > 3,000 mIU/mL or menstrual days > 38 and no gestational sac by transvaginal ultrasonography, the likelihood of a normal IUP is low.

Adult↗

PubMed1991