Review article: The use of pelvic examination within the emergency department in the assessment of early pregnancy bleeding

Abstract

Early pregnancy bleeding is a common presentation in the emergency setting. Traditionally, its assessment relied on clinical findings, including pelvic examination. However in recent years, ultrasonography and quantitative beta human chorionic gonadotropin assays have gained prominence and are now first-line in diagnosing early pregnancy bleeding. Accordingly, the role of pelvic examination in the acute setting has been increasingly questioned. This article reviews the evidence for the role of pelvic examination in the assessment of early pregnancy bleeding in the ED. A Medline search was conducted and 43 articles were included in this review. Applicable research is largely observational and of a low level of evidence. However, available data indicate that the role of pelvic examination in the assessment of early pregnancy bleeding is limited, providing that there is prompt access to transvaginal ultrasound examination. Pelvic examination does not provide further diagnostic information over ultrasonography used in conjunction with beta human chorionic gonadotropin assays. The routine use of pelvic examination is not supported by the literature. However, when ultrasonography and beta human chorionic gonadotropin testing are unavailable or the results inconclusive, pelvic examination should be considered. Assessment in these instances must focus on identifying possible life-threatening conditions, such as ectopic pregnancy, as well as determining the safety of discharge pending definitive assessment. Speculum examination is indicated in those presenting with severe bleeding or hypotension as removal of obstructing endocervical products can be a crucial resuscitative measure.

Vaginal examination does not improve diagnostic accuracy in early pregnancy bleeding

“…In this study, diagnostic accuracy was not significantly different to 50%, regardless of whether or not vaginal examination was performed (χ 2 = 1.328 with P = 0.25, and χ 2 = 1.351 with P = 0.30 for PV and non‐PV groups, respectively). This is consistent with Isoardi's review of the literature, whereby physical findings are unreliable for distinguishing a viable pregnancy from an ectopic or non‐viable pregnancy, as they are subjective with poor inter‐observer agreement. Causes of bleeding unrelated to the pregnancy are rare, and a short delay in the diagnosis of non‐pregnancy‐related bleeding (until follow up) is unlikely to be clinically significant.…”

“…The examination is however unpleasant and invasive for the patient, time consuming in the ED and its necessity has been called into question when ultrasound is readily available . A review by Isoardi concluded that routine pelvic (vaginal) examination adds little diagnostic information when ultrasound is available, but acknowledged the lack of any controlled studies . This is a prospective randomised controlled trial testing the hypothesis that vaginal examination does not improve diagnostic accuracy in the assessment of a stable patient with first trimester bleeding in the ED.…”

Plight of the pelvic exam

“…The impact of pelvic exams on outcomes was also addressed in a review published in 2009 which included 43 articles studying one specific scenario: non-hypotensive patients with mild to moderate vaginal bleeding in early pregnancy presenting to EDs where transvaginal ultrasound and beta-hCG testing were readily available 7. The authors concluded that ‘the routine use of pelvic examination is not supported by the literature’ despite cautioning that most available research was observational with low level of evidence.…”

Should reading a journal article really change my practice?

“…on the ED implications of the use of the TASER, 9 Holley and Boots on acute severe and near‐fatal asthma, 10 Senz and Nunnink on inotrope and vasopressor use, 11 O'Connor and Walsham on thoracolumbar spine imaging in trauma, 12 Shah et al . on convulsive and non‐convulsive status epilepticus, 13 Isoardi on the limited role of pelvic examination in early pregnancy bleeding, 14 Chong et al . on the challenge of increasing intern numbers, 15 Gallop on the use and efficacy of phenytoin, 16 Casey and de Alwis on stab wounds to the neck, 17 and Jones and Schimanski on the four‐hour rule 18 .…”

“…Lastly, aligned to Emergency Medicine Australasia's Mission Statement to 'To fairly publish valid emergency medicine related scientific information to educate, enlighten, inform and enthuse' many recent articles can be recommended along those grounds, irrespective of the perceived shortcomings of reading a journal article as regards its benefit in actually changing practice. Among review articles alone, many fulfil most, if not all, of the precepts in our Mission Statement, such as Robb et al on the ED implications of the use of the TASER, 9 Holley and Boots on acute severe and near-fatal asthma, 10 Senz and Nunnink on inotrope and vasopressor use, 11 O'Connor and Walsham on thoracolumbar spine imaging in trauma, 12 Shah et al on convulsive and non-convulsive status epilepticus, 13 Isoardi on the limited role of pelvic examination in early pregnancy bleeding, 14 Chong et al on the challenge of increasing intern numbers, 15 Gallop on the use and efficacy of phenytoin, 16 Casey and de Alwis on stab wounds to the neck, 17 and Jones and Schimanski on the four-hour rule. 18 Surely every reader must find something to pique his or her interest from such an eclectic list?…”