Vaginal examination does not improve diagnostic accuracy in early pregnancy bleeding

Abstract

Objective:The study aims to determine if a vaginal examination improves diagnostic accuracy when assessing women who present to the ED with vaginal bleeding in the first trimester of pregnancy. Methods:One hundred and thirty-five women with first trimester bleeding were randomised to have a vaginal examination (n = 61) or not (n = 74). They were given a provisional diagnosis, and then a final diagnosis after ultrasound, beta-human chorionic gonadotropin and gynaecological follow up. The provisional diagnosis was considered accurate if it matched the final diagnosis. Results:The provisional and final diagnoses matched in a little over half of the cases, and there was no statistical difference between the two groups (c 2 = 0.005, P = 0.94). Conclusion:In a stable patient presenting to the ED with first trimester bleeding, clinical diagnosis is highly inaccurate and is not improved by vaginal examination. Routine vaginal examination is not necessary as part of the initial patient assessment.

Plight of the pelvic exam

“…A 2013 randomised controlled trial by Johnstone involving 135 ED patients presenting with vaginal bleeding in early pregnancy concluded that ‘when ultrasound is readily available, vaginal examination is not necessary as a routine part of the patient assessment.’5 The primary outcome was concordance of provisional and final diagnoses, where the provisional diagnosis was made following history and physical, with patients randomised to pelvic exam or no pelvic exam, and the final diagnosis was reached after sonogram, beta-human chorionic gonadotropin (hCG) and gynaecology follow-up. The concordance of prediagnosis and postdiagnosis in both study arms was equally poor (43% did not match), leading to the conclusion that ‘clinical diagnosis is highly inaccurate’ in this population.…”