Clinical Policy: Critical Issues in the Initial
Evaluation and Management of Patients Presenting
to the Emergency Department in Early Pregnancy
September 9, 2002

I. Is transvaginal ultrasound useful in detecting intrauterine
pregnancy when the serum hCG level is less than 1,000 mIU/mL?

Level C recommendations. Consider transvaginal ultrasound
because it may detect intrauterine pregnancy
when the serum hCG level is below 1,000 mIU/mL.

II. Is transvaginal ultrasound useful in detecting ectopic
pregnancy when the serum hCG level is less than 1,000 mIU/mL?

Level C recommendations. Consider transvaginal ultrasound
because it may detect ectopic pregnancy when
the serum hCG level is below 1,000 mIU/mL.

III. What is the role of serial quantitative hCG determinations
in either diagnosing or excluding ectopic pregnancy?

Level B recommendations. Obtain a repeat serum hCG
determination at least 2 days after the initial presentation
because it is useful in characterizing the risk of
ectopic pregnancy and the probability of a viable intrauterine
pregnancy.

IV. Above what serum hCG level is the absence of intrauterine
pregnancy by transvaginal ultrasound presumptive evidence
of ectopic pregnancy?

Level B recommendations. Arrange follow-up for patients
with a nondiagnostic transvaginal ultrasound and a
serum hCG level above 2,000 mIU/mL because they
have an increased likelihood of ectopic pregnancy.

V. What is the frequency of treatment failure in methotrexate
therapy for ectopic pregnancy and its implication for ED management?

Level C recommendations. Because the symptoms associated
with gastrointestinal side effects of methotrexate
therapy may mimic an acute ectopic rupture, rule out
ectopic rupture resulting from treatment failure before
attributing gastrointestinal symptoms to methotrexate
toxicity. Treatment failure with single dose methotrexate
for ectopic pregnancy can occur in up to 36% of
patients.

VI. Is the administration of anti-D immunoglobulin indicated
among Rh-negative women during the first trimester of pregnancy
with threatened abortion, complete abortion, ectopic
pregnancy, or minor abdominal trauma?

Level B recommendations. Administer 50 mcg of anti-D
immunoglobulin to Rh-negative women in all cases of
documented first trimester loss of established pregnancy.

Level C recommendations. Consider administration of
anti-D immunoglobulin in cases of minor trauma in
Rh-negative patients.