Introduction: Pain and bleeding complicate 30% of pregnancies threatening viability. The objective of this systematic review is to evaluate the role of a single progesterone level in predicting viability. Methods: We comprehensively searched MEDLINE, Embase (OVID), CINAHL and Cochrane databases from inception to July 2019. We included English language studies that enrolled symptomatic first trimester pregnant patients, measured progesterone and reported viability (miscarriage, ectopic or viable). We excluded studies with patients who had progesterone treatment, or conception after induced ovulation/invitro fertilization. We extracted patient characteristics, study setting, mean progesterone, the cut off value and outcome (viability). The quality of the included studies was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We extracted data for 2X2 tables and report mean, standard deviation (SD), sensitivity, specificity, positive and negative predictive values (PPV, NPV). Results: Of the 689 studies screened, 51 studies with 15783 patients were included (1 randomized control trial, 36 prospective, 9 retrospective, 5 prospective case control studies) and 7553 were viable pregnancies. Of the 31 studies (n = 10998) that reported ectopic, 1661 patients were diagnosed with ectopic pregnancy. In 35 studies (n = 6003) that reported mean and SD, the levels were higher in viable (26.7 ± 11.2ng/ml) than non-viable (9.5 ± 5.9ng/ml; p < 0.001) or ectopic pregnancy 9.5 ± 6.8ng/ml (p < 0.001). The pooled diagnostic characteristics at different cut-off values were: <6.3ng/mL (9 studies; N = 6033) sensitivity 65.0% (95%CI 63.5,66.5), specificity 97.3% (95%CI 95.5, 98.5), PPV 99.4% (95%CI 99.1,99.7) and NPV 27.4 (95%CI 26.6,28.4); <10 ng/mL (12 studies with 5743 participants) sensitivity 65.0% (95% CI 63.5, 66.5), specificity of 97.3% (95%CI 95.5, 98.5), PPV 99.4% (95% CI 99.1, 99.7) and NPV 27.4% [95% CI 26.5, 29.4); 11-20 ng/mL (24 studies with 7141 participants) sensitivity 77.3% (95% CI 76.2,78.4), specificity 64.6% (95% CI 63.2, 65.9), PPV 73.2% [95% CI 72.3, 73.9) and NPV 69.5% (95% CI 70.7, 72.5). There was low risk of bias for patient selection, index test and low concern regarding applicability. The highest risk (82% of studies) was due to outcome ascertainment bias due to non-blinding of index and additional tests. Conclusion: A single progesterone value is useful in predicting viability of pregnancy among symptomatic patients.

Introduction: Women experiencing complications of early pregnancy frequently seek care in the emergency department (ED), as most have not yet established care with an obstetrical provider. The primary objective of this study was to explore the services available (ED management, ultrasound access, and follow-up care) for ED patients experiencing early pregnancy loss or threatened early pregnancy loss in Ontario hospitals. Methods: The emergency medicine chiefs of 71 Ontario hospital EDs with an annual census of more than 30,000 ED patient visits in 2017 were invited to complete a 30-item, online questionnaire using modified Dillman methodology. These hospitals constitute greater than 85% of the annual ED visits in Ontario, creating a sample reflective of the services available to most women older than 18 years old seeking care for early pregnancy complications in the province. Results: Respondents from 63 EDs across Ontario completed the survey (response rate 88.7%). Of the EDs surveyed, 34 (54.0%) reported they did not have access to early pregnancy clinic services for women who presented to the ED with early pregnancy complications that were safe to discharge home. At these hospitals, it was found that patients were followed up in 14 (41.2%) EDs for the same complications including pregnancy of unknown location and threatened abortion. Respondents also stated that radiologist-interpreted ultrasound was only available to 22 (34.9%) of hospital sites 24 hours a day, 7 days per week for women with early pregnancy complications. Of hospital site respondents, 55 (87.3%) reported point-of-care ultrasound (POCUS) use in the ED for patients with early pregnancy complications, and 27 (49.1%) reported the ED had access to transvaginal ultrasound probes for POCUS assessment by emergency physicians. Additionally, the proportion of ED physicians who were certified as Canadian Emergency Ultrasound independent practitioners ranged from 10% to 100%. Conclusion: The results of this study highlight the reliance of some hospitals on the ED to provide ongoing follow-up care to patients experiencing complications of early pregnancy. The lack of clinical resources and specialized personnel in Ontario hospital EDs makes supporting these women longitudinally unrealistic, exposing them to undue risk and complications.

Introduction: The objective of this study was to determine the proportion of women who had a ruptured ectopic pregnancy after being discharged from the ED where ectopic pregnancy had not yet been excluded. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women discharged home from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of the 550 included patients, 83 (15.1%) had a viable pregnancy, 94 (17.1%) had a spontaneous or missed abortion, 230 (41.8%) had an ectopic pregnancy, 72 (13.1%) had unknown outcomes and 71 (12.9%) had other outcomes which included therapeutic abortion, molar pregnancy or resolution of HCG with no location documented. Of the 230 ectopic pregnancies, 42 (7.6%) underwent expectant management, 131 (23.8%) were managed medically with methotrexate, 29 (5.3%) were managed with surgical intervention, and 28 (5.1%) patients had a ruptured ectopic pregnancy after their index ED visit. Of the 550 included patients, 221 (40.2%) did not have a transvaginal US during their index ED visit, 73 (33.0%) were subsequently diagnosed with an ectopic pregnancy. Conclusion: These results may be useful for ED physicians counselling women with symptomatic early pregnancies about the risk of ectopic pregnancy after they are discharged from the ED.

Introduction: Early detection of ectopic pregnancy and careful management is critical to prevent adverse clinical outcomes, including fallopian tube rupture and future decreased fertility, in patients presenting to the ED with symptoms suggestive of ectopic pregnancy. Methotrexate therapy is widely accepted as a first line treatment of ectopic pregnancy, with success rates greater than 90% if used according to published guidelines. This study aims to determine the outcomes of pregnant women who presented to the ED with suspected ectopic pregnancy whom received methotrexate as first line treatment. Methods: This was a retrospective chart review of pregnant (<12 week gestational age) women from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule out ectopic pregnancy, or pregnancy of unknown location (PUL) over a 7 year period. Results: Of 612 included patients, 30 (4.9%) were diagnosed with a ruptured ectopic pregnancy at the index ED visit. Of the remaining 582 patients, 256 (44.0%) were diagnosed with an ectopic pregnancy at the index ED visit, the Early Pregnancy Clinic, or a subsequent ED visit. Of these patients diagnosed with ectopic pregnancy, their initial treatments at time of discharge from the index ED visit were as follows: 102 (39.8%%) received methotrexate, 132 (51.6%) underwent expectant management, and 22 (8.6%) underwent surgical management. Of the 132 patients discharged with an expectant management plan, only 42 (31.8%) had a final outcome of expectant management; the others went on to be treated surgically or with methotrexate. Of the 165 patients treated with methotrexate at index visit or in follow-up, 30 (18.2%) went on to require surgical management with 17 (10.3%) documented as having ruptured on surgical evaluation. Clinical characteristics of patients treated with methotrexate include the following: mean age 32.8 years (SD 5.7), gestational age of 6.2 weeks (SD 1.2) and serum beta human chorionic gonadotropin level of 2702 mIU/mL (SD 8800). Conclusion: The proportion of patients receiving methotrexate as first-line treatment that resulted in rupture or required further surgical management is higher than reported literature at this institution. Further investigation is needed to determine if there was a relationship between methotrexate failure and non-adherence to recommended guidelines. Given the risk of a possible rupture, patient education of these risks is critical on discharge from the ED.

Introduction: When a female presents with abdominal pain and vaginal bleeding, a positive b-hcg level helps in the diagnosis of an ectopic pregnancy. A timely diagnosis as well as management is required for these cases. In many emergency departments, there can be delays in laboratory processing of quantitative b-hcg levels as well as qualitative urine pregnancy tests. In others, especially in rural hospitals in Canada, the laboratory closes at night and these tests cannot be processed until the morning. This may also help decrease length of stay for some patients in the emergency department. There are currently new point-of-care b-hcg tests on the market using capillary blood, but these are expensive and not readily available. The purpose of the study is to validate the most inexpensive point of care urine pregnancy tests readily available on the market for use with capillary blood samples. These point-of-care tests have only been studied with urine and whole blood. If validated with capillary blood, it would allow for a very practical, rapid, and inexpensive test which could help doctors and nurses to triage patients in a timely and more efficient fashion. Methods: In our emergency department, 385 patients between the ages of 18-50 with possible pregnancy, abdominal pain or vaginal bleeding will be included in the study. A capillary blood sample will be taken and applied to a cassette point-of-care pregnancy test with four drops of saline. Two independent investigators will assess the test. The results will be compared to a quantitative serum hCG assay and urine. If these tests are not done as part of the patients medical care, the patient will be contacted one month after to enquire if the patient is pregnant or not. The sensitivity, specificity, positive and negative predictive values will be calculated. Results: Data colleciton will begin in January 2018. Conclusion: No conclusions can yet be drawn.

Introduction: It is estimated that 6% to 13% of patients presenting to the emergency department (ED) with vaginal bleeding or abdominal pain will have ectopic pregnancy. Risk factors such as previous pelvic infections, assisted reproductive technologies and previous tubal surgery as well as prevalence of ectopic pregnancy vary geographically. To date, the surveillance of ectopic pregnancy in Canada has been limited to hospitalized patient data, excluding patients receiving methotrexate therapy, day surgery or expectant management, possibly underestimating the true prevalence. The objective of this study was to determine Ontario’s ectopic pregnancy rate and geographic variability using both inpatient and outpatient data sources. Methods: Data from the Canadian Institute for Health Information Discharge Abstract Database, Same Day Surgery Database, National Ambulatory Care Reporting System, and Ontario Health Insurance Plan (OHIP) Claims Database was retrieved for all females with valid OHIP coverage aged 15 to 45 years from July 2002 to August 2014. Using ICD-10 and OHIP codes for ectopic pregnancy, abortions and deliveries, the rates and distribution of ectopic pregnancy (per 1000 reported pregnancies) by age group and public health unit (PHU) were documented. These data were also compared to the rate of ectopic pregnancy documented using only hospitalized patient data. Results: Using inpatient and outpatient data sources, the rate of ectopic pregnancy in Ontario increased from 20.5 to 27.5 per 1000 reported pregnancies from 2002 to 2014, respectively. The rate of ectopic pregnancy using only hospitalized patient data decreased from 12.6 to 9.5 per 1000 reported pregnancies from 2002 to 2014, respectively. The median (IQR) rate of ectopic pregnancy over the 12-year study period varied across public health units in Ontario, ranging from 14.9 (12.5, 17.5) to 37.7 (29.1, 55.8) per 1000 reported pregnancies. Conclusion: The rate of ectopic pregnancy is increasing in Ontario and has been previously underreported using only hospitalized patient data. Further research is needed to identify the factors resulting in this increase as well as the outcomes of ectopic pregnancies in Ontario.

In this case-control study, we investigated the seroprevalence and molecular evidence of Chlamydia trachomatis and Waddlia chondrophila in ectopic pregnancies (EP) and uneventful control pregnancies in 343 women from Vietnam. Whereas presence of C. trachomatis IgG was strongly associated with EP [adjusted odds ratio (aOR) 5·41, 95% confidence interval (CI) 2·58–11·32], its DNA remained undetected in all tubal lesions. We confirmed an independent association between antibodies against Waddlia and previous miscarriage (aOR 1·87, 95% CI 1·02–3·42). Further investigations are needed to understand the clinical significance of Waddlia's high seroprevalence (25·9% in control pregnancies) in this urban population.