Pregnant and bleeding: A model to assess factors associated with the need for emergency care in early pregnancy

Abstract

Objective: To assess the prevalence of Critical or Emergent patient classification among pregnant patients presenting to the Emergency Department (ED) and to identify characteristics that discriminate between patients requiring Emergency care from those who can be safely triaged to the ambulatory setting.

Study design: In this cross-sectional study conducted in 3 urban EDs, patients under 16 weeks gestation who presented with bleeding and/or cramping completed a 7-item questionnaire. We compared baseline clinical variables and survey responses among patients classified as Critical or Emergent per the American Board of Emergency Medicine's patient acuity definitions with those classified as Lower Acuity to identify independent risk factors for outcomes.

Results: Of 484 participants, 21 (4.3%) were classified as Critical or Emergent and required interventions. While no demographic characteristics differentiated Critical patients from Lower Acuity patients, survey questions associated with a higher likelihood of emergency intervention included history of prior ectopic pregnancy (OR 8.7, 95% CI 3.2-23.5) heavy bleeding in the past two hours (OR 11.8, 95% CI 3.8-36.1), as well as having made a prior ED visit in the current pregnancy (OR 1.9, 95% CI 0.7-5.1). Joint consideration of these risk factors in a multivariable model performed well at discriminating between Critical and Lower Acuity patients with an area under the ROC curve of 0.82 (95% CI 0.71-0.93).

Conclusion: Patients with a history of ectopic pregnancy, heavy bleeding in the past two hours, and/or prior presentation to the ED in the current pregnancy had the highest risk of needing emergency-level care. The vast majority of patients presenting to the ED with early pregnancy complaints were discharged without intervention.

Keywords: Critical care; Early pregnancy loss; Miscarriage; Spontaneous abortion.