Episode 3 – ACEP 2012 Management of Early Pregnancy

The original ACEP guidelines can be found here.

This table from (Annals of Emergency Medicine  Volume 58, Issue 1, July 2011, Pages 12–20) shows the IUPs eventually discovered on f/u vs. what was seen in the ED at various thresholds of bHCGs.

 What is EMCrit drinking?

Rare Vos by Omegang

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  1. SamG says

    Scott- agree with all you said in this podcast.. I think the major problem with the use of a single discriminatory zone, lies largely in the definition of IUP. These old studies with 1500-2000 endocavitary, and 6000-6500 for trans-abdominal, are all based on the definition of IUP being a gestational sac. With our current definition of at least seeing yolk sac to call it IUP (due to pseudogesational sacs), I don’t think those old numbers for discriminatory zone even apply anymore whatsoever: When we’re talking about discriminatory zone for Yolk Sac, the numbers, as expected, much higher:

    Here’s a study showing this– check out the numbers:


    I don’t understand why everyone keeps pretending that this zone is even at all applicable anymore when they were based on gestational sac, and we’re looking for yolk sac.

    I think this is the study you referred to in the audio- when you factor in Emergency Physicians performing the ultrasound, and the disparity in ultrasound equipment, etc…now the discriminatory zone is even that much more, way, ridiculously off:


    What ends up happening is OB gets consulted on a ton of stable patients, with no evidence of ectopic on ultrasound bc of a beta hCG that was at the “discriminatory zone” that tells us we should see a gestational sac by this quant– which we usually do! It’s not the worse thing in the world– just sort of unnecessary I think. I do believe getting betas is worthwhile in the cases however, even though one isolated beta doesn’t tell me much, bc they I think they are important for tending.

    I totally agree with your caution of starting Methotrexate as an ED Doc. This is a great article recently published in the NEJM- it gives insight into how much of a problem it has become that intervention is happening on suspected ectopics(ie: starting methotrexate, etc), only to find the normal IUP hadn’t declared itself yet— now leading to malformations, abortions, etc..
    This has been an increasing problem medically as well as medical-legally. The nice thing for us is our job is to rule out ectopic– OBGYN has to rule out ectopic, and almost becoming more of a problem for them– rule out IUP!



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