Abdominal pain is a common presentation to the Emergency Department and the causes of it is different between the genders.

One of my previous bosses warned me that not to consider that every woman of child bearing age could be pregnant would lead to missing both pregnancy and one of the serious complications of pregnancy an ectopic pregnancy. It has an incidence of around 2% in all pregnancies.

Asking such questions particularly to young person often accompanied by a parent may require tact both in asking the question, maybe getting a nurse to enquire without the parent present and if there is a risk then undertaking the appropriate investigations and referral.

The NICE guidelines on Ectopic Pregnancy and Miscarriage supports the development of Early Pregnancy Assessment Units (EPAU) to manage such patients where skills can be developed to manage the whole range of pregnancy and its complications.

This creates potential problems for the Emergency Department in that these units often operate on an appointment basis and therefore patients presenting to the Emergency Department are often discharged with an appointment to attend the EPAU.

Such arrangements mean that the Emergency Department has to be cogniscent that the patient must not only be stable when discharged from the Emergency Department but remain so until there is a review in the EPAU. 

Managing the shocked patient

Sometime a patient presents to the Emergency Department in shock with a low blood pressure and tachycardia and such a patient requires urgent resuscitation and probable surgical intervention.

Such treatment needs to be carried out in the hospital where the patient arrives at even if a gynaecologist is not present and such a surgeon should come to the patient and not transfer the patient to the hospital where the specialist unit is.  

Making the diagnosis of ectopic pregnancy

One of the problems with making the diagnosis of ectopic pregnancy particularly when a patient denies that they could be pregnant is when the doctor does not consider that diagnosis.

The NICE guidelines give a list of symptoms and signs often seen in patients that have been associated with ectopic pregnancy. These include abdominal or pelvic pain, dizziness, shoulder tip pain and urinary tract infection for example, symptoms not all of which would easily suggest pregnancy as a cause for the presentation to the Emergency Department.

Not to consider doing a pregnancy test in such patients may mean the doctor does not make the correct diagnosis and may lead a stable patient rapidly becoming unstable and require emergency surgery that knowing they were pregnant would have avoided.