Utility of the Vaginal Exam in First Trimester Pain or Bleeding
October 2018
Utility of the Vaginal Exam in First Trimester Pain or Bleeding
Vignette
You are working a busy afternoon shift in EM-2, and have just completed your tenth
pelvic exam of the day, when you go in to see yet another patient with a pelvic
complaint. You encounter a pleasant, 25-year-old woman who is nine weeks
pregnant with a very desired pregnancy. She reports light vaginal bleeding without
passage of tissue for the last six hours. She denies any lightheadedness or dizziness
and reports only mild, intermittent, lower abdominal cramping. She has only gone
through two pads since the bleeding began.
On exam she has stable vital signs has no abdominal tenderness to palpation. Her
bedside ultrasound reveals a live IUP with a heart rate of 150. Her quantitative HCG
is 8,000 and her blood type reveals that she is A positive. You present the patient to
your attending and show her the ultrasound images. When she asks you what the
pelvic exam revealed, you admit that you haven’t done it yet and dutifully trudge
back to patient’s room like a child whose been sent to the principal’s office.
The pelvic exam reveals a closed cervical os with minimal blood in the vaginal vault
and the patient ends up being discharged with bleeding precautions. As you bid her
farewell, you wonder if you really needed to do that pelvic exam at all. You’re pretty
sure the patient didn’t enjoy it and you certainly could have done without it, and you
wonder if there’s any evidence to support of refute the utility of the pelvic exam in
the evaluation of vaginal bleeding in early pregnancy. You vow to do some digging to
support your hypothesis that it is an unnecessary, and uncomfortable, waste of
time…
PICO Question
Population: Pregnant women <20 weeks gestational age with vaginal bleeding or abdominal pain
Intervention: Omission of pelvic (speculum and/or bimanual examination in the ED
Comparison: Standard of care, including full pelvic examination
Outcome: Change in management or disposition, missed ectopic pregnancy, need for intervention (e.g. manual vacuum aspiration, dilatation and curettage)
Search Strategy
PubMed was searched using the terms “((pelvic OR vaginal) AND examination) AND
early pregnancy” limited to clinical trials (https://tinyurl.com/yda24s5t). This
resulted in 74 citations, from which four articles were chosen.
Articles
Article 1: Seymour A, Abebe H, Pavlik D, Sacchetti A. Pelvic examination is
unnecessary in pregnant patients with a normal bedside ultrasound. Am J Emerg
Med. 2010 Feb;28(2):213-6.
ANSWER KEY
Article 2: Hoey R, Allan K. Does speculum examination have a role in assessing
bleeding in early pregnancy? Emerg Med J. 2004 Jul;21(4):461-3.
ANSWER KEY
Article 3: Hoey R, Allan K. Does speculum examination have a role in assessing
bleeding in early pregnancy? Emerg Med J. 2004 Jul;21(4):461-3.
ANSWER KEY
Article 4: Johnstone C. Vaginal examination does not improve diagnostic accuracy in early pregnancy bleeding. Emerg Med Australas. 2013 Jun;25(3):219-21.
ANSWER KEY
Bottom Line
Vaginal bleeding and abdominal pain are frequent complaints seen in the ED during
early pregnancy. Typical evaluation consists of a pelvic ultrasound to confirm the
presence of an intrauterine pregnancy (IUP), often accompanied by a pelvic
examination (speculum and bimanual) to evaluate the extent of bleeding and to
confirm a closed cervical os. Give the time consumed performing the pelvic
examination and the perceived discomfort experienced by the patient, some have
called into question the utility of this portion of the work-up.
Unfortunately, there is little research into this question, and what evidence exists is
mostly of low quality. Three prospective observational studies were identified,
though two of these (Johnstone 2013, Hoey 2004) were severely limited by the lack
of a pelvic ultrasound during the ED stay to confirm an IUP. Given that our primary
diagnostic modality in these patients is ultrasound to confirm an IUP, the results of
these studies are of little value (external validity). The third observational study
(Seymour 2010) only enrolled pregnant patients of 16 weeks gestational age or less
with a confirmed IUP on ultrasound. They found that the pelvic examination did not
affect patient disposition, but did not look at the effect on management outside of
this (e.g. need for manual vacuum aspiration, dilatation and curettage) or the timing
of follow-up.
The fourth article reviewed (Linden 2017) was a prospective randomized controlled
trial conducted at two academic ED’s in Boston and Washington, D.C. Pregnant
patients < 16 weeks gestational age with vaginal bleeding or abdominal pain and
with a documented IUP were randomized to either undergo a pelvic examination
omitted or to have one performed. The incidence of the primary outcome (a 30-day composite that included need for further treatment or intervention, unscheduled
return visits to the ED or clinic, need for hospital admission, emergency procedure
transfusion, infection, or subsequent identification of other source of symptoms
occurred with similar frequency in the no pelvic exam group (19.6%) and the pelvic
exam group (22.0%) for an absolute risk reduction (ARR) of -2.4% (95% CI -11.8%
to 7.1%). Unfortunately, this study was limited by its small size as well as its chosen
outcomes. While it assessed many sources of comorbidity, it did not address the
potential need for an urgent procedure among those patients with limited follow-up,
the potential for missed infectious diagnoses, or the long-term effects of delayed
treatment and/or diagnosis. While this subject remains controversial, there is
insufficient evidence to recommend omitting the pelvic examination in this
population of patients.