- Email: [email protected]
Novel use of a urine pregnancy test using whole blood
American Journal of Emergency Medicine (2011) 29, 840.e3–840.e4
www.elsevier.com/locate/ajem
Case Report Novel use of a urine pregnancy test using whole blood Abstract We present the case of a 35-year-old woman with hypotension and abdominal tenderness after acute vomiting and syncope. The patient had been breast-feeding since the birth of a child 8 months earlier, was not yet menstruating, and felt that she was having a reaction to sushi. She was unable to provide a urine sample during initial evaluation, and a drop of whole blood was therefore applied to a qualitative urine human chorionic gonadotropin point-of-care test. This test result was positive for pregnancy, ultrasound revealed free fluid in the abdominal cavity, and emergency laparotomy by our gynecologists confirmed ruptured ectopic pregnancy. Often, patients are too unstable or dehydrated to provide a urine sample; and serum human chorionic gonadotropin testing may be difficult to obtain in a timely fashion. This use of the point-of-care urine qualitative test has not been previously described and may be valuable in cases where rapid diagnosis is critical. A 35-year-old woman presented to our emergency department (ED) after having several episodes of nonbloody, nonbilious vomiting followed by syncope. She reported eating sushi earlier and felt that she was “having an allergic reaction.” Her medical history was significant for regular breast-feeding since giving birth 8 months earlier. She denied fever or chills, cough or hemoptysis, vaginal bleeding, or abdominal pain. Initial triage vital signs included a blood pressure of 70/43, a heart rate of 85 beats per minute, a respiratory rate of 17, an oral temperature of 95.2°F, and an oxygen saturation of 99% on oxygen via nonrebreather mask. The patient's airway appeared patent and stable. Her breathing was grossly normal; but her circulatory status appeared challenged, based on her hypotension. Immediate bedside physical examination (not including speculum or bimanual pelvic examination) revealed the abdomen to be exquisitely tender in all quadrants, although soft and nondistended. No other positive examination findings were noted. The patient seemed surprised by her abdominal tenderness and commented that she had felt no abdominal pain besides that associated with the wretching while vomiting. 0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Bedside emergency ultrasound revealed free fluid in both the splenorenal and hepatorenal views (Fig. 1). On further questioning, the patient asserted that she could not be pregnant because she was breast-feeding and had not yet experienced a menstrual period since her previous pregnancy. Surgery consultation was emergently requested, blood transfusion and intravenous fluids were prepared, and a repeat blood pressure was noted to be 62/45. The patient's mental status waxed and waned, with verbal responsiveness and mild confusion. Large bore and central venous access was secured; and we placed a drop of the patient's blood, mixed with a drop of saline, on a bedside qualitative urine pregnancy test (OSOM hCG Combo Test; Genzyme Diagnostics, Framingham, MA). The test result was positive for pregnancy (Fig. 2). The gynecology service was then also emergently contacted; repeat blood pressure was 82/41 with both crystalloid and packed red blood cells infusions ongoing. On repeat examination, a much more rigid abdomen was appreciated. Bedside transvaginal ultrasound by the gynecology consultants confirmed free fluid and an adnexal mass consistent with a ruptured ectopic pregnancy. The patient was taken to the operating room where an exploratory laparotomy revealed 3 L of blood in the peritoneum and a ruptured fallopian tube from a right cornual ectopic pregnancy. Postoperatively, the patient recovered rapidly and was discharged home on postoperative day 3. Ectopic pregnancy is a potentially fatal disease that has been increasing in incidence since the 1970s [1], with current estimates suggesting rates of ectopic pregnancy between 6% and 16% among women presenting to EDs with first-trimester vaginal bleeding or abdominal pain [2]. The classic triad of abdominal pain, vaginal bleeding, and an adnexal mass is uncommon; abdominal pain is present greater than 95% of the time, and vaginal bleeding is present in 68% to 75% of cases [3]. The incidence of syncope as the presenting symptom of ectopic pregnancy has not been well studied, although one study suggests an incidence of 21% [4]. The rapid qualitative urine pregnancy test has been in use since the late 1970s, with improving monoclonal antibody technology and increasing sensitivity. When
840.e4
Case Report
Fig. 1 Bedside Focused Assessment with Sonography in Trauma ultrasound of splenorenal space, grossly positive for free fluid.
performed correctly, levels of 20 to 25 mIU β-subunit human chorionic gonadotropin may be detectable in the urine. In many pregnancies, this correlates with a temporal period that may begin as early as 1 day after a missed period [5]. Most qualitative pregnancy tests used in EDs are approved for use with either urine or blood serum, although not whole blood [6,7]. When used in the ED, these tests have been found to have high sensitivities and specificities following the first missed menstrual period [8,9]. Although our method of whole blood used in conjunction with the urine pregnancy test has not been studied or evaluated for accuracy, it is biologically sensible, given that β-subunit human chorionic gonadotropin is also found in significant concentrations in the serum. We suspect that the reliability of a negative result may be limited, particularly in the setting of a high suspicion of pregnancy. A positive test result, however, seems very likely to be a true pregnancy. In the case we present, this method led to a rapid diagnosis and an immediate change in the patient's disposition and may potentially have assisted in the avoidance of substantial morbidity from this patient's time-sensitive condition. Joseph P. Habboushe MD Department of Emergency Medicine New York Hospital–Queens of Cornell University 56-45 Main St, Queens, NY 11355, USA E-mail address: [email protected]
Fig. 2 Whole blood used in standard urine pregnancy point-ofcare test, positive for pregnancy.
Graham Walker MD Department of Emergency Medicine St Luke's–Roosevelt Medical Center of Columbia University New York, NY 10019, USA doi:10.1016/j.ajem.2010.06.020
References [1] Centers for Disease Control and Prevention (CDC). Ectopic pregnancy—United States, 1990-1992. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1995;44:46-8. [2] Murray H, Baakdah H, Bardell T, et al. Diagnosis and treatment of ectopic pregnancy. Can Med Assoc J 2005;173(8). [3] Braen GR and Pierce DL (eds): Culdocentesis. Clinical Procedures in Emergency Medicine, 5th ed. Philadelphia, PA, 2010, Saunders Elsevier, pp. 1144–1150. [4] Poonam UD, Banerjee B. Ectopic pregnancy—two years review from BPKIHS, Nepal. Kathmandu Univ Med J (KUMJ) 2005;3(4):365-9. [5] Lenton E, Neal L, Sulaiman R. Plasma concentrations of human chorionic gonadotropin from the time of implantation until the second week of pregnancy. Fertil Steril 1982;37(6):773-8. [6] OSOM hCG Combo Test Package Insert (Genzyme Diagnostics, Framingham, MA) and conversation with Genzyme Diagnostics. [7] Personal communication. Telephone conversation with Genzyme Diagnostics Lab, 1-800-332-1042. January 27, 2010. [8] O'Connor RE, Bibro CM, Pegg PJ, et al. The comparative sensitivity and specificity of serum and urine HCG determinations in the ED. Am J Emerg Med 1993 Jul;11(4):434-6. [9] Lazarenko GC, Dobson C, Enokson R, et al. Accuracy and speed of urine pregnancy tests done in the emergency department: a prospective study. CJEM 2001;3(4):292-5.
www.elsevier.com/locate/ajem
Case Report Novel use of a urine pregnancy test using whole blood Abstract We present the case of a 35-year-old woman with hypotension and abdominal tenderness after acute vomiting and syncope. The patient had been breast-feeding since the birth of a child 8 months earlier, was not yet menstruating, and felt that she was having a reaction to sushi. She was unable to provide a urine sample during initial evaluation, and a drop of whole blood was therefore applied to a qualitative urine human chorionic gonadotropin point-of-care test. This test result was positive for pregnancy, ultrasound revealed free fluid in the abdominal cavity, and emergency laparotomy by our gynecologists confirmed ruptured ectopic pregnancy. Often, patients are too unstable or dehydrated to provide a urine sample; and serum human chorionic gonadotropin testing may be difficult to obtain in a timely fashion. This use of the point-of-care urine qualitative test has not been previously described and may be valuable in cases where rapid diagnosis is critical. A 35-year-old woman presented to our emergency department (ED) after having several episodes of nonbloody, nonbilious vomiting followed by syncope. She reported eating sushi earlier and felt that she was “having an allergic reaction.” Her medical history was significant for regular breast-feeding since giving birth 8 months earlier. She denied fever or chills, cough or hemoptysis, vaginal bleeding, or abdominal pain. Initial triage vital signs included a blood pressure of 70/43, a heart rate of 85 beats per minute, a respiratory rate of 17, an oral temperature of 95.2°F, and an oxygen saturation of 99% on oxygen via nonrebreather mask. The patient's airway appeared patent and stable. Her breathing was grossly normal; but her circulatory status appeared challenged, based on her hypotension. Immediate bedside physical examination (not including speculum or bimanual pelvic examination) revealed the abdomen to be exquisitely tender in all quadrants, although soft and nondistended. No other positive examination findings were noted. The patient seemed surprised by her abdominal tenderness and commented that she had felt no abdominal pain besides that associated with the wretching while vomiting. 0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Bedside emergency ultrasound revealed free fluid in both the splenorenal and hepatorenal views (Fig. 1). On further questioning, the patient asserted that she could not be pregnant because she was breast-feeding and had not yet experienced a menstrual period since her previous pregnancy. Surgery consultation was emergently requested, blood transfusion and intravenous fluids were prepared, and a repeat blood pressure was noted to be 62/45. The patient's mental status waxed and waned, with verbal responsiveness and mild confusion. Large bore and central venous access was secured; and we placed a drop of the patient's blood, mixed with a drop of saline, on a bedside qualitative urine pregnancy test (OSOM hCG Combo Test; Genzyme Diagnostics, Framingham, MA). The test result was positive for pregnancy (Fig. 2). The gynecology service was then also emergently contacted; repeat blood pressure was 82/41 with both crystalloid and packed red blood cells infusions ongoing. On repeat examination, a much more rigid abdomen was appreciated. Bedside transvaginal ultrasound by the gynecology consultants confirmed free fluid and an adnexal mass consistent with a ruptured ectopic pregnancy. The patient was taken to the operating room where an exploratory laparotomy revealed 3 L of blood in the peritoneum and a ruptured fallopian tube from a right cornual ectopic pregnancy. Postoperatively, the patient recovered rapidly and was discharged home on postoperative day 3. Ectopic pregnancy is a potentially fatal disease that has been increasing in incidence since the 1970s [1], with current estimates suggesting rates of ectopic pregnancy between 6% and 16% among women presenting to EDs with first-trimester vaginal bleeding or abdominal pain [2]. The classic triad of abdominal pain, vaginal bleeding, and an adnexal mass is uncommon; abdominal pain is present greater than 95% of the time, and vaginal bleeding is present in 68% to 75% of cases [3]. The incidence of syncope as the presenting symptom of ectopic pregnancy has not been well studied, although one study suggests an incidence of 21% [4]. The rapid qualitative urine pregnancy test has been in use since the late 1970s, with improving monoclonal antibody technology and increasing sensitivity. When
840.e4
Case Report
Fig. 1 Bedside Focused Assessment with Sonography in Trauma ultrasound of splenorenal space, grossly positive for free fluid.
performed correctly, levels of 20 to 25 mIU β-subunit human chorionic gonadotropin may be detectable in the urine. In many pregnancies, this correlates with a temporal period that may begin as early as 1 day after a missed period [5]. Most qualitative pregnancy tests used in EDs are approved for use with either urine or blood serum, although not whole blood [6,7]. When used in the ED, these tests have been found to have high sensitivities and specificities following the first missed menstrual period [8,9]. Although our method of whole blood used in conjunction with the urine pregnancy test has not been studied or evaluated for accuracy, it is biologically sensible, given that β-subunit human chorionic gonadotropin is also found in significant concentrations in the serum. We suspect that the reliability of a negative result may be limited, particularly in the setting of a high suspicion of pregnancy. A positive test result, however, seems very likely to be a true pregnancy. In the case we present, this method led to a rapid diagnosis and an immediate change in the patient's disposition and may potentially have assisted in the avoidance of substantial morbidity from this patient's time-sensitive condition. Joseph P. Habboushe MD Department of Emergency Medicine New York Hospital–Queens of Cornell University 56-45 Main St, Queens, NY 11355, USA E-mail address: [email protected]
Fig. 2 Whole blood used in standard urine pregnancy point-ofcare test, positive for pregnancy.
Graham Walker MD Department of Emergency Medicine St Luke's–Roosevelt Medical Center of Columbia University New York, NY 10019, USA doi:10.1016/j.ajem.2010.06.020
References [1] Centers for Disease Control and Prevention (CDC). Ectopic pregnancy—United States, 1990-1992. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1995;44:46-8. [2] Murray H, Baakdah H, Bardell T, et al. Diagnosis and treatment of ectopic pregnancy. Can Med Assoc J 2005;173(8). [3] Braen GR and Pierce DL (eds): Culdocentesis. Clinical Procedures in Emergency Medicine, 5th ed. Philadelphia, PA, 2010, Saunders Elsevier, pp. 1144–1150. [4] Poonam UD, Banerjee B. Ectopic pregnancy—two years review from BPKIHS, Nepal. Kathmandu Univ Med J (KUMJ) 2005;3(4):365-9. [5] Lenton E, Neal L, Sulaiman R. Plasma concentrations of human chorionic gonadotropin from the time of implantation until the second week of pregnancy. Fertil Steril 1982;37(6):773-8. [6] OSOM hCG Combo Test Package Insert (Genzyme Diagnostics, Framingham, MA) and conversation with Genzyme Diagnostics. [7] Personal communication. Telephone conversation with Genzyme Diagnostics Lab, 1-800-332-1042. January 27, 2010. [8] O'Connor RE, Bibro CM, Pegg PJ, et al. The comparative sensitivity and specificity of serum and urine HCG determinations in the ED. Am J Emerg Med 1993 Jul;11(4):434-6. [9] Lazarenko GC, Dobson C, Enokson R, et al. Accuracy and speed of urine pregnancy tests done in the emergency department: a prospective study. CJEM 2001;3(4):292-5.