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Patient-centered care is one of the six aims for improvement in health care quality outlined by the National Academy of Medicine (previously known as the Institute of Medicine). We propose an algorithm for patients who are presenting with a pregnancy of unknown location that emphasizes pregnancy desiredness to improve patient-centered care. Health care professionals should assess pregnancy desiredness at a patient's initial consultation for evaluation of pregnancy of unknown location; desiredness, along with other clinical criteria, should guide management. For women with an undesired pregnancy, health care professionals should offer expedient active management. Uterine aspiration will allow for quick clinical diagnosis and resolution of the pregnancy. Alternatively, for women with a desired pregnancy or for those who are ambivalent, we recommend careful conservative management. Adopting this algorithm will recenter the patient in the complex management of pregnancy of unknown location.

Objective: To estimate the extent to which duration and quality of reproductive endocrinology rotations are associated with residents' knowledge of reproductive endocrinology and infertility., Methods: An anonymous, multiple-choice survey was provided to 4,744 examinees during the 2008 Council on Resident Education in Obstetrics and Gynecology In-Training Examination. The survey queried residents' experiences on their reproductive endocrinology and infertility rotation, satisfaction with the quality and duration of the rotation, and knowledge of reproductive endocrinology and infertility. Binomial regression was used to estimate the relationship between components of the reproductive endocrinology and infertility rotation and self-reported knowledge of reproductive endocrinology and infertility., Results: Forty percent of residents described their knowledge of reproductive endocrinology and infertility as poor. Fewer weeks dedicated to reproductive endocrinology and infertility increased the risk of poor knowledge (P<.001). Required vacation during the rotation and non-reproductive endocrinology and infertility coverage more than two times a week was associated with a 40% increase in risk of perceived poor knowledge (relative risk [RR] 1.38, 95% confidence interval [CI]): 1.20-1.60; and RR 1.40, 95% CI: 1.16-1.70, respectively), while 3 hours of didactics per week were associated with a 61% reduction in risk (RR 0.39, 95% CI: 0.31-0.50)., Conclusion: A number of residents perceive their knowledge of reproductive endocrinology and infertility to be poor. Conflicting commitments during the reproductive endocrinology rotation results in both lower satisfaction and less knowledge. There is the potential to improve resident knowledge of reproductive endocrinology and infertility, and perhaps other aspects of obstetrics and gynecology training, with focused rotations, including didactics., Level of Evidence: II.

Objective: To estimate whether a gel containing the spermicide C31G was noninferior to a commercially available product containing nonoxynol-9., Methods: Participants were healthy, sexually active women aged 18-40 years. Measured outcomes included pregnancy rates, continuation rates, adverse events, and acceptability. The primary study outcome was contraceptive efficacy. Sample size was calculated at a 2.5% significance level using a one-sided test based on assumed 6-month pregnancy probability of 15% in the nonoxynol-9 group. Sample size was sufficient to reject, with 80% power, the null hypothesis that pregnancy probability in the C31G arm would be more than 5% higher., Results: Nine hundred thirty-two women were randomized in the C31G group and 633 in the nonoxynol-9 group. For randomized patients with at least one episode of coitus (modified intent-to-treat group), 6-month pregnancy probabilities were 12.0% (95% confidence interval [CI] 9.3-14.7%) and 12.0% (95% CI 8.7-15.3%) for C31G and nonoxynol-9,respectively. Twelve-month pregnancy probabilities were 13.8% (95% CI 7.6-20%) for C31G and 19.8% (95% CI 10.9-28.7%) for nonoxynol-9. Two serious adverse events were deemed possibly related to study product and neither occurred in the C31G group. Three fourths of users in either group reported that they liked their assigned study product. Approximately 40% of patients discontinued prematurely for reasons other than pregnancy with 11% lost to follow-up., Conclusion: C31G demonstrated noninferior contraceptive efficacy compared with nonoxynol-9. C31G may provide another marketable option for women seeking spermicidal contraception., Clinical Trial Registration: ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00274261.

Objective: To understand if the contraceptive ring or patch was more acceptable, as measured primarily by continuation, to women using an oral contraceptive and interested in a nondaily, combined hormonal contraceptive., Methods: Five hundred women were randomly assigned to use the contraceptive ring (n=249) or contraceptive patch (n=251) for four consecutive menstrual cycles, starting with their next menses. Participants returned for a single follow-up visit during the fourth cycle for an evaluation, which included a questionnaire to assess acceptability and adverse effects., Results: Rates of completion of three cycles were 94.6% (95% confidence interval [CI] 91.0-97.1%) and 88.2% (95% CI 83.4-92.0%) for ring and patch users, respectively (P=.03). Of these women, 71.0% (95% CI 64.8-76.6%) and 26.5% (95% CI 21.0-32.6%), respectively, planned to continue their method after the study (P<.001). Women switching to the patch were significantly more likely than women switching to the ring to experience longer periods (38% compared with 9%), increased dysmenorrhea (29% compared with 16%), frequent nausea (8% compared with 1%), frequent mood swings (14% compared with 8%), and frequent skin rash (12% compared with 2%) and were less likely to experience frequent vaginal discharge (8% compared with 17%). Ring users preferred the ring to the oral contraceptive (P<.001), and patch users preferred the oral contraceptive to the patch (P<.001). Nugent scores increased only in patch users (P=.01), although most of these women were asymptomatic., Conclusion: Women satisfied with combined oral contraceptives and interested in a nondaily method are more likely to continue using the contraceptive ring than the contraceptive patch., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269620., Level of Evidence: I.

Objective: To identify potential predictors for treatment success in medical management with misoprostol for early pregnancy failure., Methods: We conducted a planned secondary analysis of data from a multicenter trial that compared medical and surgical management of early pregnancy failure. Medical management consisted of misoprostol 800 mug vaginally on study day 1, with a repeat dose if indicated on day 3. Women returned on days 3 and 15, and a telephone interview was conducted on day 30. Failure was defined as suction aspiration for any reason within 30 days. Demographic, historical, and outcome variables were included in univariable analyses of success. Multivariable analyses were conducted using clinical site, gestational age, and variables for which the univariable analysis resulted in a P < .1 to determine predictors of overall treatment success and first-dose success., Results: Of the 491 women who received misoprostol, 485 met the criteria for this secondary analysis. Lower abdominal pain or vaginal bleeding within the last 24 hours, Rh-negative blood type, and nulliparity were predictive of overall success. However, only vaginal bleeding within the last 24 hours and parity of 0 or 1 were predictive of first-dose success. Overall success exceeds 92% in women who have localized abdominal pain within the last 24 hours, Rh-negative blood type, or the combination of vaginal bleeding in the past 24 hours and nulliparity., Conclusion: Misoprostol treatment for early pregnancy failure is highly successful in select women, primarily those with active bleeding and nulliparity. Clinicians and patients should be aware of these differences when considering misoprostol treatment., Level of Evidence: II-2.

Objective: To analyze serial human chorionic gonadotropin (hCG) levels in women presenting to the emergency department who were ultimately confirmed to have ectopic pregnancies., Methods: Human chorionic gonadotropin levels were obtained over time until definitive diagnosis. To be included, women had to have at least 2 hCG measurements. Human chorionic gonadotropin curves were characterized and their slopes calculated., Results: Two hundred women received diagnoses of ectopic pregnancy with the help of serial hCG values and were included in the study. No curve adequately characterized the pattern of hCG values so attention was focused on the initial 2 values. The median slope of log hCG among all subjects was 0.11 (25% increase in 2 days). However, 60% of subjects had an initial rise in hCG, and 40% had an initial fall. The rise in hCG for women with ectopic pregnancies (0.28; 75% increase in 2 days) was slower than the mean increase reported for a viable intrauterine pregnancy. The decline in hCG for women with ectopic pregnancies (-0.225; 27% decline in 2 days) was slower than the mean reported for completed spontaneous abortion. However, 20.8% of women presented with a rise in hCG values similar to the minimal rise for women with a viable gestation, and 8% of women presented with a fall in hCG values similar to women with a completed spontaneous abortion., Conclusion: There is no single way to characterize the pattern of hCG for ectopic pregnancy. The number of women with ectopic pregnancy who experience an increase in hCG values is approximately equal to the number of those who experience a decrease. The hCG profile in women with ectopic pregnancy can mimic that of an intrauterine pregnancy or a completed spontaneous abortion in approximately 29% of cases., Level of Evidence: II-2.

Objective: We sought to estimate a standard curve of serum human chorionic gonadotropin (hCG) decline that characterizes spontaneous abortion., Methods: Data were extracted from a clinical database of women with symptomatic early pregnancies and nondiagnostic ultrasonography who required follow-up with serial hCG levels. The evaluation was restricted to women who had a pregnancy of unknown location, a decrease in serum levels, and who were ultimately diagnosed with miscarriage (a decrease in serum hCG to < 5 mIU/mL in the absence of surgical intervention or confirmation of products of conception after dilation and curettage). The starting point of the curve was the hCG concentration at presentation, with serial levels plotted until the time of definitive diagnosis. Semiparametric statistical techniques were used to characterize the shape of the curve. We present slopes for the decrease in log hCG levels and the projected rate of fall., Results: Of the 1,543 patients, 710 were diagnosed with miscarriage. A quadratic curve for log hCG with a steeper rate of decline for large initial hCG values best described the pattern of change. One curve could not fully estimate the decline because the rate was dependent on the initial hCG level. In other words, more rapid decline was associated with a higher starting concentration. The rate of decline ranged from 21% to 35% at 2 days and 60% to 84% at 7 days, depending on initial hCG value., Conclusion: The rate of hCG decrease in spontaneous abortions is described by a quadratic profile, with a faster decline in hCG value with higher presentation levels. A rate of decline less than 21% at 2 days or 60% at 7 days suggests retained trophoblasts or an ectopic pregnancy.

Objective: To compare six published methods of diagnosing ectopic pregnancy., Methods: Decision analysis compared six diagnostic algorithms involving combinations of clinical examination, transvaginal ultrasound, serum progesterone, serum hCG, and D&C. The population was composed of hemodynamically stable women who presented to a tertiary care university emergency department with abdominal pain or bleeding in their first trimesters. Outcome measures included number of missed ectopic pregnancies, potentially interrupted intrauterine pregnancies, surgical and diagnostic procedures, time until diagnosis, and cost., Results: Ultrasound followed by serum hCG in women with nondiagnostic scans yielded the most favorable outcomes; no ectopic pregnancy was missed, only 1% of all potential intrauterine pregnancies were interrupted, and time to diagnosis averaged 1.46 days. Quantitative hCG measurement followed by ultrasound only in women with hCG levels above the discriminatory zone was optimal if sensitivity of ultrasound to diagnose intrauterine pregnancy was less than 93%. Serum progesterone measurement was not favored because it was associated with missed ectopic pregnancies (2.6%)., Conclusion: Given the current accuracy of tests for diagnosing ectopic pregnancy, algorithms using a combination of ultrasound and hCG resulted in the best outcomes. Ultrasound as the first step was the most efficient and accurate method of diagnosing ectopic pregnancies.

Background: Several cases of spontaneous second trimester uterine rupture have been reported, but none as early as 15 weeks' gestation after classical cesarean and with placenta percreta., Case: A 23-year-old woman, gravida 5, para 3, at 15 37 weeks' gestation with a history of classical cesarean incision presented to the emergency department with abdominal pain, hypotension, and tachycardia. Ultrasound showed a normal intrauterine pregnancy. She developed worsening pain, abdominal rebound, and abdominal distention. On exploratory laparotomy, a large uterine rupture was found and hysterectomy was done., Conclusion: Spontaneous uterine rupture after classical cesarean can occur as early as 15 weeks' gestation. Uterine rupture must be considered in differential diagnoses of severe abdominal pain even in the early second trimester.

Objective: We conducted a randomized trial to determine whether pretreatment with meclizine reduces the incidence of nausea and vomiting associated with the Yuzpe regimen of emergency contraception., Methods: We randomly assigned 343 women aged 18-45 years who were not at risk for pregnancy to pretreatment with 50 mg of meclizine, placebo, or no drug 1 hour before the first of two doses of emergency contraceptive pills. We asked participants to complete three questionnaires over the following 48 hours., Results: The incidence of nausea was 47% in the group pretreated with meclizine and 64% in the other two groups (relative risk adjusted for center 0.7, 95% confidence intervals 0.6, 0.9 for comparisons of meclizine with both placebo and no drug). The severity of nausea and the incidence of vomiting were also significantly lower in the meclizine pretreatment group than in the other two groups. Drowsiness was reported by about twice as many women in the meclizine pretreatment group (31%) than in the other two groups (13% in the placebo group, 16% in the no-pretreatment group; P < .01 for both comparisons)., Conclusion: Meclizine is effective for preventing nausea and vomiting associated with the Yuzpe regimen of emergency contraceptive pills. Women using this drug should be cautioned to anticipate drowsiness.

Objective: To evaluate clinical use and accuracy of transvaginal ultrasound for diagnosing intrauterine pregnancies, spontaneous miscarriages, and ectopic pregnancies in women who present with beta-hCG concentrations above or below an established discriminatory zone., Methods: Ultrasound diagnosis at presentation was compared with final clinical diagnosis in 333 consecutive pregnant women who presented to an emergency department with vaginal bleeding or abdominal pain. The sensitivity, specificity, predictive value, and overall diagnostic accuracy of ultrasound were calculated., Results: Transvaginal ultrasound was nondiagnostic in 59 (17.7%) of 333 subjects and 43 (67.2%) of 64 subjects with beta-hCG levels below 1500 mIU/mL at presentation. Preliminary ultrasound diagnoses were reported significantly more frequently when presenting beta-hCG levels were above 1500 mIU/mL (253 [94.1%] of 269 subjects) compared with levels below 1500 mIU/mL (21 [32.8%] of 64 subjects: P < .001; relative risk (RR) 3.4 [95% confidence interval (CI) 2.23, 5.18]). The proportion of accurate preliminary ultrasound diagnoses was significantly higher in subjects who presented with beta-hCG levels above 1500 mIU/mL (227 [91.5%] of 248 subjects) compared with levels below 1500 mIU/mL (18 [28.6%] of 63 subjects: P < .001; RR 2.9 [95% CI 2.04, 4.15]). Sensitivity of transvaginal ultrasound diagnosis of intrauterine pregnancy, spontaneous miscarriage, and ectopic pregnancy in women who presented with beta-hCG levels below 1500 mIU/mL was 33.3%, 28.2%, and 25.0%, respectively., Conclusion: The sensitivity, predictive value, and accuracy of transvaginal ultrasound for diagnosing complications of early pregnancy were poor when beta-hCG levels were below the discriminatory zone at presentation. Ultrasound impressions should be correlated with beta-hCG concentrations.

Objective: To evaluate quantitative hCG measurements and transvaginal ultrasound in the diagnosis of ectopic pregnancy in patients presenting to the emergency department., Methods: A discriminatory zone for detecting the presence or absence of an intrauterine pregnancy by transvaginal ultrasound was established prospectively. Women presenting to the emergency department were evaluated prospectively using a diagnostic algorithm consisting of clinical examination, quantitative serum hCG, and transvaginal ultrasound. Finally, ectopic pregnancies diagnosed over a 22-month period were evaluated prospectively., Results: All viable intrauterine pregnancies were identified in those subjects with hCG levels of 1500 mIU/mL (First International Reference) or greater. One thousand two hundred sixty-three subjects were evaluated prospectively; 59.8% were diagnosed with intrauterine pregnancy, 26.8% with spontaneous abortion, and 7.8% with ectopic pregnancy. At presentation, 13.2% of intrauterine pregnancies were diagnosed by clinical examination, whereas 82.9% were diagnosed by transvaginal ultrasound. Only 4% of normal intrauterine pregnancies were not confirmed on initial visit. Of 205 ectopic pregnancies diagnosed, 81.5% were hemodynamically stable; of these, 49.1% were diagnosed on initial presentation. Of all ectopics, 59% never reached an hCG level of 1500 mIU/mL and 35.8% had an hCG lower than the level at presentation. This protocol diagnosed ectopic pregnancies with a sensitivity of 100% and a specificity of 99.9%., Conclusion: A protocol of quantitative hCG levels (available within hours of presentation to an emergency department) combined with transvaginal ultrasound is effective in diagnosing ectopic pregnancy.