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- clinical assessment
- emergency department management
- obstetrics and gynaecology
I was worried about vaginas. I was worried what we think about vaginas, and I was even more worried that we don’t think about them.
—Eve Ensler, The Vagina Monologues1
In recent years, a series of clinical studies have questioned the utility of the pelvic exam, and have concluded that it may be routinely omitted from patient evaluations in the ED. Tintinalli’s 2016 text states: ‘Vaginal examinations in stable women presenting with first-trimester bleeding may add little to the clinical diagnosis; some providers are moving away from routine use of vaginal examinations in initial patient assessment as long as a transvaginal US is obtained.’2 A recent article in Emergency Medicine News was boldly entitled ‘Why Are You Still Performing Pelvic Exams?’ as if it were already an obsolete intervention.3 Yet a closer examination of the literature suggests these conclusions are far too premature.
Pelvic exam in first trimester pregnancy
Several studies have evaluated the practice of obtaining a pelvic ultrasound in pregnant patients prior to, or possibly in lieu of, a pelvic exam.
In 2017, Annals of Emergency Medicine published a study by Linden et al, suggesting that pelvic exams for ED patients with vaginal bleeding or lower abdominal pain, and ultrasound-confirmed first-trimester intrauterine pregnancy (IUP), may be unnecessary.4 This prospective, randomised equivalence trial measured the composite morbidity (unscheduled return, subsequent admission, emergency procedure, transfusion, infection and alternate source of symptoms) in the intervention (no pelvic exam) and control (pelvic exam performed) groups. The observed difference (−2.4% in the intervention arm) was not statistically significant, with a vast CI (−11.8% to 7.1%). The study was far underpowered: designed to involve 720 patients, it only enrolled 202 patients. Selection bias may have occurred: enrolment took place only on weekdays, for 15 hours/day; and language barriers were among their exclusion criteria, which may …
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