Telemedicine medical abortion service in Georgia: an evaluation of a strategy with reduced number of in-Clinic visits.

PURPOSE: To evaluate feasibility and acceptability of a medical abortion service that offers: a telemedicine visit (in place of an in-person visit) during a mandatory waiting period, and at-home follow-up with the use of multi-level pregnancy tests (MLPT). METHODS: Participants were screened for eligibility in clinic, and during the waiting period, received a telephone call to confirm desire to proceed with the service. Participants were mailed a study package containing mifepristone, misoprostol, two multi-level pregnancy tests, and instructions for their use. Follow-up consultation took place by phone to evaluate abortion completeness. The analysis was descriptive. RESULTS: One-hundred twenty-two participants were enrolled in the study, and 120 chose to proceed with the abortion after the waiting period and were sent a study package. One participant was lost to follow up. The majority of participants did not experience problems receiving the study package (94.1%, n = 112), took mifepristone (100%, n = 119), misoprostol (99.2%, n = 118), and MLPTs (99.1%, n = 116) as instructed, and forwent additional clinic visits (91.6%, n = 109). All participants were satisfied with the service. Most participants had a complete abortion without a procedure (95.8%, n = 114). CONCLUSIONS: The adapted telemedicine medical abortion service was feasible and satisfactory to participants and has the potential to make medical abortion more patient-centered where waiting periods are mandated.

Gender disparities in isotretinoin prescribing patterns for pediatric patients before and during the COVID-19 pandemic

Background: Isotretinoin is an effective therapy for severe, recalcitrant, and nodular acne. Due to its teratogenic effects, isotretinoin requires strict adherence to the iPLEDGE risk management program and mandatory lab work. During the COVID-19 pandemic, the U.S. Food and Drug Administration lifted laboratory requirements, accepted remote pregnancy tests, and permitted telemedicine visits. This study examines the impact of reduced in-person evaluation and testing on physician likelihood of prescribing isotretinoin. Method(s): A retrospective review on demographics, acne history, and treatment was conducted on 142 patients <=18 years old who met inclusion criteria. Dates were divided into 1/1/2019-3/16/2020 (pre-MGH COVID shutdown and required in-person lab testing) and 5/25/2020-8/8/2021 (post-MGH COVID shutdown and paused lab testing requirements). Multivariate linear regression with backward elimination and Wilcoxon rank-sum tests were conducted. Result(s): The median number of dermatology visits to isotretinoin initiation was 3 visits pre-COVID and remained 3 visits during COVID (p=0.85). Backward elimination demonstrated gender (p<.0001) and the interaction between gender and acne severity (p=0.042) as significantly associated with increased number of visits before isotretinoin initiation, with female patients requiring more visits than males before starting isotretinoin at every acne severity level. Race, pre- or during COVID, and insurance type were removed as nonsignificant. Discussion(s): Removal of lab mandates during the COVID-19 pandemic did not result in fewer visits to initiation of isotretinoin. Female patients continue to face delays in receiving isotretinoin even with the acceptance of remote pregnancy tests and increased utilization of virtual visits, highlighting the persistent gender disparities in prescribing practices for pediatric patients with acne.Copyright © 2023

Complete response to eculizumab in atypical hemolytic uremic syndrome with homozygous C3 mutation

Case Report: Atypical Hemolytic Uremic Syndrome (atypical HUS) is a rare and severe form of thrombotic microangiopathy (TMA) characterized by thrombocytopenia, intravascular hemolysis, and acute kidney injury with an incidence of 1 per million.1 Dysregulation and overactivation of the complement alternative pathway due to genetic mutations have been detected in 40-60% of patients with sporadic or familial atypical HUS.2,4 Triggers include viral illness, pregnancy, malignancy, sepsis, or sporadically with no known inciting event.1 Atypical HUS is a severe disease with a 2-10% risk of mortality, 33% risk of end-stage renal failure, and 50% chance of relapse.5 A 24-year-old female with prior history of atypical HUS at the age of 16 (with response to plasmapheresis) presented to the ER with a 5-day history of fever, chills, sore throat, nausea, vomiting, and dark urine. She tested positive for COVID-19. The exam revealed scleral icterus and scattered petechiae. Labs demonstrated nadir hemoglobin (Hgb) of 9.2 g/dL, platelet count of 52 000k/uL, haptoglobin < 30 mg/dL, peak LDH 1128U/L and creatinine 4.62 mg/dL. Urinalysis is consistent with hemoglobinuria. Schistocytes were noted on the peripheral smear. Rapid streptococcal antigen test and C3, C4, and IgA levels were unremarkable. Chest X-Ray, X-ray KUB, and ultrasound abdomen were unremarkable. The pregnancy test was negative. ADAMTS13 was >100%. Genetic analysis after the initial episode at age 16 revealed autosomal recessive inheritance c.193A > c gene mutations in C3. The patient received IV fluids, ceftriaxone for cystitis, and two units of Fresh Frozen Plasma. She initiated treatment with eculizumab. She also received the MENVEO and meningitis B vaccine per protocol due to the risk of meningitis from terminal complement deficiencies. After 4 infusions of eculizumab, patient's labs improved to platelet count of 307 000 k/uL, Hgb 12.2 g/ dL (nadir 9.2 g/dL), haptoglobin 78 mg/dL normalization of LDH and improved creatinine. Atypical HUS is a rare form of TMAwith mutations in C3 noted in 5% of cases. Complement cascade dysfunction leads to endothelial deposits and microvasculature damage. The resulting prothrombotic state causes obstructive microvascular thrombi predominantly affecting the kidneys but can cause multiorgan dysfunction. The SARS-CoV-2 virus may precipitate atypical HUS relapse due to endothelial damage and complement activation further intensified in patients with existing complement aberrations. Plasma exchange remains a standard of care for atypical HUS, as it effectively removes the antibodies and other proteins. Eculizumab a humanized monoclonal IgG antibody binds to complement proteins, preventing cleavage into C5a and C5b blocking C5b-9(MAC) activation. In patients with CFH, CFI, C3, and CFB mutations, eculizumab is the preferred intervention. Copyright © 2023 Southern Society for Clinical Investigation.

DURAL VENOUS SINUS THROMBOSIS: A RARE PRESENTING CONSEQUENCE OF COVID-19

SESSION TITLE: Post-COVID-19 Infection Complications SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: The severe acute respiratory syndrome coronavirus (SARS-COV2) and its resulting coronary virus 2019 syndrome (COVID-19) has resulted in an unprecedented global pandemic affecting more than 250 million people and resulting in at least 5 million deaths worldwide. Clinical manifestations of the Covid-19 disease process include but are not limited to respiratory dysfunction and failure, coagulopathy, malaise and cytokine storm. We report a case of dural sinus thrombosis (DST) as a sequelae to COVID-19. CASE PRESENTATION: A 26-year-old woman with a history of migraines presented with sudden diffuse headache and photosensitivity. She reported no palpitations, oral ulcers, dizziness, diaphoresis, slurred speech, weakness, paresthesias or recent head trauma. Her presenting vital signs were within normal range. Physical exam was negative for focal neurologic deficits, weakness, or sensory loss. A rapid pregnancy test was negative. D-dimer was 7,200 ng/mL (reference <500 ng/mL). A COVID test was positive. A computed tomography (CT) of the head revealed diffuse hypodensity in the torcula and the transverse sinuses bilaterally extending into the cerebellar folia, suspicious for DST, which was confirmed on magnetic resonance venography. A full hypercoagulable panel resulted negative. It was determined that the patient's coronavirus disease infection resulted in a prothrombotic state and her dural sinus vein thromboses. The patient was started on a high intensity heparin drip for seven days, then transitioned to Dabigatran and Topiramate for management of headache upon discharge. DISCUSSION: COVID-19 typically manifests as fever, hypoxia, and dyspnea. If coagulopathy were to occur, the most common of them are deep vein thromboses. Cerebral thrombotic events, specifically, a DST has been underreported in literature. It is suspected that the burden of cerebral thrombosis in COVID-19 patients is 0.08%. In the same study, it was also identified that 31% of those who developed a cerebral thrombosis also had other hypercoagulable risk factors not present in this patient. Advancement in neuroimaging has allowed these thrombotic issues to be identified, however, early recognition, especially with a lack of risk factors, creates a less straightforward management plan. Our patient manifested a DST in the setting of an active COVID-19 infection. Higher levels of evaluation are required in patients who test positive for Covid-19 when clinically indicated. Such indications include headaches that are new in onset, severe in nature, and diffuse. Delayed diagnosis and management can be permanently damaging. CONCLUSIONS: Dural venous sinus thrombosis is a rare, yet deadly complication of COVID-19. All risk factors and other etiologies of hypercoagulable states should be ruled out followed by early detection based on clinical and physical exam, and accompanied by appropriate imaging followed by prompt intervention. Reference #1: Baldini, T., Asioli, G. M., Romoli, M., Carvalho Dias, M., Schulte, E. C., Hauer, L., Aguiar De Sousa, D., Sellner, J., & Zini, A. (2021). Cerebral venous thrombosis and severe acute respiratory syndrome coronavirus-2 infection: A systematic review and meta-analysis. European journal of neurology, 28(10), 3478–3490. https://doi.org/10.1111/ene.14727 Reference #2: Hemasian, H., & Ansari, B. (2020). First case of Covid-19 presented with cerebral venous thrombosis: A rare and dreaded case. Revue neurologique, 176(6), 521–523. https://doi.org/10.1016/j.neurol.2020.04.013 Reference #3: Thompson, A., Morgan, C., Smith, P., Jones, C., Ball, H., Coulthard, E. J., Moran, E., Szewczyk-Krolikowski, K., & Rice, C. M. (2020). Cerebral venous sinus thrombosis associated with COVID-19. Practical neurology, practneurol-2020-002678. Advance online publication. https://doi.org/10.1136/practneurol-2020-002678 DISCLOSURES: No relevant relationships by Steven Douedi No relevant relationships by slam Elkherpitawy No relevant relationships by Justin Ilagan No relevant relationships by David Kountz No relevant relationships by Anton Mararenko No relevant relationships by Mihir Odak

MANAGEMENT OF AUTOIMMUNE HAEMOLYTIC ANAEMIA DURING PREGNANCY OR POST-PARTUM: AN INTERNATIONAL MULTI-CENTRE EXPERIENCE

Background: Autoimmune haemolytic anaemia (AIHA) during pregnancy is a rare finding, and few is known about maternal and foetal outcomes. AIHA may either develop or relapse during gestation and postpartum or be an issue in a patient on active therapy who becomes pregnant. AIHA management during pregnancy and lactation is not standardized and drug use is often limited by safety concerns. Aims: We studied AIHA impact on pregnancy focusing on disease severity, treatment need and maternal/foetal outcome. Methods: Through a multicentric retrospective cohort study, we identified 38 pregnancies occurred in 28 women from 1997 to 2021 in 10 European centres in Italy, Denmark, France, the Netherlands, USA, and Spain. All included patients had a previous AIHA history or developed/exacerbated AIHA during gestation or postpartum. AIHA was classified according to the direct antiglobulin test. Results: We registered 18 warm AIHA (10 IgG;8 IgG+C3d), 2 cold agglutinin disease, 3 mixed and 5 atypical forms (Table 1). Evans syndrome (i.e., association of AIHA and immune thrombocytopenia or neutropenia) was present in 4. Mean age at AIHA diagnosis was 27 (3-39) and at pregnancy 32 (21-41) years. AIHA diagnosis predated pregnancy in 15 women and had required at least 1 therapy line in all of them, and >2 lines in 12 (rituximab, N=7;cytotoxic immunosuppressants, N=6;splenectomy, N=5). Among these 15 patients, 6 had a relapse during pregnancy, 3 during postpartum and 9 were on active treatment at the time of pregnancy (steroids, N=8;cyclosporine, N=1;azathioprine, N=1;the latter stopped after positive pregnancy test). A patient with a previous AIHA, relapsed as immune thrombocytopenic purpura during pregnancy. Further 8 patients had an AIHA onset during gestation and 2 postpartum. A patient had AIHA onset during the postpartum of the 1st pregnancy and relapsed during the 2nd one. In the 20 women experiencing AIHA during pregnancy/postpartum, median Hb and LDH levels were 6,4 g/dL (3,1 - 8,7) and 588 UI/L (269-1631), respectively. Management consisted in blood transfusions (N=10) and prompt establishment of steroid therapy+/-IVIG (N=20), all with response (complete N=13, partial N=7). After delivery, rituximab was necessary in 4 patients and cyclosporine was added in one. Anti-thrombotic prophylaxis was given in 7 patients. Overall, we registered 10 obstetric complications (10/38, 26%), including 4 early miscarriages, a premature rupture of membranes, a placental detachment, 2 preeclampsia, a postpartum infection and a biliary colic. Apart from the case of biliary colic and one of the two cases of preeclampsia, 8/10 complications occurred during active haemolysis and treatment for AIHA. Nine foetal adverse events (9/38, 24%) were reported: a transitory respiratory distress of the new-born in a mother with active AIHA, 3 cases of foetal growth restriction, a preterm birth, an infant reporting neurologic sequelae, a case of AIHA of the new-born requiring intravenous immunoglobulins, blood transfusions and plasma exchange, and 2 perinatal deaths. The latter both occurred in women on active AIHA therapy and were secondary to a massive placental detachment and a symptomatic SARS-CoV-2 infection. (Figure Presented ) Summary/Conclusion: AIHA developing/reactivating during pregnancy or postpartum is rare (about 5%) but mainly severe requiring steroid therapy and transfusions. Importantly, severe maternal and foetal complications may occur in up to 26% of cases mostly associated with active disease, pinpointing the importance of maintaining a high level of awareness. Passive maternal autoantibodies transfer to the foetus seems a rare event.

A REVIEW OF THE MANAGEMENT OF PELVIC INFLAMMATORY DISEASE AT A COMMUNITY CLINIC COMPARING PRACTICES BEFORE AND DURING THE COVID-19 PANDEMIC

Background Pelvic inflammatory disease (PID) usually results from infection ascending from the endocervix. The British Association for Sexual Health and HIV guidelines state that the diagnosis of PID should be considered in women under 25 with recent onset, bilateral lower abdominal pain and local tenderness on bimanual examination where pregnancy has been excluded. They recommend testing for chlamydia, gonorrhoea and mycoplasma genitalium. Method Electronic patient records were reviewed to identify episodes coded C5A during the last six months of 2019 and 2020. 46 patients were identified in 2019 and 43 in 2020. The following were recorded: demographics, symptoms, sexual history, examination findings, investigations, treatment, partner notification, follow-up. Results The age range of the 89 patients was 18-62, 51% were aged 25-34. Patients came from a range of ethnicities reflecting the diverse population. All patients were tested for chlamydia and gonorrhoea, none for mycoplasma genitalium. A pregnancy test was not performed in 19/89 (21%) patients. Documentation of examination findings was sometimes absent. Follow-up was recorded in 8/89 (9%) cases. Results were similar in 2019 and 2020, although ceftriaxone administration was more common pre-pandemic. Key results are summarised in the accompanying table 1. Conclusions PID management in 2019 and 2020 was similar. Increased testing for mycoplasma could guide antibiotic therapy. The importance of pregnancy testing in women presenting with lower abdominal pain should be highlighted to clinicians. Telephone calls could be used to facilitate follow-up appointments. (Figure Presented).

The hidden foetus

Objective: Healthcare teams often forget the possibility of pregnancy when fecund women present for non-obstetric problems. In this patient group, routine pregnancy tests are often omitted and related documentation is missing. This patient safety issue was further highlighted by an anecdotal story when a surgical procedure was performed and mid surgery a pregnancy was identified. Prior to our intervention, simple point of care testing was limited to the emergency department. At ward level, pregnancy tests could only be performed using blood serum. Also, the admission forms did not specifically ask to exclude a pregnancy. Design: We reviewed whether all female surgical admissions of childbearing age underwent pregnancy testing. A baseline audit highlighted the need to introduce point of care pregnancy kits on the surgical ward. The initial audit was presented to surgical and anaesthetic departments. In collaboration with management, funding was secured to provide pregnancy kits for the surgical wards and the admission protocol was changed accordingly. Method: The project was completed over a period of 19 months (delayed by Covid). The base-line data collection was from November to December 2019 with presentation of the results in December 2020. Introduction of pregnancy kits in April 2021 and follow-up data collection in May to June 2021. A total of 159 case notes were reviewed using the hospital patient information system named 'Portal'. In the baseline survey, 86 case notes were screened for pregnancy tests and whether the findings were documented. After the introduction of pregnancy kits, the survey was repeated involving 73 women. The mean age was 32 with a range from 17 to 52 years of age. Results: Results were obtained retrospectively using the Portal system to screen for pregnancy tests (urine/serum β-HCG), any radiation exposure and surgical intervention. In 2021, prior to intervention, 75% of fecund patients were exposed to radiation and 95% underwent surgery without pregnancy testing. In 2021 the rates dropped to 32% for radiation exposure and surgery without pregnancy testing to 27%. Overall pregnancy testing in fecund women for surgical admission improved to 60%. Conclusions: Omitting pregnancy tests and subsequent documentation could be due to time pressures in particular during same day admissions. The remaining 40% could be captured by using a computer-based admission protocol which prompts the health care staff to undertake a pregnancy test, but adds more complexity to an already busy surgical admission ward.

From Inferior Vena Cava to Right Atrium: A Rare Case of a Unique Large Burden Thrombus in a Patient with Antiphospholipid Syndrome

Introduction: Antiphospholipid Syndrome is a condition where self-antibodies are directed against phospholipid binding proteins resulting in thrombosis and/or pregnancy loss. Diagnosis is made via history, physical, positive anticardiolipin and anti-beta-2-glycoprotein antibodies. We describe a case of a large thrombus in a previously diagnosed patient with antiphospholipid syndrome and discuss the need for prophylaxis in these patients. Case Report: 34-year-old G7P1161 Hispanic female with past medical history of uncontrolled diabetes mellitus type 2 presents with an acute onset of sharp abdominal pain radiating to the back associated with nausea, non-bloody non-bilious emesis and dysuria. Vital signs on admission are significant for tachycardia and hypertension. Labs are noteworthy for elevated Creatinine at 1.7 mg/dl, thrombocytopenia, transaminitis, elevated Ddimer at 14272 ng/ml. Urine analysis is positive for nitrites, trace leukocytes and bacteria. Her serum pregnancy test and COVID PCR are negative. CT Abdomen/Pelvis with contrast revealed an extensive thrombus in the Inferior Vena Cava (IVC) to the Right Atrium (RA), also extending into the hepatic veins and upper lumbar veins. Moderate perinephric fat stranding is also noted around bilateral kidneys. Ultrasound of the abdomen reveals cholelithiasis without evidence of acute cholecystitis. Venous Doppler of lower extremities reveals patent deep veins. Patient was started on heparin drip immediately and intravenous Cefepime. Interventional Radiology performed mechanical thrombectomy. Hematology was consulted and converted patient to Warfarin with an INR goal of 2.5-3. Patient was discharged and instructed to follow up with hematology. Discussion: There are few case reports of extensive thrombi ranging from IVC to RA with most cases occurring in elderly population. We present a unique case of an extensive thrombus ranging not only from the IVC to RA but also extending into the hepatic veins and the upper lumbar veins. The patient described has a history of multiple spontaneous abortions with her only successful preterm birth required daily therapeutic Lovenox during pregnancy. Her recurrent pregnancy loss and current large burden thrombus can be attributed to her antiphospholipid syndrome. This begs the question whether these patients should be started on prophylaxis anticoagulation. There have been limited studies with aspirin and warfarin which at times demonstrated positive results. Our patient had her thrombus identified incidentally due to an admission for pyelonephritis. If her thrombus was not recognized in time, outcomes could have been devastating. In conclusion, there should be further studies to determine the efficacy of anticoagulation prophylaxis in patients with positive antiphospholipid antibodies. (Figure Presented).

BEDSIDE TEST TO RULE OUT AN ECTOPIC PREGNANCY USING A MODIFIED FDA APPROVED KIT

OBJECTIVE: To evaluate the accuracy of a modified bedside test in ruling out an ectopic pregnancy. The test is based on a lateral flow immunoassay for alpha-fetoprotein (AFP). It has been shown that a high AFP level in vaginal blood indicates the passage of fetal tissue, suggestive of a miscarriage [1].We hypothesized that high AFP levels in sampled intrauterine tissue, assuming non-heterotopic pregnancy, rules out the presence of an ectopic pregnancy. MATERIALS AND METHODS: This is a prospective cohort study. The study included pregnant women undergoing a dilation and curettage (D&C) for pregnancy loss or termination, women with pregnancy loss or an ectopic pregnancy presenting with vaginal bleeding, and non-pregnant women with vaginal bleeding. Vaginal blood was collected on gauzes, sanitary pads, and cotton swabs. Samples were then tested for AFP levels using a commercial kit (ROMplus, Laborie, USA) originally designed to detect leakage of amniotic fluid. This kit contains a lateral flow immunoassay strip capable of detecting the presence of AFP. Positive samples for AFP were retested at a later date (after 3 to 20 days) to ascertain the stability of AFP and reliability of the test. Official sonograms, pregnancy tests, and final pathology results were obtained to confirm pregnancy status as well as the presence or absence of fetal tissue in the vaginal blood. A sensitivity and specificity analysis was performed against these final results to validate the accuracy of the test strip in ruling out an ectopic pregnancy. RESULTS: A total of 30 vaginal blood samples were tested for AFP. All pregnant women who had a miscarriage or D&C had detectible AFP in their vaginal blood (n=13). On retesting the samples 3 to 20 days later, these results remained the same (positive test strip). The remaining 17 vaginal blood samples were from 4 women with ectopic pregnancies and from 13 non-pregnant women with vaginal bleeding. All 4 ectopic pregnancies had no AFP detected in the vaginal blood and only 1 out of 13 non-pregnant patient samples had AFP detected. The ROMplus test strip correctly detected AFP in all samples tested containing fetal tissue (n=13) resulting in a test sensitivity of 100%. ROMplus correctly identified the absence of AFP in 16 out of the 17 samples lacking fetal tissue, a 94% test specificity. CONCLUSIONS: ROMplus has the potential to accurately and reliably detect the presence of AFP, and hence fetal tissue, in vaginal blood samples. This could be a vital non-invasive aid in ruling out an ectopic pregnancy at the bedside (currently off-label use). Furthermore, it could limit the amount of invasive testing and visits needed in cases of pregnancies of unknown location. IMPACT STATEMENT: In light of the recent COVID-19 pandemic, a simple non-invasive bedside test to rule out an ectopic pregnancy is highly desired given its potential for reducing the number of visits, investigations performed, and personnel involved in the workup of a pregnancy of unknown location.

FIRST TRIMESTER OUTCOMES OF PATIENTS SEEKING INFERTILITY CARE AFTER COVID-19 INFECTION

OBJECTIVE: To assess if COVID-19 infection differentially impacts first trimester outcomes in patients seeking infertility care at one large fertility practice. MATERIALS AND METHODS: A retrospective chart review of all female patients actively pursuing fertility care in a single fertility center with positive COVID-19 test results from March 2020 to February of 2021 was performed. Positive COVID-19 test results included PCR tests performed in our clinic and symptomatic patients who informed us of their outside positive test results by phone during their treatment with our clinic. This was compared to a control group of all comers in our clinic in 2020. Information was gathered on infertility treatment type, and pregnancy outcomes. Chemical pregnancy rate (CPR) is documented as a positive pregnancy test and ongoing pregnancy was documented as a positive fetal heart beat between 7-8 weeks of gestation and discharge to routine OBGYN care. Fishers exact test was used to calculate p value, statistically significant associations were considered to exist when the p value ≤0.05. RESULTS: A total of 178 cases of COVID-19 were documented in patients between April 2020 and February 2021. After COVID-19 infection (Covid+) sixty-two pregnancies were documented, with sustained implantation in fifty-three (85%) patients. In the subgroup of Covid+ patients that underwent subsequent fertility treatment the CPR was 30.1% with IUI, and 70.1% with IVF and single frozen embryo transfer. This is in comparison to our control population CPR of 14.1 % with IUI (p=0.002) and 68% (p=0.78) with IVF with single embryo transfer (Table 1). Clinical pregnancy loss rate was recorded and shown in Table 1. CONCLUSIONS: In an infertile population, a recent history of COVID-19 diagnosis did not negatively impact pregnancy outcome as measured against a control population. One of the limitations of this study was the relatively small sample size, which may have conflated our data on COVID-19 patients who underwent IUI, whose higher rate of pregnancy is unlikely to be clinically significant. IMPACT STATEMENT: Patients who have had COVID-19 and then proceeded with infertility treatment were no more likely than our control population to have first trimester complications in one fertility clinic. The findings from this study should provide reassurance that attempts at pregnancy do not need to be delayed after recovery from a COVID-19 diagnosis.

Impact of Coronavirus Disease 2019 (COVID-19) on emergency department visits for ectopic pregnancies in New York City

Background: Ectopic pregnancy is a potential cause of morbidity and mortality among women and is a common diagnosis for women presenting to the emergency room. During the height of the COVID-19 pandemic in New York City (NYC) in the spring of 2020, emergency room visits for all non-COVID related health problems appeared to decrease. We examined visits for ectopic pregnancies and pregnancies of unknown location (PUL) in the emergency department (ED) of three NYC hospitals during the height of the early pandemic and compared them to the same months in the prior year. Methods: Our study is an IRB-approved retrospective chart review of all patients who presented to the ED with a positive pregnancy test during the months of March–June 2020 (pandemic period) and March–June 2019 (pre-pandemic). Demographic data, history, labs, imaging, number of visits and treatment and outcomes were measured. Results: We found that there were 324 ED visits for PUL in 2019 (pre-pandemic) compared to 195 in 2020 (pandemic). Ectopic pregnancies remained somewhat stable and were diagnosed in 59 patients in 2019 and 51 patients in 2020. The percentage of patients diagnosed with ectopic pregnancy increased from 25.1% of all patients with PUL in 2019 to 39% of all patients diagnosed with PUL in 2020. Rates of complications were similar between the two cohorts. Conclusion: Although the number of visits to the ED for PUL fell dramatically from the pre-pandemic to the pandemic time period, the number of patients actually diagnosed with ectopic pregnancy was similar between the two time periods.

Seizure, abdominal pain, and urine pink in an adolescent female-what's the link?

Case Report A 17 year-old female with history of depression was transferred to the pediatric intensive care unit (PICU) from an emergency department (ED) for first time seizure and subsequent encephalopathy after five days of severe, diffuse abdominal pain and vomiting. The night prior to admission, she complained of lightheadedness and then had a witnessed generalized tonic-clonic seizure lasting 45 seconds. She initially returned to her baseline but then had three additional seizures requiring ED evaluation. She received intravenous doses of lorazepam and levetiracetam that aborted the clinical seizures. She remained encephalopathic and was orotracheally intubated for airway protection. Family denied known ingestions but reported she did vape nicotine. Urine drug screen was positive for benzodiazepines, consistent with seizure management. Cerebrospinal fluid analysis was unrevealing. Urinalysis showed moderate ketones and trace blood. Urine pregnancy test and nasopharyngeal SARS-CoV-2 polymerase chain reaction were negative. Head computerized tomography scan showed no intracranial pathology. On arrival to the PICU, the patient was afebrile, tachycardic, and hypertensive to 171/118 mmHg. She was somnolent on arrival but aroused to sternal rub without focal neurologic deficit. She presented with a Foley catheter that drained pinkorange urine. A nicardipine infusion was started given concern for the development of posterior reversible encephalopathy syndrome (PRES). Thyroid function tests were consistent with euthyroid sick syndrome. BioFire meningitis panel, plasma SARS-CoV-2 IgG, and toxicologic evaluation were all negative. Electrocardiogram showed sinus tachycardia. Magnetic resonance imaging of the brain revealed cortical and subcortical areas of diffusion restriction consistent with PRES. Ultimately, a random urine porphobilinogen and a 24-hour measurement of urine porphyrins collected on hospital day 1 were both markedly elevated. A diagnosis of Acute Intermittent Porphyria (AIP) was made. A gastrointestinal porphyria specialist was consulted and recommended monthly outpatient injections of givosiran upon hospital discharge. Discussion This case illustrates the importance of considering AIP in the differential diagnosis of new onset seizure or encephalopathy associated with hypertension, tachycardia, and abdominal pain in an adolescent. This case also adds to a small number of cases associating AIP with PRES. AIP is often viewed as an adult disease because it typically presents in the third or fourth decade of life. Timely recognition of AIP in the pediatric setting is critical to preventing delays in diagnosis, treatment, and patient education on triggers of acute attacks. AIP attacks are treated with dextrose and hemin infusions to reduce production of porphyrin precursors. Prophylactic treatment of AIP now includes givosiran, an interfering mRNA that reduces levels of intermediates in heme synthesis that are neurotoxic when elevated.

Developing novel referral pathways in emergency surgery

Introduction: In line with the principles of GIRFT and recognising the demand on the Emergency Department (ED) the Acute Surgical Unit (ASU) developed a direct admission pathway entitled 'ASU Direct' (ASUD). Nurse led ED triage with adherence to a referral proforma allows direct admission of suitable surgical patients eliminating medical ED review or discussion with the on-call Registrar. Aim: Investigate the usefulness of the ASUD pathway and adherence to admission criteria. Method: Two retrospective audits of ASUD referrals were completed and compared with concurrent traditional registrar referrals. Inter-departmental discussions occurred between audit cycles. Results: Audit 1: 13 days, 150 cases (8 excluded). 75 (53%) referred via ASUD, 67 (47%) via surgical registrar. Sixteen ASUD cases (22%) breached pathway protocols including 3 young women referred without pregnancy tests. Seventeen (25%) cases referred via the Registrar fulfilled ASUD criteria. Documentation complete in 56% of ASUD cases. Audit 2: (3 weeks after feedback)-10 days, 120 patients (25 excluded). Fifty one ASUD cases (54%) and 44 (46%) registrar referrals. 24% cases breached ASUD criteria, 7 registrar referrals (15%) appropriate for ASUD. ASUD documentation completed in 60% with 100% pregnancy status recorded. Conclusions: Proportion of ASUD / registrar referrals remained constant but there were fewer missed opportunities for ASUD. Inappropriate ASUD admissions remained similar. While ASUD worked well for visible pathology, less-so for protocol-driven abdominal pain. Senior 'front-door' triage in ED might improve protocol compliance, helping to develop such pathways, observing GIRFT and avoid unnecessary transfer of patients (especially during the COVID pandemic).