According to our data, physical examination cannot be used alone to safely rule out a surgical emergency in a woman presenting with acute pelvic pain. Inversely when both the physical examination and TVUS are normal, the risk of a surgical emergency is less than 1%. This suggests the benefit of adding bedside standardized ultrasonography in the first-line diagnostic management of suspected gynecologic emergencies.
One of the strengths of our study is that TVUS findings are recorded routinely at our institution using a standardized protocol
. This standardized protocol, with a routine recording of standardized images, allows a reviewing of those scans, even a long time after. Recording pictures in the patient’s chart may also decrease the need for subsequent repeat ultrasonography, thereby saving time and diminishing healthcare costs. Furthermore, we did not have to rely on a written description of the TVUS findings in the medical record. The TVUS findings were determined by blinded observers using objective criteria. These criteria are reliable and have been proven useful for diagnosing specific gynecologic emergencies
[9, 10, 13, 15, 21].
It has been demonstrated that the availability of TVUS at the initial assessment of both pregnant and nonpregnant women decreased patient time management, unnecessary admissions, outpatient follow-up examinations and also modified treatment decisions
[22, 23]. Nonetheless, we did not find any published study showing clear-cut evidence that routine ultrasonography decreases unfavorable patient outcomes. We demonstrate that including around-the-clock TVUS as a first step investigation in addition to the physical examination is an effective strategy to rule out surgical emergencies at the gynecologic ED by reducing the risk of diagnostic errors.
In France, there is at least one resident on duty around the clock with unlimited access to TVUS in gynecological EDs, even when no radiologist or board-certified obstetrician/gynecologist is available. Another particularity in France is that ultrasonography for gynecologic emergencies are under the supervision of board-certified obstetricians/gynecologists instead of radiologists. In contrast, in most of the developed countries, emergency ultrasonography is performed at the request of ED physicians by radiologists or board-certified obstetricians/gynecologists
[22, 23]. Although, this strategy optimizes the quality of ultrasound examination, our results suggest that suspecting surgical emergencies based on the physical examination alone does not perform well for the diagnosis of gynecologic emergencies. Instead, the French strategy of first-line ultrasonography performed by non-specialized healthcare providers should be compared with the so-called “limited” sonogram in the 2nd/3rd trimester of pregnancy. These examinations do not replace a standard complete ultrasound examination but are performed to obtain an immediate answer to a specific clinical question
, as FAST scanning in EDs. Bedside abdominal ultrasonography by a surgeon was also introduced several years ago as a routine examination for patients with acute abdominal pain and produced similar results, improving the rate of correct diagnoses
The quality of bedside ultrasonography by obstetrics/gynecology residents is obviously not comparable to that obtained by board-certified specialists, as the quality of examination is highly variable
. Furthermore, experience is a key factor in the ability of transvaginal ultrasound to manage women with pelvic pain with accuracy
. Nonetheless, in our center, we made important efforts to implement a standardized ultrasonography protocol
 to reduce the heterogeneity of the quality of ultrasonography performed by residents. This quality process probably increased the usefulness of bedside TVUS for the diagnosis of gynecologic emergency. One application of this process would that these scans could be performed by anyone involved in gynecologic emergencies management with appropriate training (ie ED physicians, Family Medical doctors, midwife or advanced nurse practitioners). This training should include rigorous implementation of standardized ultrasonography protocol in EDs, with quality control of ultrasonography by board-certified obstetricians/gynecologists or radiologists to obtain individual accreditation. Thus, this accreditation could decrease the heterogeneity of ultrasound examination and allow correct interpretation in order to make correct clinical decision regarding surgical emergencies.
Nonetheless, our study has several limitations. First, we were not able to have the physical examination and TVUS done by two different individuals, in contrast to another group
. The physical examination was performed before TVUS, and its results may therefore have influenced the recording of the images. However, calculating the conditional statistics of one examination according to the result of the other showed no differences with the main results (data not shown).
Second, our strategy of including only women who underwent laparoscopy may have led to verification bias. We chose to select patients with laparoscopy to ensure that the final diagnosis was established with certainty. However, the decision to perform laparoscopy was taken by a senior physician, based possibly on the result of the physical and TVUS findings by the resident, which may have artificially increased Se and decreased Sp of both examinations.
Third, our follow-up data on patients in whom emergency laparoscopy was deemed unnecessary may have been incomplete. We believe that the risk of missing a surgical emergency among patients who leave the ED without undergoing laparoscopy is low as pregnant women received very close follow-up after ED discharge until the hCG test became negative and patients discharged with undiagnosed surgical emergencies would eventually come back to our ED, which serves a vast geographic area.