In a recent issue of American Journal of Obstetrics and Gynecology , Nurmohamed et al conclude that methotrexate administered to patients misdiagnosed with ectopic pregnancy may cause severe fetal malformations or demise, and imply in their discussion that ultrasound performed by emergency physicians with limited training contributed to misdiagnosis. We agree that such errors are catastrophic; however, we find it extremely unlikely that point-of-care emergency ultrasound has contributed to these errors.

The source of data for this study was the teratogen information service, which does not have access to patient records. Therefore, while the authors may be able to determine that half of their cases were diagnosed in the emergency department, they are unable to determine who performed the imaging study or how the decision to administer methotrexate was made. We would be shocked if the emergency physicians performed these ultrasound examinations and then unilaterally proceeded to give methotrexate without obstetric consultation at a minimum.

The American College of Emergency Physicians policy statement clearly states that the goal for focused emergency ultrasound is to identify intrauterine pregnancy. In patients not utilizing assisted reproductive technologies, this has been shown to exclude ectopic pregnancy with a negative predictive value of essentially 100%. “Intrauterine pregnancy” is thus listed as a core application, not the diagnosis of ectopic pregnancy. Thus, while the diagnosis of an intrauterine pregnancy is reassuring that the patient does not have an ectopic, failure to identify an intrauterine pregnancy on point-of-care ultrasound would prompt most emergency physicians to obtain consultative imaging and recommendations, as stated in well-established algorithms in the literature.

In most centers, there is a process for case and imaging review among the obstetrician, emergency physician, and/or radiologist prior to methotrexate administration. The article refers to the “relative ease of methotrexate administration.” If this is the case, at any institution, then there are inherent process issues that must be addressed. In addition, the indications for methotrexate are clear. We would be very curious to know what the findings were on these ultrasound examinations that led the caregivers to proceed with medical termination and who ultimately decided to give the medication. As noted in the article, emergency physician–performed pelvic ultrasound has been shown to be a safe and effective method to evaluate first-trimester symptoms, and it is often difficult to obtain timely ultrasound studies through the radiology department at many institutions. All clinicians, community emergency department physicians or otherwise, should only perform those procedures where they have been appropriately trained and have the adequate skill set. While we agree that caution in the diagnosis of ectopic pregnancy and the administration of methotrexate is essential, this study should not be used to question the safety or effectiveness of properly utilized point-of-care emergency physician–performed ultrasound in the hands of well-trained and experienced users.