Study Information and Consent

Thank you for your interest in our multi-site repository.

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Cesarean Scar Ectopic and Cervical Ectopic Multisite Repository

IRB #: 20824

PROTOCOL APPROVAL DATE: 12/16/2019

PRINCIPAL INVESTIGATOR: Jessica Reid, MD, MCR reidje@ohsu.edu

PURPOSE

We are asking you to participate in this research study titled Cesarean Scar Ectopic and Cervical Ectopic Multisite Repository (eIRB #20824) because you care for patients with early pregnancy complications, including ectopic pregnancy. The purpose of this study is to create a multisite case series of patients treated for cesarean scar ectopic and cervical ectopic pregnancies. We will examine outcomes based on patient factors and therapeutic interventions in order to develop evidence-based guidelines regarding management.

PROCEDURES

Please answer each question on the data collection form as accurately as possible. You may reference the patient’s electronic medical record as necessary for specific details, but please do not include any patient Protected Health Information (PHI).

We will ask for your name and email, so that we can send you another very short electronic questionnaire in approximately 1 month to collect information on patient follow up and/or delayed complications. If follow up is not complete at 1 month, you may be contacted a third time (3 months from the initial report). You will not be contacted after this.

You can complete this more than once if you have multiple cases.

If you have any questions, concerns, or complaints regarding this study now or in the future please contact me or other members of the study team at the OHSU Women’s Health Research Unit whru@ohsu.edu.

Alison Edelman, MD, MPH

Professor, OB/GYN

edelmana@ohsu.edu

Jessica Reid, MD, MCR

Assistant Professor, OB/GYN

reidje@ohsu.edu

Department of Obstetrics & Gynecology

Oregon Health & Sciences University

3181 SW Sam Jackson Park Road, UHN-50

Portland, OR 97239

503-494-3666

Consent Date

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M-D-Y

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