Adolescents who have had pelvic inflammatory disease, tubal surgeries, or previous ectopic pregnancies are at risk of having ectopic pregnancy, though many patients with ectopic pregnanc
Trang 1levels on serial measurement or an increase of less than 66% in 48 hours suggests
a nonviable fetus
Septic abortion may complicate an intrauterine infection from a spontaneous abortion or from an induced abortion The patient may have signs of fever, severe pelvic pain, and leukocytosis Retained products of conception may still be present and will require surgical evacuation Broad-spectrum parenteral antibiotics should be initiated to cover for gram-positive and gram-negative bacteria Infections may also occur from polymicrobial organisms, anaerobic bacteria, and fungi Consultation with a specialist is imperative
Bleeding During an Ectopic Pregnancy
An ectopic pregnancy is a pregnancy that is not intrauterine Nearly all ectopic pregnancies occur in the fallopian tubes Adolescents who have had pelvic inflammatory disease, tubal surgeries, or previous ectopic pregnancies are at risk
of having ectopic pregnancy, though many patients with ectopic pregnancy will present with no risk factors Sharp pain, lateralized pain, and pain of moderate to severe intensity favor ectopic pregnancy Examination findings that favor ectopic pregnancy include cervical motion tenderness, lateral pelvic tenderness, and signs
of peritoneal irritation β-hCG levels may be low compared to an intrauterine pregnancy of the same gestational age If an intrauterine pregnancy is not seen on ultrasound, a transvaginal ultrasound should be performed to look for an ectopic pregnancy Sonographic signs suggestive of ectopic pregnancy include a solid or complex adnexal mass, a pelvic mass, particulate fluid in the fallopian tube, an endometrial pseudogestational sac, and cul-de-sac fluid that is either moderate to large in volume or echogenic Ultrasound and serial β-hCG testing are the main diagnostic studies for ectopic pregnancy, though in rare circumstances obtaining a serum progesterone concentration may be helpful; serum progesterone levels are usually higher in intrauterine pregnancies than in ectopic and nonviable pregnancies If an ectopic pregnancy is diagnosed, an obstetrician/gynecologist or other appropriate surgical service should be called to manage the patient The mainstay of treatment is surgery, though early ectopic pregnancies may be managed medically with the administration of methotrexate Patients who present with ruptured ectopic pregnancy must be monitored closely for signs of hemodynamic instability, sepsis, and shock in the hospital
Bleeding During Late Pregnancy
If the patient is 20 weeks pregnant or more by history or abdominal examination, potential causes of bleeding that must be identified urgently are placenta previa (placenta close to or overlying cervical os), abruptio placentae (premature
Trang 2separation of the placenta), uterine rupture, and vasa previa (fetal vessels traversing closely to cervical os) An obstetrician should be consulted at the earliest opportunity regarding further ED management of the pregnant patient with second- or third-trimester bleeding
Digital vaginal examination in a female in late pregnancy presenting with vaginal bleeding should initially be avoided because uncontrollable hemorrhage may be provoked in a patient with placenta previa Vital signs, physical examination, and laboratory studies should be obtained to evaluate for hemodynamic instability A transabdominal ultrasound should be performed to assess for the location of the placenta A transvaginal ultrasound may also need to
be performed to better visualize the placenta location in relation to the cervical os The fetal heart rate should be monitored, and a large-bore intravenous catheter should be inserted Initial laboratory evaluation should include determinations of the blood type and antibody screen, hematocrit, platelet count, fibrinogen level, and coagulation studies to screen for disseminated intravascular coagulation, which may be present in moderate and severe abruption
Bleeding With Shock
If the patient with vaginal bleeding is in the first or early second trimester of pregnancy and has shock or early signs of cardiovascular instability (pallor, perspiration, vomiting), ruptured ectopic pregnancy or septic abortion must be ruled out Because of the urgency of the situation, treatment of shock and diagnostic measures should be undertaken simultaneously Pelvic examination is performed and obstetric consultation should be obtained rapidly Emergency surgery may be necessary for critically ill patients with ectopic pregnancy Fluid resuscitation and antibiotics should be administered for patients with suspected septic abortion
If the patient is ≥20 weeks of gestation, hypovolemic shock should be suspected from placenta previa, abruption placenta, uterine rupture, or vasa previa Appropriate measures should be taken to provide volume resuscitation, and obstetrics must evaluate urgently
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