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Ectopic Pregnancy
Definition
- Any pregnancy occurring outside the uterine cavity
Location
- 95% of all ectopic pregnancies occur in the fallopian tubes with 5% being ovarian or abdominal pregnancies.
- Heterodoxies pregnancy, described as simultaneous intrauterine and ectopic pregnancy may also occur.
Incidence
- Annually 70,000 cases of ectopic pregnancy occur in the United States with a current incidence of 20 ectopics per 1000 pregnancies.
- The incidence of Heterodoxies pregnancy is 1 in 4000 pregnancies.
Clinical Presentation
Rupture of an Ectopic Pregnancy
- Rupture of an ectopic pregnancy is associated with:
- syncope
- sudden onset of severe pelvic/abdominal pain
- hypotension
- When an ectopic pregnancy ruptures, there occurs hemorrhage into the peritoneal cavity leading to peritoneal signs.
- Hemorrhage from ectopic pregnancy is the major cause of pregnancy-related death during the first trimester.
- Maternal death in these patients is often related to a delay in initial diagnosis.
Diagnostic Evaluation
Emergency Department Management
Vaginal Bleeding in the First Half of Pregnancy
Forty percent of pregnant patients present with some degree of vaginal bleeding
during early pregnancy. Approximately one-half of these will progress on to spontaneously abort. The vast majority of these spontaneous abortions occur prior to 8 wk of gestation. At least half of all spontaneous abortions are due to genetic abnormalities; the rest being due to a combination of factors such as uterine abnormalities, incompetent cervix, progesterone deficiency, tobacco or alcohol use.
Once again, one must always consider ectopic pregnancy in the differential when evaluating the pregnant patient with vaginal bleeding. The patient with unilateral pelvic pain and vaginal bleeding needs thorough evaluation to differentiate early abortion from ectopic pregnancy.
Definitions
- Threatened Abortion-Uterine bleeding in the first 20 wk of pregnancy without any passage of tissue or cervical dilatation. The cervical os is closed.
- Inevitable Abortion-Uterine bleeding in the first 20 wk of pregnancy without any passage of tissue but with a dilated cervical os.
- Incomplete Abortion-Uterine bleeding in the first 20 wk of pregnancy with a dilated cervical os and only partial expulsion of the products of conception.
- Complete Abortion-Uterine bleeding in the first 20 wk of pregnancy with complete expulsion of all the products of conception.
- Missed Abortion-Fetal death in utero at < 20 wk gestation with the products of conception retained.
- Septic Abortion-This is an incomplete abortion in which infection has ascended into the uterus causing endometritis, parametritis and peritonitis.
- Blighted Ovum-An embryo that has failed to develop, although there is an identifiable gestational sac, can also lead to uterine bleeding.
- Molar Pregnancy/Gestational Trophoblastic Disease-Occurs in 1/2000 pregnancies; tumors that arise from proliferation of the placental trophoblast and occur in both a benign and malignant form. A fetus is generally absent in this process. These patients present with vaginal bleeding in the first half of pregnancy 90% of the time. They generally have higher than expected serum HCG levels and their pelvic ultrasound shows a classic snow storm appearance caused by intrauterine hydropic villi. OB/Gyn consultation is necessary for treatment.
Clinical Evaluation
- Obtain a detailed menstrual history from the patient.
- Information that is important to obtain in this history includes:
- the date of the last normal menstrual period
- the date of the last menstrual period
- the number of pads used per hour can help to quantify the amount of vaginal bleeding that has occurred.
- Past OB/GYN history should be obtained to include the number of prior pregnancies ,the number of term/preterm deliveries and the number of abortions both spontaneous and therapeutic
- An important step in the evaluation of vaginal bleeding in pregnancy is the complete pelvic examination which allows the localization and the quantification of the source of vaginal bleeding.
- Bleeding from the cervical os this indicates a uterine source.
- It should be noted whether or not the internal cervical os is open or closed and whether or not there are any products of conception present at the cervical os.
- It can be determined whether or not the internal cervical os is open by gentle insertion of a finger into the os on bimanual examination. Ring forceps can also be carefully used to make this evaluation. Force should never be used in either of these techniques.
- The uterus should be evaluated for tenderness, size, shape and consistency.
- The patient�s adnexa should be palpated for the presence of masses and/or tenderness.
- The presence of cervical motion tenderness should be determined.
Diagnostic Evaluation
- Standard laboratory testing to be obtained in the setting of vaginal bleeding in the first half of pregnancy should include all of the following.
- Complete blood count (CBC)
- Quantitative serum HCG level (to help with interpretation of ultrasound results and to serve as a baseline)
-
- Rh type
- Urinalysis obtained by catheterization (to screen for urinary tract infection which is a common cause of abortion/threatened abortion.)
- Emergent pelvic ultrasound should be obtained to help with a definitive diagnosis and to help guide subsequent treatment. Patients with a visualized intrauterine pregnancy with a closed cervical os can be considered to have a threatened abortion. Correlation of ultrasound results with the patient�s history and physical findings will allow the type of abortion to be identified.
- Any products of conception (tissue) passed from the cervical os should be sent to pathology for evaluation.
Emergency Department Management
- The hemodynamically stable patient with a documented intrauterine pregnancy can usually be discharged home with a follow-up evaluation with their OB/Gyn physician in 48 h. They should be instructed to return to the Emergency Department if vaginal bleeding increases and/or returns, if they notice any passage of tissue, or if they develop significant pelvic pain or fever. The patient should be placed on pelvic rest which means no intercourse, no douching and physical activity. If the patient is limited Rh negative, they will need to receive Rh immune globulin(RhoGAM) to prevent isoimmunization.
- In the patient who is hemodynamically unstable and/or presenting with heavy persistent vaginal bleeding:
- intravenous access should immediately be obtained and volume resuscitation initiated with normal saline.
- A bedside hemacue and urine pregnancy test should be obtained while awaiting formal lab results.
- The patient should be placed on supplemental oxygen, cardiac monitor, automated blood pressure monitor and pulse oximetry.
- An emergent bedside ultrasound should be performed looking for an intrauterine pregnancy.
- Immediate OB/GYN consultation should be also be obtained.
- OB/GYN consultation should be obtained regarding patients with inevitable, incomplete, missed, septic abortions or molar pregnancies.
Vaginal Bleeding in the Second Half of Pregnancy
Vaginal bleeding after 20 wk of gestation can present a complicated clinical management situation with the lives of the mother and fetus often both in serious jeopardy.
Abruptio Placentae/Placental Abruption
- Definition-The complete or partial placental separation from the decidua basalis (uterine implantation site) after 20 wk of gestation. When this separation develops, blood vessels are ruptured leading to hematoma formation which leads to significant hemorrhaging and fetal hypoxia. DIC may also develop in this situation.
Incidence
- Abrubtio placentae occurs in approximately 1/100 pregnancies and is the cause of approximately 14% of all stillbirths in the United States.
Clinical Presentation
- Variability of clinical presentation is related to the quantity and location of hemorrhaging.
- Classical findings include painful vaginal bleeding with uterine tenderness and contractions. The patient may complain of back and/or abdominal pain, and the pain is usually relatively sudden in its onset and constant in nature.
- On exam the uterus may be firm and hypertonic.
- Vaginal bleeding is visible approximately 80% of the time and concealed 20% of the time.
- Fetal heart sounds and visualized fetal cardiac activity by ultrasound may be absent.
- In a small percentage of cases usually involving very small or marginal abruptions, the patient may not present with pain.
- Clinical evidence of DIC may be present as the abruption may activate the coagulation cascade. Early awareness of this possibility may become apparent if the patient is noted to have excessive hemorrhaging at venopuncture or intravenous access sites, mucosal/gingival hemorrhaging, easy bruising and/or hematuria.
- Pelvic examination should be delayed until a placenta previa has been ruled out.
Emergency Department Management
Placenta Previa
Definition
Incidence
- Placenta previa occurs in approximately 1/200 pregnancies in the United States.
- Approximately 90% of placenta previas resolve spontaneously prior to term.
Clinical Presentation
- The patient usually presents with painless vaginal bleeding in the 2nd half of pregnancy.
- Vaginal examination should be avoided as manipulation of the placenta during the
examination may cause the tearing of blood vessels leading to potentially life threatening hemorrhage to the mother and/or the fetus.
Emergency Department Management
- When placenta previa is clinically suspected emergent obstetrical consultation should be obtained.
- Pelvic examination should initially be avoided.
- Intravenous access should be established with appropriate hemodynamic monitoring and pulse oximetry.
- Blood should be obtained for a CBC, Type/Cross and Rh.
- Ultrasound should be performed on an emergent basis.
- Fetal monitoring should be placed.
- Emergent cesarean section versus close observation may be the indicated treatments to be decided by the obstetrical consultant.
Hyperemesis Gravidarum.
- It is normal to have some degree of nausea and vomiting for most patients during the course of pregnancy and these episodes are especially frequent in first 12 wk.
- The diagnosis of hyperemesis is defined as severe refractory nausea and vomiting with evidence of dehydration, weight loss, ketonuria and increased urine specific gravity.
- Hyperemesis gravidarum is a diagnosis of exclusion after no other cause for the patient�s symptoms are found.
Diagnostic Evaluation
- Laboratory testing in hyperemesis gravidarum should include a CBC, electrolyte panel, urinalysis, checking for the presence of urine or serum ketones.
- The finding of large amounts of ketones in the patient�s urine or serum indicates that the patient may be obtaining much of her caloric requirement from lipolysis due to depleted glucose and glycogen stores.
Emergency Department Management
- The initial Emergency Department treatment of hyperemesis gravidarum includes intravenous rehydration with crystalloid solution (normal saline or lactated ringers).
- Subsequent intravenous rehydration continues with the use of either D5-lactated Ringers or D5-normal saline.
- Urine ketones and the specific gravity should be monitored during the course of the patients rehydration for improvement.
- Parenteral antiemetics are frequently used for control of further nausea and vomiting. Frequently used antiemetics are promethazine (phenergan), prochlorperazine (compazine) and trimethobenzamide (tigan).
- Potassium may need to be added to the patient�s intravenous fluids based on laboratory findings.
- Indications for admission in a patient with hyperemesis graviderum include:
- uncertainty regarding the etiology of the patients severe nausea and vomiting;
- electrolyte imbalances and/or ketosis that are not resolving with treatment;
- persistent nausea and vomiting in spite of adequate treatment; a >10% weight loss.
- The patient who shows significant improvement in symptomatology with Emergency Department treatment is able to tolerate PO intake; has no major electrolyte abnormalities and demonstrates resolving ketosis can be discharged home.
- The patient should be instructed to eat small frequent meals and increase oral fluid intake.
- The patient may be discharged home with a prescription for an antiemetic, usually in the form of a rectal suppository
- They should be instructed to be rechecked either in the Emergency Department or with their private obstetrician in 24 h.
- The patient�s obstetrician should also be contacted to inform them of the patient�s visit to the ED.
Pregnancy Induced Hypertension
Definition
Clinical Presentation
- The diagnosis of preeclampsia is made in the presence of the following:
- Sustained systolic blood pressure =140 or diastolic blood pressure =90 measured on two separate occasions =6 h apart
AND EITHER
- Significant proteinuria
OR
- Generalized edema or weight gain of at least 5 lb in 1 wk
- Although preeclampsia usually occurs after 20 wk gestation, it may be seen earlier in the presence of molar pregnancy.
- In cases of severe preeclampsia the patient may also complain of scotomas, severe headache and upper abdominal pain.
Diagnostic Evaluation
- Laboratory evaluation should include a CBC with a peripheral blood smear, platelet count, liver function tests, electrolytes, blood type and screen and urinalysis.
- If the fetal gestational age is < 24 wk (nonviable), intermittent fetal heart rate assessment should be performed. If the fetal gestational age is >24 wk, then fetal monitoring and biophysical profile should be obtained.
Emergency Department Management
Cardiopulmonary Arrest during Pregnancy
- The incidence of cardiac arrest is approximately 1 in every 30,000 pregnancies.
- The most common etiologies are pulmonary embolism, trauma, post-partum hemorrhage with hypovolemia, amniotic fluid embolism and congenital/acquired cardiac disease.
- In the treatment of cardiac arrest in pregnancy initial resuscitative measures and procedures should be employed as they would in the nonpregnant patient.
- Large bore intravenous access should be obtained at a site above the diaphragm so as to
enhance the systemic circulation of resuscitation medications. Again, vena caval compression may decrease venous return and medications administered below the diaphragm may be delayed in their ability to reach the central circulation in a timely manner.
- The standard medications indicated in the Current ACLS Guidelines are considered safe for use in the pregnant cardiopulmonary arrest patient based on limited data.
- Electrical therapy which includes defibrillation or cardioversion are performed if clinically indicated in the same manner and with the same energy levels as in the non pregnant patient.
- Perimortem C-section may be clinically indicated. The circumstances regarding the arrest , gestational age, potential survival of the fetus and the time interval since the onset of the maternal cardiac arrest are all factors to be considered when making this decision.
- If the postmortem C-section can be performed in < 5 min from the onset of the maternal cardiac arrest there is a good prognosis for the survival of a viable infant.
- The emergency physician must also be prepared to perform a neonatal resuscitation and have appropriate equipment and staff available should it be needed.
- Bedside ultrasound in the emergency department is extremely helpful in the decision making process regarding whether to initiate a perimortem C-section by providing information regarding fetal age and viability.
- If gestational age is >20 wk and there is positive fetal cardiac activity perimortem, C-section may be indicated.
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