Rosen & Barkin's 5-Minute Emergency Medicine Consult (232 page)

• For outpatient treatment the team must establish modest goals and clear parameters, including expected weight gain for anorexic patients and compliance with follow-up appointments.
  
• Internist/pediatrician: Monitor vital signs, weight, BMI, electrolytes, and ECG.
  
• Nutritionist: Monitor diet, calorie intake, and exercise.
  
• Psychotherapy:
  
  • Cognitive behavioral therapy and interpersonal psychotherapy are the most effective forms of psychotherapy for BN.
    
  • Cognitive behavioral therapy, family therapy, and psychodynamic therapies are all useful for AN.
    
  • Family-based treatment is the preferred therapy for teenagers with AN, and it is promising for teenagers with BN as well.
    
• Pharmacotherapy:
  
  • Only indicated within the context of psychotherapy, especially with comorbid psychopathology.
    
  • No accepted pharmacologic treatment of AN.
    
    • Case studies suggest that 2nd-generation antipsychotics may be helpful in AN.
      
    • There is no clear evidence for specific treatment of osteoporosis in AN apart from weight restoration and nutritional calcium supplementation.
      
  • Antidepressant medications are shown to significantly reduce bingeing and purging behaviors:
    
    • Fluoxetine is the best studied
      

• Eating disorders are associated with high medical risk and risk of suicide; prioritize safety assessment
  
• Rapid restoration of nutrition, volume resuscitation, and/or failure to replete vitamins and electrolytes can result in potentially fatal refeeding syndrome
  
• Avoid trying to “out-obsess” the obsessional patient
  
• Coordinate care with PCP and other members of a multidisciplinary team
  

• Aigner M, Treasure J, Kaye W, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders.
  World J Biol Psychiatry.
  2011;12:400–443.
  
• American Psychiatric Association.
  Diagnostic and Statistical Manual of Mental Disorders
  . 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  
• American Psychiatric Association (APA).
  Practice Guidelines for the Treatment of Patients with Eating Disorders
  . 3rd ed. Washington, DC: 2006, and Guideline Watch (update) August 2012.
  
• Mascolo M, Trent S, Colwell C, et al. What the emergency department needs to know when caring for your patients with eating disorders.
  Int J Eat Disord.
  2012;45:977–981.
  
• Mitchell JE, Crow S. Medical complications of anorexia nervosa and bulimia nervosa.
  Curr Opin Psychiatry
  . 2006;19(4):438–443.
  
• Rosen DS, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents.
  Pediatrics
  . 2010;126:1240–1253.
  

CODES

• 307.1 Anorexia nervosa
  
• 307.50 Eating disorder, unspecified
  
• 307.51 Bulimia nervosa
  

BASICS

• Implantation of fertilized ovum outside of uterus:
  
  • Most commonly fallopian tube (93–97%)
    
• Abdominal and peritoneal implantations:
  
  • Associated with higher morbidity
    
  • Difficulty in diagnosis
    
  • Tendency to bleed
    
• Occurs in 2–2.6% of pregnancies
  
• Accounts for 6% of all maternal deaths (leading cause of 1st-trimester pregnancy-related death)
  
• 60% of women with ectopic pregnancy are subsequently able to have a normal pregnancy
  

• Risk factors include:
  
  • Woman >35 yr old
    
  • African American
    
  • Previous fallopian tube damage from infections, such as pelvic inflammatory disease (PID)
    
  • Previous tubal surgery (i.e., tubal ligation)
    
  • Previous ectopic pregnancy
    
  • Intrauterine device (IUD) use:
    
    • 25–50% of pregnancies with IUD are ectopic
      
  • Diethylstilbestrol (DES) exposure
    
  • In vitro fertilizations
    
  • Being a current smoker
    
• More than half of women with ectopic pregnancies have no risk factors
  

DIAGNOSIS

Classic triad of amenorrhea, vaginal bleeding, and abdominal pain are present in only 15% of women with ectopic pregnancies:

• Amenorrhea (75–95%)
  
• Abdominal pain (80–100%):
  
  • Frequently unilateral
    
• Abnormal vaginal bleeding (50–80%)
  
• Symptoms of pregnancy (10–25%)
  
• Orthostatic hypotension, dizziness, and syncope (5–35%)
  
• Abdominal tenderness (55–95%)
  
• Adnexal tenderness (75–90%)
  
• Adnexal mass (35–50%)
  
• Cervical motion tenderness (43%)
  

• Last menstrual period (LMP):
  
  • Majority of ectopics present 5–8 wk after LMP.
    
• Gestation and parity history
  
• Vaginal bleeding
  
• Location, nature, and severity of pain
  
• History of pelvic surgery, prior ectopic, IUD
  
• History of fertility treatments
  

• Evaluate for signs of peritoneal irritation
  
• Pelvic exam:
  
  • Note uterine size
    
  • Adnexal size, mass
    
  • Adnexal tenderness
    
  • Presence of tissue in vaginal vault
    
  • Cervical motion tenderness
    
  • Cervical OS open or closed
    

• Pregnancy testing:
  
  • Women of potential childbearing age with vaginal bleeding or abdominal pain
    must
    have urine or serum pregnancy test
    
  • Include testing of patients with history of recent elective or spontaneous abortion, tubal ligations, or IUD use
    
  • Quantitative β-human chorionic gonadotropin (β-hCG) in patients with positive qualitative test
    
• Vital signs unstable:
  
  • 2 large-bore IVs
    
  • Type and cross-match, hemoglobin (Hg)/hematocrit (Hct)
    
  • Bedside ultrasound (US), if immediately available, simultaneous with resuscitation (transvaginal preferred)
    
  • Consult obstetrics/gynecology (OB/GYN) and prepare for immediate surgical intervention
    
• Vital signs stable:
  
  • Rapid Hg/Hct determination
    
  • Type and Rh
    
  • US (transvaginal preferred)
    

• Urine pregnancy tests can detect β-hCG levels of 25–50 mIU/L
  
• Serum can detect β-hCG levels of 25 mIU/L
  
• Quantitative serum β-hCG; for diagnosis and follow-up:
  
  • Doubles every 2 days in normal early pregnancy (early pregnancy <10,000 β-hCG mIU/L, 8 days–7 wk)
    
  • β-hCG increases less in ectopic pregnancy
    
  • Correlation with vaginal US increases predictive value
    

• Ultrasonographic evidence of IUP makes ectopic pregnancy less likely:
  
  • Heterotopic pregnancies are possible
    
• Positive IUP is indicated by double-ringed gestational sac, yolk sac, or fetal pole, and heartbeat seen in uterus
  
• Transvaginal US; visualization of gestational sac at 5 wk, cardiac activity at 6.5 wk
  
• Transabdominal US; visualization of gestational sac at 5–6 wk, cardiac activity at 8 wk
  
• Complex adnexal mass and fluid in cul-de-sac seen in 22% of ectopics and has 94% positive predictive value when present
  
• Positive pregnancy test with no confirmed IUP and fluid in pelvis; high risk for bleeding ectopic pregnancy
  

• US in conjunction with quantitative β-hCG
  
• Patients with β-hCG levels >6,500 mIU/L and no intrauterine gestational sac seen on US have 100% chance of having ectopic pregnancy
  
• Patients with β-hCG levels >6,500 mIU/L with intrauterine gestational sacs present have 94% chance of having normal pregnancy
  
• Patients with β-hCG <2,000 mIU/L are too early to have gestational sac seen by abdominal US and thus cannot be ruled out for ectopic pregnancy
  
• Patients with β-hCG >2,000 and <6,500 mIU/L should have IUP visualized on transvaginal US; suspect ectopic pregnancy if IUP is absent
  
  • Discriminatory hCG value for transvaginal US is between 1,500 and 3,000 mIU/mL
    
• Culdocentesis to evaluate for intraperitoneal blood if US is unavailable
  

• Positive pregnancy test with vaginal bleeding:
  
  • Spontaneous abortion
    
  • Cervicitis
    
  • Trauma
    
• Positive pregnancy test with no evidence of IUP:
  
  • Completed spontaneous abortion
    
  • Early threatened abortion
    
• Positive pregnancy test with evidence of IUP, abdominal pain, or adnexal tenderness:
  
  • Septic abortion
    
  • Threatened abortion
    
  • Ruptured corpus luteal or ovarian cyst
    
  • Ovarian torsion
    
  • UTI
    
  • Nephrolithiasis
    
  • Gastroenteritis
    
  • Appendicitis
    
  • Heterotopic pregnancy (IUP + ectopic)
    
  • PID
    

TREATMENT