Rosen & Barkin's 5-Minute Emergency Medicine Consult (752 page)

• US:
  
  • Essential diagnostic modality:
    
    • Confirms intrauterine pregnancy (IUP)
      
    • Detects gestational sac at 5 wk (usually with β-hCG ≥1,000–2,000 IU), yolk sac at 6 wk, and cardiac activity at 5–6 wk of gestation
      
    • Essentially rules out ectopic pregnancy by showing IUP (except in women at high risk for heterotopic pregnancy)
      
    • Proves ectopic pregnancy by showing fetal pole outside uterus
      
    • Suggests ectopic pregnancy by detecting free fluid in cul-de-sac or adnexal mass
      
    • Detects retained POC
      
    • Demonstrates “snowstorm” appearance within uterus with gestational trophoblastic disease
      

• Culdocentesis:
  
  • Limited use
    
  • Identifies free fluid in cul-de-sac
    
• D&C or vacuum aspiration:
  
  • Indicated if suspected incomplete or septic abortion, embryonic demise, gestational trophoblastic disease, or anembryonic gestation to evacuate retained POC
    
• Laparoscopy/laparotomy:
  
  • Indicated for unstable patients
    
  • Definitive diagnosis and treatment of ectopic pregnancy
    

• Early pregnancy (<20 wk):
  
  • Implantation bleeding
    
  • Threatened abortion
    
  • Complete, incomplete, inevitable, embryonic demise (missed abortion), and septic abortion
    
  • Ectopic pregnancy
    
  • Heterotopic pregnancy
    
  • Gestational trophoblastic disease (molar pregnancy)
    
  • Subchorionic hemorrhage
    
  • Anembryonic gestation (blighted ovum)
    
  • Infection (e.g., cervicitis)
    
  • Trauma
    
  • Cervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)
    
  • Bleeding disorders
    
• Late pregnancy (>20 wk):
  
  • Placental abruption (30%)
    
  • Placenta previa (20%)
    
  • Bloody show (associated with cervical insufficiency or labor)
    
  • Vasa previa
    
  • Cervical/vaginal trauma or pathology
    
  • Uterine rupture (uncommon)
    
  • Infection (e.g., cervicitis)
    
  • Trauma
    
  • Cervical and vaginal lesions (e.g., polyps, ectropion, carcinoma)
    
  • Bleeding disorders
    

TREATMENT

• Unstable vital signs warrant aggressive resuscitation
  
• In late pregnancy, position patient on left side to decrease uterine compression of inferior vena cava (IVC)
  
• Consider preferential transport of a woman with late pregnancy to a facility with obstetric capabilities
  

• Airway management
  
• Oxygen
  
• Pulse oximetry
  
• Cardiac monitor
  
• 2 large-bore IV lines
  
• Blood transfusion as indicated
  
• Continuous fetal monitoring in later pregnancy
  

• All women with early pregnancy vaginal bleeding must be evaluated for ectopic pregnancy (preferably by transvaginal US)
  
• Administer Anti-Rh
  ₀
  (D) immune globulin if patient is Rh-negative
  
• Suspected ectopic pregnancy:
  
  • Unstable: Consider bedside US with emergent OB/GYN consultation for laparoscopy/laparotomy
    
  • Stable: Perform US:
    
    • If confirmatory or suggestive of ectopic pregnancy, obtain OB/GYN consultation for surgery or methotrexate therapy
      
    • If inconclusive, obtain OB/GYN consultation and arrange for repeat β-hCG testing in 2 days
      
• Threatened abortion:
  
  • Emergent OB/GYN consultation for heavy/uncontrolled bleeding
    
  • Arrange OB/GYN follow-up for minimal bleeding
    
• Inevitable/incomplete/missed (embryonic demise) abortion:
  
  • POC in the cervical os can result in profuse bleeding
    
  • If POC cannot be removed with gentle traction, obtain emergent OB/GYN consultation
    
  • Arrange OB/GYN follow-up if bleeding minimal
    
• Complete abortion:
  
  • Emergent OB/GYN consultation for heavy/uncontrolled bleeding
    
  • Arrange OB/GYN follow-up if bleeding minimal
    
• Septic abortion:
  
  • Initiate broad-spectrum antibiotic therapy
    
  • Emergent OB/GYN consultation for D&C
    
• Late pregnancy vaginal bleeding:
  
  • Hemodynamic stabilization:
    
    • Fluid resuscitation
      
    • Positioning of patient onto left side or displacement of uterus laterally to relieve compression by IVC
      
  • DIC:
    
    • Associated with late pregnancy bleeding
      
    • Especially with placental abruption
      
    • Treated with blood products
      
  • Immediate obstetric consultation and rapid transfer to obstetric unit
    

• Anti-Rh
  ₀
  (D) immune globulin: <12 wk–50 μg IM; >12 wk–300 μg IM
  
• Methotrexate:
  
  • Variable dosing regimens
    
  • Only recommended for hemodynamically stable women with unruptured ectopic pregnancy with low β-hCG
    
• Antibiotics for septic abortion:
  
  • Multiple acceptable antibiotic regimens
    
  • Must provide polymicrobial coverage
    

Misoprostol has been used in completed abortion to facilitate uterine evacuation in completed miscarriage

FOLLOW-UP

• Early pregnancy vaginal bleeding with:
  
  • Unstable vital signs or significant bleeding
    
  • Ruptured ectopic pregnancy
    
  • Incomplete abortion (open os)
    
  • Septic abortion
    
• All patients with late pregnancy vaginal bleeding need to be admitted to a labor and delivery unit
  

• Stable patients with threatened abortion complete abortion, embryonic demise, or anembryonic gestation
  
• Asymptomatic, hemodynamically stable patient with small, unruptured ectopic (or suspected ectopic) pregnancy after OB/GYN consultation
  
• Controlled bleeding from vaginal/cervical source
  

• Patients with embryonic demise, anembryonic gestation, or gestational trophoblastic disease need to be referred for uterine evacuation if D&C not performed in ED
  
• Women with threatened, inevitable, complete, or missed (embryonic demise) abortion should have OB/GYN follow-up within 24–48 hr
  

• Discharge instructions:
  
  • No strenuous activity, tampon use, douching, or intercourse
    
  • Seek medical advice for increased pain, bleeding, fever, or passage of tissue
    
• All pregnant women with vaginal bleeding during pregnancy who are discharged from the ED require follow-up care
  
• Women with threatened abortions, known or suspected ectopic pregnancy require repeat β-hCG testing and repeat exams in 2 days
  

• Failure to check Rh status in pregnant women with vaginal bleeding
  
• Failure to give Anti-Rh
  ₀
  (D) immune globulin in Rh-negative women with vaginal bleeding
  
• Placenta previa or vasa previa must be ruled out by US prior to pelvic exam in late pregnancy
  

• Hahn SA, Lavonas EJ, Mace SE, et al. Clinical policy: Critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy.
  Ann Emerg Med.
  2012;60:381–390.
  
• Huancahuari N. Emergencies in early pregnancy.
  Emerg Med Clin North Am.
  2012;30:837–847.
  
• Jurkovic D, Wilkinson H. Diagnosis and management of ectopic pregnancy.
  BMJ.
  2011;342:d3397.
  
• Meguerdichian D. Complications in late pregnancy.
  Emerg Med Clin North Am.
  2012;30:919–936.
  
• Wang R, Reynolds TA, West HH, et al. Use of a β-hCG discriminatory zone with bedside pelvic ultrasonography.
  Ann Emerg Med.
  2012;58:12–20.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Abortion, Spontaneous
  
• Ectopic Pregnancy
  
• Hydatidiform Mole
  
• Placental Abruption
  
• Placenta Previa
  
• Postpartum Hemorrhage
  

CODES

• 634.90 Spontaneous abortion, without mention of complication, unspecified
  
• 640.90 Unspecified hemorrhage in early pregnancy, unspecified as to episode of care or not applicable
  
• 641.80 Other antepartum hemorrhage, unspecified as to episode of care or not applicable