EPISODE 23 - VAGINAL IN EARLY - EMERGENCYMEDICINECASES.COM

SUMMARY OF EPISODE 23: IN EARLY PREGNANCY WITH DR. ROSS CLAYBO AND DR. DAVID DUSHENSKI Approach to vaginal bleeding in early pregnancy

Big Categories to Consider: When taking a history, determine: Anembryonic Pregnancy: Fertilized ovum that does not develop • ◊ degree and duration of bleeding, into a normal . Presents with • Threatened/spontaneous ◊ is the pain lateral or central, bleeding in 1st trimester & ultrasound showing a without • Anembryonic pregnancy ◊ history of trauma, visualization of yolk sac or embryo at • Non obstetrical causes (vaginal ◊ obstetric and fertility history, appropriate sizes. Management is laceration, neoplastic polyps, fibroids) bleeding disorders, infections, similar to a missed abortion (see below) once ectopic is ruled out. • Gestational trophoblastic disease ◊ previous history.

WHEN IS BHCG TESTING USEFUL? Key BhCG facts to remember: BhCG levels become positive 8–11 days after At expected time of missed menses: 2000IU/mL conception. Levels peak at 10–12 weeks, then gradually decrease. **Test all women of child- IUP visible by transvaginal ultrasound: >1500IU/mL bearing age regardless of history suggesting possibility of pregnancy(1,2).** Urine BhCG IUP visible by abdominal ultrasound: >3000IU/mL becomes positive 1 week later than serum tests, and may be falsely negative if urine is very dilute. Cardiac activity visible on ultrasound: >1500IU/mL by transvaginal Is there value for serum ? >6500IU/mL by abdominal Progesterone may identify patients who have high likelihood of viable BhCG doubling time: intrauterine pregnancy (levels >22ng/mL), and patients who likely have a 48 –72 hours nonviable pregnancy (levels <5ng/mL)(3)—however, our experts believe it Levels becomes undetectable: does not significantly change practice enough to warrant its use in the ED. 3–4 weeks postpartum Work-up + Management of Abortion & Ectopic Pregnancy

Categories of Miscarriage/ What is the value of the pelvic may be falsely Spontaneous Abortion examination in stable patients? reassuring in ectopic pregnancy: If ultrasound findings are available and Patients with ectopics often have normal Threatened: bleeding with closed reassuring, our experts suggest a pelvic vital signs, even with significant bleeding, and no evidence of fetal exam may be deferred. However, if high and may have a reflex bradycardia demise on ultrasound (U/S) quality ultrasound is not available, or not caused by a vagal response to definitive & reassuring, a pelvic exam is intraperitoneal (4). Risk of complete abortion is 50%, but if required to assess the and Physical examination findings in fetal heart rate seen (possible at >7 adnexae. The pelvic exam is also an ectopic pregnancy (5): weeks), risk decreases to ~5% opportunity for STI screening. • Abdominal tenderness (80-90%) Inevitable: open cervix, products What about unstable patients • Adnexal tenderness (75-90%) with miscarriage and bleeding? of conception not yet expelled • (50%) Manage similar to all unstable bleeding Almost all progress to complete • Uterine enlargement (25%) patients (resus room, monitors, vascular • Orthostasis (10%) Incomplete: products of access, IV fluid +/- unmatched O neg Pelvic exams can be completely normal. conception not completely expelled, blood, foley). Investigate for DIC, and urgently consult OB/GYN. based on U/S or exam Serial BhCG measurement is most Tranexamic acid (1g IV) +/- oxytocin useful to confirm (BhCG Compete: All products expelled (40U by IV in 1L NS at 150cc/hour) can should rise at least 66% over 48hrs) from uterus, bleeding usually be given to slow bleeding before rather than to identify ectopic minimal, and os closed definitive management (in the OR). pregnancy. However if the BhCG >50,000, ectopic is very unlikely. Missed: U/S shows fetal demise, **In an unstable patient with massive but products remain in uterus, with vaginal bleeding, a pelvic exam is indicated to identify a source and to look for and or without bleeding or symptoms VERY LOW BHCG (<1000) extract tissue found in the cervix.** DOES NOT RULE OUT Septic: rare result of pelvic ECTOPIC; ULTRASOUND IS instrumentation (esp. non sterile STILL NEEDED! conditions), may be mistaken as PID

Bedside ED Ultrasound: ED U/S for ectopic is very specific for How should we manage stable ruling out ectopic (6), and involves patients with miscarriage? looking for intrauterine pregnancy Management options are expectant (IUP), and free fluid in the pelvis and management, medical management . To confirm an IUP by U/S, a ( 800mg inserted vaginally decidual reaction with a gestational sac encourages passage of products), and Ectopic Pregnancy and yolk sac (+/- fetal pole) must be surgical management (D&C). Only 50% of patients have classic risk seen *within* the uterus. Even if an IUP Counseling in the ED must also address factors (past history of ectopic, tubal is seen, if the patient is unstable with psychological concerns: surgery, , free fluid in the abdomen, it may be a treatment, or PID). The classic triad of ruptured cyst or a “heterotopic”! - use sensitivity and empathy, (80–90%), missed When to give Rhogam: Give Anti- - acknowledge distress and grief, menses 4–12 wks after LMP (75–90%) D immunoglobulin to non sensitized Rh- - reassure the patient that neither she & vaginal bleeding (50–80%) is NOT D negative women to prevent nor her partner did anything to cause sensitive. Up to 25% lack the full triad, development of RhD antibodies. It the miscarriage, and and 10% may have no symptoms. should be given as soon as possible after Consider ectopic when a patient presents - there is no increased risk for future the immunizing event (within 72 hours) with and has a positive BhCG. (if < 3 have occurred). and effects last for 12 weeks. How are ectopic treated and what are the complications that may occur?

Treatment options for ectopic pregnancy What is a molar pregnancy: ECTOPIC PITFALLS Expectant: in stable patients with a Molar pregnancies are tumors from BhCG below 200 and not increasing, abnormal fertilization of an ovum, with >75% will resolve spontaneously. Close overproliferation of trophoblastic tissue. monitoring is needed until BhCG <15. A complete mole has no fetal tissue, while an incomplete mole has abnormal (MTX): MTX is a fetal tissue. folic acid antagonist that is up to 95% effective in appropriate patients (BhCG Most common presentation is <5000, no fetal cardiac activity, ectopic vaginal bleeding, but they can present with due mass <3–4cm, hemodynamically stable, AVOID these major pitfalls of to generation of reactive cysts. no sign of rupture, reliable patient.) diagnosing ectopic pregnancy in the The uterus will be larger than dates, and emergency department: Failure of MTX is related to BhCG level: ultrasound may show a “snowstorm” Failure rates are approx. 15% with BhCG appearance. Ultrasound is not sensitive • assuming low BhCG rules out >5000 and 5% with BhCG <5000. for molar pregnancy in first trimester. ectopic Prior to MTX treatment, blood tests must • relying on the “classic triad” confirm normal liver and kidney function, and relying on inexperienced patients must be counseled to avoid folic • ultrasonographer or non-hospital acid and alcohol. Strenuous exercise and ultrasound lab reports intercourse must also be avoided due to the risk of tubal rupture. Patients must also • assuming no products of discontinue folic acid supplementation. conception seen on U/S means it was a complete abortion (and not Surgical: for patients who do not Patients may present with preeclampsia an ectopic) qualify for or have failed other and/or hyperthyroid symptoms due to management, or patients who have intra- very high BhCG levels (>100,000). • failure to appreciate degree of abdominal bleeding or are unstable, Treatment is surgery, and blood loss surgical management is indicated. includes a workup for metastatic • failure to consider heterotopic* if disease. 15–20% of complete molar unstable and IUP seen on U/S pregnancies and 2% of incomplete If a patient who received MTX become neoplastic, so patients need a • failure to assure adequate follow returns with abdominal pain: CXR and liver enzyme measurements, up if no IUP is seen or if the ultrasound is indeterminate Abdominal pain is a common side effect and close follow-up with OB/GYN. of MTX treatment, but may indicate tube *heterotopic risk of 1 in 30,000 rupture (occurs in 4% of patients, usually pregnancies rises to 1 in 100 if the 2 weeks after MTX treatment). Patients References: patient is receiving fertility treatments need a full workup for ectopic rupture: 1) Minnerop et al. Am J Emerg Med. 2011; hematocrit, BhCG, and ultrasound to 29:212 look for bleeding. If there are any signs 2) Ramoska et al. Ann Emerg Med. 1989;18:48 of rupture, urgent OB consult is needed. 3) Buckley et al. Ann Emerg Med. 2000;36:95 **Due to the risk of tubal rupture, do not 4) Hick et al. Am J Emerg Med. 2001;19:488 do a pelvic exam on a patient who has had MTX treatment and presents with pain or 5) Dart et al. Ann Emerg Med. 1999;33(3):283 vaginal bleeding,. Begin workup for ectopic 6) Stein et al. Ann Emerg Med. 2010;56(6):674 rupture and consult OB/GYN.** SUBSCRIBE TO EMCASES