Part 2 Of EMC #23 – “Vaginal Bleeding [And Abdominal Pain] In Early Pregnancy” [Ectopic Pregnancy]

Please see additional resources on this topic from Emergency Medicine Cases:

More on Vaginal Bleeding on EM Cases:
          Episode 7: Medical and Surgical Emergencies in Pregnancy
          Best Case Ever 9 Vaginal Bleeding in Early Pregnancy
          BCE 68 Ectopic Pregnancy Pitfalls in Diagnosis
          Rapid Reviews Videos on First Trimester Bleeding and Ectopic Pregnancy

Please also review Part 1 Of EMC #23 – “Vaginal Bleeding [And Abdominal Pain] In Early Pregnancy” [Differential Diagnosis]
Posted on April 26, 2020 by Tom Wade MD

Vaginal bleeding and/or abdominal pain in women can be harbinger of ectopic pregnancy which is responsible for 10% of all maternal morality from pregnancy.

Thus either of these complaints in women must be approached with the utmost caution.

Every patient  with either of the above complaints requires a serum beta-hCG. The authors state that the urine beta-hCG can be falsely negative. So if available in your practice setting the beta-hCG is preferred.

The Abbott I-Stat point of care system has a cartridge for blood or plasma quantitative or qualitative Beta-hCG. I don’t yet know of the performance characteristics of the test.

Every patient with one of the above complaints AND a positive beta-hCG requires a point of care pelvic ultrasound. If a normal intrauterine pregnancy is not detected (if the scan is indeterminate) the patient requires a transvaginal ultrasound.

In this post I link to and excerpt from the outstanding Emergency Medicine Cases podcast and show notes on how to approach these two potentially life-threatening problems in Episode 23: Vaginal Bleeding in Early Pregnancy, [Link is to the podcast and show notes] May 2012, by Drs Dushenski, D, Claybo, and R, Helman, A:

Here are excerpts from the second half of the podcast  covering Ectopic Pregnancy:

Ectopic Pregnancy

  • Only 50% of patients have classic risk factors (past history of ectopic, tubal surgery, tubal ligation, infertility treatment, or PID).
  • The classic triad of abdominal pain (80–90%), missed menses 4–12 wks after LMP (75–90%) & vaginal bleeding (50–80%) is NOT sensitive. Up to 25% lack the full triad, and 10% may have no symptoms.
  • Consider ectopic when a patient presents with syncope and has a positive BhCG.
  • Vital signs may be falsely reassuring in ectopic pregnancy: Patients with ectopics often have normal vital signs, even with significant bleeding, and may have a reflex bradycardia caused by a vagal response to intraperitoneal blood (4).
  • Physicalexaminationfindings in ectopic pregnancy (5):
    1. Abdominal tenderness (80-90%)
    2. Adnexal tenderness (75-90%)
    3. Adnexal mass (50%)
    4. Uterine enlargement (25%)
    5. Orthostasis (10%)
  • Pelvic exams can be completely normal.
  • Serial BhCG measurement is most useful to confirm fetal viability (BhCG should rise at least 66% over 48hrs) rather than to identify ectopic pregnancy.
    • However if the BhCG >50,000, ectopic is very unlikely.
  • Bedside ED Ultrasound (POCUS):
    • ED U/S for ectopic is very specific for ruling out ectopic (6), and involves looking for intrauterine pregnancy (IUP), and free fluid in the pelvis and abdomen.
    • To confirm an IUP by U/S, a decidual reaction with a gestational sac and yolk sac (+/- fetal pole) must be seen *within* the uterus.
    • Even if an IUP is seen, if the patient is unstable with free fluid in the abdomen, it may be a ruptured cyst or a “heterotopic”!

For practical tips on picking up Ectopic Pregnancy on POCUS visit the EDEblog

  • When to give Rhogam:
    • Give Anti- D immunoglobulin to non sensitized Rh- D negative women to prevent development of RhD antibodies.
    • It should be given as soon as possible after the immunizing event (within 72 hours) and effects last for 12 weeks.
  • Treatment options for ectopic pregnancy
    • Expectant: in stable patients with a BhCG below 200 and not increasing, >75% will resolve spontaneously.
      • Close monitoring is needed until BhCG <15.
    • Methotrexate (MTX): MTX is a folic acid antagonist that is up to 95% effective in appropriate patients (BhCG <5000, no fetal cardiac activity, ectopic mass <3–4cm, hemodynamically stable, no sign of rupture, reliable patient.)
      • Failure of MTX is related to BhCG level: Failure rates are approx. 15% with BhCG >5000 and 5% with BhCG <5000.
      • Prior to MTX treatment, blood tests must confirm normal liver and kidney function, and patients must be counseled to avoid folic acid and alcohol. Strenuous exercise and intercourse must also be avoided due to the risk of tubal rupture. Patients must also discontinue folic acid supplementation.
    • Surgical:for patients who do not qualify for or have failed other management, or patients who have intra- abdominal bleeding or are unstable, surgical management is indicated.
  • If a patient who received MTX returns with abdominal pain:
    • Abdominal pain is a common side effect of MTX treatment, but may indicate tube rupture (occurs in 4% of patients, usually 2 weeks after MTX treatment).
    • Patients need a full workup for ectopic rupture: hematocrit, BhCG, and ultrasound to look for bleeding.
    • If there are any signs of rupture, urgent OB consult is needed.
    • **Due to the risk of tubal rupture, do not do a pelvic exam on a patient who has had MTX treatment and presents with pain or vaginal bleeding,. Begin workup for ectopic rupture and consult OB/GYN.**
  • AVOID these major pitfalls of diagnosing ectopic pregnancy in the emergency department:
    • assuming low BhCG rules out ectopic
    • relying on the “classic triad”
    • relying on inexperienced ultrasonographer or non-hospital ultrasound lab reports
    • assuming no products of conception seen on U/S means it was a complete abortion (and not an ectopic)
    • failure to appreciate degree of blood loss
    • failure to consider heterotopic* if unstable and IUP seen on U/S
      • *heterotopic risk of 1 in 30,000 pregnancies rises to 1 in 100 if the patient is receiving fertility treatments
    • failure to assure adequate follow up if no IUP is seen or if the ultrasound is indeterminate

Molar Pregnancy

  • What is a molar pregnancy:
    • Molar pregnancies are tumors from abnormal fertilization of an ovum, with overproliferation of trophoblastic tissue. A complete mole has no fetal tissue, while an incomplete mole has abnormal fetal tissue.
  • Most common presentation is vaginal bleeding, but they can present with ovarian torsion due to generation of reactive cysts.
  • The uterus will be larger than dates, and ultrasound may show a “snowstorm” appearance. Ultrasound is not sensitive for molar pregnancy in first trimester.
  • Patients may present with preeclampsia and/or hyperthyroid symptoms due to very high BhCG levels (>100,000).

Treatment is surgery, and includes a workup for metastatic disease.

  • 15–20% of complete molar pregnancies and 2% of incomplete
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