Transcript First-Trimester Emergencies: A Practical Approach To Abdominal

2007.05.31
김의중
Ectopic Pregnancy
목
적
 Identify readily available tests:
 risk-stratify women at risk for ectopic pregnancy
 List management strategies for treating women with
nonviable IUP
 Describe one reasonable approach to managing the
unstable early pregnant woman
 List U/S findings most suggestive of the D/x of
ectopic pregnancy
 Discuss the clinical utility of the quantitative ß-hCG
test and progesterone level
증
례
 1주일 전 응급실을 방문한 25세 여자가 심한 복통을 주소로 다
시 응급실을 방문을 하였다. 환자의 남편은 병원에 오기 전 복통
으로 1차례의 실신을 한 후에 구급차를 불러서 응급실로 왔다고
한다.
 환자 clammy & tachycardic 하였고 임신상태처럼 보이지는 않
았다.
 Systolic BP : 70 mmHg, HR : 130bpm.
 Her abdomen is diffusely tender.
증
례
 Your first thought is the obvious one to any
experienced emergency physician—she has a
ruptured ectopic pregnancy.
 Your second thought is,
 "Who was the idiot who discharged her last week?"
 As she’s wheeled into the trauma room, you
notice that her face looks familiar.
Critical Appraisal Of The Literature
 Kohn et al
 Retrospective medical record review of 730 women -
abdominal pain, vaginal bleeding, or both and a nonzero quantitative ß-hCG.
 In this cohort, 13% of the women were diagnosed with
ectopic pregnancies.
Female genital tract
Clinical Policies
 ACEP (American College of Emergency
Physicians) - 3 clinical policies in the 1st trimester
Abdominal pain, vaginal bleeding, or both.
1. “Clinical Policy for the Initial Approach to Pts
Presenting with a C.C. of Vaginal Bleeding. ”
- ß-hCG, Rh testing
Clinical Policies
 ACEP (American College of Emergency
Physicians) - 3 clinical policies in the 1st trimester
Abdominal pain, vaginal bleeding, or both.
2. “Critical Issues for the Initial Evaluation & Mana
gement of Pts Presenting with a C.C. of Non-trau
matic Abdominal Pain.”
Clinical Policies
 ACEP (American College of Emergency Physicians)
- 3 clinical policies in the 1st trimester
Abdominal pain, vaginal bleeding, or both.
3. “Critical Issues in the Initial Evaluation &
Management of Pts Presenting to the Emergency
Department in Early Pregnancy.”
- 6 clinical questions ranging from the role of U/S when the
ß-hCG < 1000 mIU/mL to the indications for anti-D
immunoglobulin
Epidemiology
 Implantation of a fertilized ovum outside the
endometrial cavity of the uterus.
 Occur in up to 2%
 fallopian tube - 95% of ectopic pregnancies.
 Ampullary portion ; 80%
 Isthmus ; 12%
 Fimbriated end of the tube ; 5%
 Junction of the fallopian tube and uterus ; 2%
 interstitial or a cornual ectopic pregnancy.
 The abdomen, the cervix, and the ovary.
Etiology
 Mucosa Damage - M/C
 result of tubal infection.
 S/P tubal surgery
 Diethylstilbestrol exposure
 Defects in the fertilized ovum – decreased tubal
motility or premature implantation
 Hormonal factors
Pathophysiology

4 possible outcomes from tubal preg.
1.
2.
3.
4.

Erode through the muscularis and lamina propria of
the tube, resulting in tubal rupture
Persist within an intact tube with or without an
associated tubal hematoma
Abort out of the fimbriated end of the fallopian tube
Ectopic pregnancy may spontaneously involute.
Intraabdominal hemorrhage may occur in the
absence of tubal rupture.
Early Pregnancy Development
Possible anatomic sites in
ectopic pregnancies
Large tubal pregnancy
Large tubal pregnancy
Terminology
 Threatened Abortion
• Abdominal pain or vaginal bleeding without history of
passing tissue, closed os, uterus appropriately sized for
dates.
• 30%-50% of patients classified as having a "threatened
abortion"
 Stovall et al –
 history and physical examination were used as the
primary mode to assess first-trimester vaginal bleeding,
almost ½ of the ectopic pregnancies were discharged.
Terminology
• Inevitable & Incomplete Abortions
• “Inevitable abortion"

Situation when the cervical os is open but tissue has
not yet passed.
• “Incomplete abortion "
 Situation in which tissue has passed but the cervical os remains
open, suggesting that products of conception still remain within
the endometrial cavity
Terminology
• “Complete abortion"
 Situation in which the patient has passed tissue & the
closed cervical os.
• Clinically useful and is appropriate if definite products
of conception are evident.
• Frequently mistake blood clots for the products of
conception.
Terminology
• “Missed Abortion”
• Prolonged retention of products of conception in
the uterus.
• Complications
 Coagulation defects
Differential Diagnosis
Differential Diagnosis
Differential diagnosis of peripubertal and
pubertal ovarian masses
Gynecologic
Ovarian functional masses
Ovarian tumors: epithelial, stromal, germ cell tumors
Endometriosis/endometrioma
Paraovarian/paratubal cysts (embryonic remnants)
Ovarian torsion
Hydrosalpinx/pyosalpinx
Tubo-ovarian abscess
Ectopic pregnancy
Hematometra (mullerian anomalies, fusion defects)
Fibroids (rare)
Vaginal/cervical tumor (extremely rare)
Gastrointestinal
Intestinal duplication
Mesenteric cysts
Appendiceal abscess
Urinary
Pelvic kidney
Hydronephrosis
Wilms' tumor
Urachal cyst
Other
Neuroblastoma
ED Evaluation
 Triage & Initial Management
 Unstable Patients
 To a major resuscitation area, start 2 large-bore IV lines,
& begin resuscitation with boluses of isotonic saline.
 Rapid assessment of anemia & confirmation of the
pregnancy
 CBC, type and crossmatch, Rh testing
 A rapid quantitative pregnancy test
 The need for blood products
 Emergent U/S exam & gynecology consultation
ED Evaluation
 Triage & Initial Management
 Stable Patients
 Mild pain or bleeding & stable vital signs can typically
wait if an exam room is not immediately available
 Frequent reassessment by the triage nurse
ED Evaluation
 History
 History Of Present Illness



Location, character, onset & severity of the pain.
Pain originating from the uterus ; typically midline & crampy
Pain originating from the adnexa ; typically unilateral & sharp
 Review Of Systems
 Syncope or near-syncope
ED Evaluation
 Past Medical History
 Outcome of prior pregnancies
 Past gynecologic surgeries
 Intrauterine device (IUD) use
 Prior ectopic pregnancies
 Infertility treatments
 History of PID or STD
 Medications - method of birth control, as well as
the use of ovulation induction agents.
Protective effects of oral
contraceptives
Oral contraceptives
Decreased risk of endometrial &
ovarian cancer
 Lower risk of benign breast
disease & ovarian cysts
Decreased risk of major
gynecologic problems including PID
& ectopic pregnancy,
significant menstrual benefits
including decreased menstrual flow
(and thus anemia) and relief of
dysmenorrhea
ED Evaluation
 Physical Examination
 Vital Signs - assessment of circulation
 Abdominal Exam.
- The location of the tenderness
 Pelvic Exam
Open internal cervical os ; suggestive of the diagnosis of
nonviable IUP.
ED Evaluation
 Diagnostic Studies
 ß-hCG ; one of the most important & accurate
lab tests
 Progesterone;
the corpus luteum during the first 8 weeks.
 > 25ng/mL : strongly associated with the Dx of a
viable IUP
 < 5ng/mL : accurately excludes the Dx of a viable
IUP
ED Evaluation
 U/S ; most useful test for evaluating
(표 참조)
Empty uterus : an empty endometrial cavity
 Normal sac : anechoic intrauterine fluid collection < 10 mm
in mean sac diameter with a regular echogenic border
 Abnormal gestational sac : anechoic intrauterine fluid
collection either > 10 mm in mean sac diameter or with a
grossly irregular border
 Nonspecific fluid : anechoic intrauterine fluid collection
< 10 mm in mean sac diameter without an echogenic border
 Echogenic material : within the endometrial cavity without
a defined sac or multiple discrete anechoic collections of
varying sizes divided by echogenic septations

U/S finding
Indeterminate of
U/S finding
Incidence of
ectopic
pregnancy
Empty uterus
14%
Nonspecific fluid
5%
Echogenic material
4%
Abnormal gestational sac
0%
Normal gestational sac
0%
ED Evaluation
 Risk Stratification
 Combining the Hx, P/Ex, Lab values & U/S findings
 Rough estimate of the risk of ectopic preg. for a woman
with abdominal pain, vaginal bleeding, or both during
early preg.
Ectopic pregnancy after index PID
episode
0, no PID;
1, mild PID;
2, moderately severe PID;
3, severe PID
Likelihood Of Ectopic Pregnancy In Women With
Abdominal Pain, Vaginal Bleeding, Or Both In Early
Pregnancy
Higher likelihood of ectopic pregnancy
ß-hCG < 1000 mIU/mL
Progesterone < 5 ng/mL
Empty uterus on ultrasound
Adnexal mass on physical examination or U/S
Moder ~large amount of free pelvic fluid on U/S
Fertility treatments
Falling ß-hCG on repeat testing, but < 50% at 48
hours
History of PID or other pelvic infection
History of tubal ligation
History of prior ectopic pregnancy
History of intrauterine device (IUD) use
Localized, sharp pain with CMT
Peritoneal signs
Likelihood Of Ectopic Pregnancy In Women With
Abdominal Pain, Vaginal Bleeding, Or Both In Early
Pregnancy
Lower likelihood of ectopic pregnancy
ß-hCG > 3000 mIU/mL
Progesterone > 25 ng/mL
Intrauterine fetus on ultrasound
Uterine size appropriate for dates (especially if > 8
week size)
Small amount of anechoic pelvic fluid on
ultrasound
No fertility treatments
Rising ß-hCG on repeat testing, > 66% at 48 hours
Midline, crampy pain
Clinical Pathway
Management Of The Hemodynamically Unstable Woman In Early Pregnancy
 General management
 Place patient on monitored bed (Class II)
 High-flow oxygen by facemask (Class III)
 Prompt vascular access with large-bore peripheral venous catheters






(Class II)
Bedside qualitative urine pregnancy test if any doubt exists about
pregnancy (Class I)
Check bedside glucose if mental status is not normal, treat
hypoglycemia (Class I)
Check bedside hemoglobin if available, identify anemia (Class II)
Fluid resuscitate with N/S 1L rapid bolus (Class I)
Frequently reassess vital signs (Class II)
CBC, blood type and cross and Rh testing (Class II)
Clinical Pathway
Management Of The Hemodynamically Unstable Woman In Early Pregnancy
Ten Pitfalls To Avoid
1. She clearly didn’t have an ectopic preg.
because she wasn’t having any pain.
: Overreliance on the history & physical exam is one of the great
mistakes when evaluating women for suspected ectopic
pregnancy. Although it seems intuitive that all patients with an
ectopic pregnancy should complain of pain, approximately 10%
of patients with a final diagnosis of ectopic pregnancy have no
pain at their initial presentation.
Ten Pitfalls To Avoid
2. What do you mean she had an ectopic? The
radiologist said the ultrasound looked normal!
: The description of an empty uterus, no adnexal mass,
and no free fluid on ultrasound as being “normal
appearing” may be misleading. Both very early
pregnancy and ectopic pregnancy can give these
findings.
Ten Pitfalls To Avoid
3. What do you mean she now has an IUP?
Last week she had a complex mass on U/S and her
ß-hCG was only 800 mIU/mL. We started her on
methotrexate!
: Although identification of a complex adnexal mass
suggests the presence of an ectopic pregnancy, this
finding is not conclusive. It is imperative that the
possibility of a viable intrauterine pregnancy be
excluded prior to the initiation of methotrexate
treatment.
Ten Pitfalls To Avoid
4. The ß-hCG is rising appropriately;
it couldn’t be an ectopic pregnancy.
: Approximately 15% of ectopic pregnancies will have
a “normal” rise in their ß-hCG value at the first
follow-up blood draw. In fact, in the setting of an
empty uterus on U/S , a “normal” ß-hCG rise
increases the likelihood of an ectopic pregnancy being
present.
Ten Pitfalls To Avoid
5. I ruled out an ectopic pregnancy, and she wasn’t
bleeding much last week. What do you mean she’s
back with profound anemia and hypotension? Her
gynecologist should have been able to take care of
her.
: Many times it is difficult for patients to get in to see
doctors in their offices. Assisting patients in arranging
follow-up with a specific doctor at a specific location
at a given time can help.
Ten Pitfalls To Avoid
6. I knew she was bleeding a lot, but what was
I supposed to do? I couldn’t take her to the
operating room myself!
Ten Pitfalls To Avoid
7. I didn’t see any reason to check a
quantitative ß-hCG.
She said that she had just had a therapeutic
abortion a couple days prior to the visit.
Ten Pitfalls To Avoid
8. The U/S just showed some retained
products of conception, and she wasn’t
bleeding too heavily in the ED.
I prescribed methergine and ibuprofen and
told her to check with her gynecologist in a
couple of weeks.
Ten Pitfalls To Avoid
9. I know her U/S showed a mass, but her
quantitative ß-hCG was low and she really
wanted this pregnancy.
Ten Pitfalls To Avoid
10. She was undergoing fertility treatment
and had severe pain and tenderness.
I really thought she had an ectopic pregnancy,
but her U/S showed an intrauterine
pregnancy, so I sent her home
Treatment
 3 broad categories of patients
1. Ectopic pregnancies
2. Nonviable IUP
3. Others that are classified simply as
"threatened abortions."
Treatment
 Ectopic Pregnancy
 Surgical Approach
 Salpingectomy (excision of the affected tube)
 Tubal preserving surgery
 Pharmacological Approach

Methotrexate - the primary C/Tx agent

Inhibits the formation of nucleotides, necessary
for DNA and RNA synthesis
Treatment
 Methotrexate
 Indication
1. Hemodynamically stable
2. Would prefer to avoid surgery
3. Reliable, available for weekly follow-up visits
4.
ß-hCG of 3000 mIU/mL or less
5. U/S exam - no fluid outside of the pelvis & mass
< 4.0 cm max. diameter ( < 3.5 cm if a fetal
heartbeat is present on U/S ).
 Methotrexate
 Contraindications
1.
2.
Neutropenia, thrombocytopenia
Liver dysfunction, kidney disorders (sCr. > 1.5 mg/dL).
Methotrexate
Treatment
 Nonviable Intrauterine Pregnancy
Emergent D&E of the uterus is mandatory
 Circulatory compromise
 Persistent heavy vaginal bleeding
 Fall in the Hct or signs of infection
 Surgical Approach



D&C - uterine evacuation until the middle of the 20th century
D&E - with vacuum evacuation was developed.
The D&E is safer and easier to perform than the sharp D&C
Treatment

Pharmacological Approach

Prostaglandin analogs ; Misoprostol
- Induce therapeutic abortions.
Speeding cervical dilation & initiating uterine
contractions, leading to the expulsion of the products of
conception.
- Contraindications
1. Maternal anemia
2. Crohn’s disease
3. Previous adverse reactions to prostaglandins
Treatment
 Expectant Management
- recent studies : some women do well with
observation alone
Jurkovic et al
- 16% of expectantly managed women failed expectant
management and required surgical evacuation.
1.2% experienced hemorrhages to require a transfusion
Treatment
 Threatened Abortion
 F/U with her obstetrician in one week.
 Although not evidence-based, it is generally
recommended that the pt should refrain from douching
or intercourse in order to avoid introducing an
ascending infection through an open cervical os
Special Circumstances
 Rh-Negative Patients
 Rh isoimmunization - in ectopic pregnancy or threatened abortion even
without fetal loss.
 Rh status of all symptomatic pregnant patients be checked anti-D Ig be
administered to all Rh-negative patients with vaginal bleeding or
threatened abortion
 ACEP committee –
the administration of anti-D Ig among women in the 1st trimester with
threatened abortion, complete abortion, ectopic pregnancy, or minor
trauma.
 Fertility Treatments
 Higher risk for heterotopic pregnancy
 Close consultation with the patient’s gynecologist
Cutting Edge & Controversies
1. Who can be safely discharged home from the ED
when the initial evaluation is non-diagnostic?
2. Are there better pharmacological agents being
developed to treat ectopic pregnancies?
3. What is the best treatment for nonviable IUP?
Disposition
 Discharge From The ED
Outpatient gynecologic follow-up:
1.
2.
3.
4.
5.
6.
7.
A viable IUP by U/S
A nonviable IUP with minimal bleeding & a small volume of
intrauterine retained products of conception on U/S
An intrauterine gestational sac (NL or abNL) by U/S
A progesterone level > 25 ng/mL
Crampy, midline, mild pain with an inconclusive U/S
evaluation
Hemodynamic stability with minimal or no anemia
An appropriate rise in ß-hCG when a prior for comparison
Disposition
 Gynecologic Consultation Or Admit
1.
2.
3.
4.
5.
A history of fertility treatments
Heavy or persistent vaginal bleeding with anemia
U/S findings diagnostic or suggestive of ectopic
pregnancy.
Moderate or large volumes of free fluid in the pelvis on
U/S exam.
Hemodynamic instability
Key Points In Managing 1st Trimester
Emergencies
1. Except in rare circumstances, the history and physical
2.
3.
4.
5.
exam alone should not be used to exclude ectopic
pregnancy.
U/S is the best initial test to evaluate the severely
symptomatic pregnant pt.
The combination of U/S findings and the quantitative ßhCG is useful in stratifying pts with regard to their risk
for ectopic preg.
Given other indications, the quantitative ß-hCG value is
the best predictor of success with methotrexate treatment.
In pts with nonviable IUPs, the volume of endometrial
contents at U/S is the best predictor of the need for
surgical evacuation
FIN
감사합니다.
Complications of assisted
reproductive techniques
Ovarian hyperstimulation syndrome: a risk if the ovaries are
hyperstimulated (>25 follicles) or the estradiol level is higher than 5000 pg/mL; this
risk can be reduced by lowering the gonadotropin dose, using progesterone instead
of hCG injections for luteal support, canceling the cycle, and avoiding hCG
administration
Possible ovarian neoplasm association with use of fertility drugs
Multiple gestations: approximately 37% of births resulting from ART, whereas 2% of such
births occur in the general population
Adverse outcome of pregnancy (22% of clinical pregnancies) ; ectopic pregnancy,
spontaneous abortion, induced abortion, or stillbirth
Bleeding: rare; includes vaginal blood loss and intraperitoneal bleeding resulting from
inadvertent laceration of vessels with the retrieval needle
Bowel or ureteral injury with the aspiration needle
Infection: although tubo-ovarian abscess formation has been reported following
transvaginal oocyte aspiration & transcervical embryo transfer , infection is now rare with
the use of prophylactic antibiotics
Anesthetic complications: resulting from conscious intravenous sedation; includes drug
reaction, apnea, cardiac arrest, and need for intubation
Reproductive causes of abnormal uterine
bleeding
Early miscarriage
Threatened abortion
Incomplete abortion
Missed abortion
Ectopic pregnancy
Retained products of conception
1. Ectopic pregnancy:
a. is defined as the implantation of a fertilized ovum
outside the endometrial cavity of the uterus.
b. may be more common than is reported because of
advances in the diagnosis and treatment of ectopic
pregnancy in the past few decades, a substantial
decrease in inpatient hospital treatment for ectopic
pregnancy, and an increase in multiple outpatient
visits for a single ectopic pregnancy.
c. usually occurs in the fallopian tube.
d. is usually due to mucosal damage, which is usually
due to tubal infection.
e. all of the above.
2. Heterotopic pregnancy:
a. is the simultaneous occurrence of at least one
intrauterine and at least one ectopic pregnancy.
b. are quite common in naturally occurring
pregnancies.
c. are relatively rare with ovulation induction and in
vitro fertilization as compared to naturally
occurring pregnancies.
d. can be ruled out by visualization of an
intrauterine pregnancy
3. ß-hCG production begins:
a. about six days after fertilization.
b. about two weeks after fertilization.
c. about three weeks after fertilization.
d. about five weeks after fertilization
4. Abnormal pregnancies, including
ectopic pregnancies, are very likely
when the ß-hCG is greater than 1000
mIU/mL and a gestational sac cannot
be visualized on ultrasound.
a. True
b. False
5. Because patients frequently
mistake blood clots for the products
of conception, the passage of true
products of conception should not be
made by history alone.
a. True
b. False
6. Which of the following features of a
patient’s past medical history
presents the greatest risk for ectopic
pregnancy in a patient in early
pregnancy?
a. Intrauterine device use
b. Prior ectopic pregnancies
c. Tubal ligation
d. Infertility treatments
e. A history of pelvic inflammatory disease
7. Which of the following is/are
true regarding abdominal pain
in the first trimester?
a. Pain originating from the uterus is typically
midline and crampy.
b. Pain originating from the adnexa is typically
unilateral and sharp.
c. If hemorrhage into the pelvis from an adnexal
process has occurred, the pain often becomes
bilateral.
d. Pain originating from the bladder is midline in
location and often associated with dysuria.
e. All of the above.
8. Which of the following ultrasound
results is associated with the greatest
risk for ectopic pregnancy?
a. Empty uterus
b. Normal sac
c. Abnormal gestational sac
d. Nonspecific fluid
e. Echogenic material