CCS Interactive Case 4

Question 1

26 y/o F presenting to the office w/lower abdominal pain, nausea, slight vaginal bleeding LMP 7 weeks ago. Sexually active, 2 prior episodes PID. Afebrile, HDS.

DDx?

Answer 1

Ectopic pregnancy, spontaneous abortion, molar pregnancy, degenerating leiomyoma, adnexal torsion, ruptured corpus luteum, PID, acute appendicitis, pyelonephritis

Question 2

Exam?

Answer 2

General
HEENT/Neck
Chest/lung
CV
Abdominal
Genital
Rectal
Extremities/Spine

[Monitor for signs of rupture - increasing abdominal pain, tenderness, shock, bleeding]

Question 3

Exam shows LLQ tenderness, bluish discoloration of the vulva, blood oozing from a closed cervical os, slightly enlarged uterus, L adnexal tenderness

Next step?

Answer 3

Pregnancy test -> quantitative if suspected ectopic

necessary for interpreting pelvic US and determining treatment

Question 4

Next step?

Answer 4

TV US

Differentiates ectopic from intrauterine, molar, and other pregnancy-related conditions

Question 5

Presence of an adnexal mass and absence of intrauterine pregnancy (confirms ectopic)

Next step + logic?

Answer 5

Treat - given that this patient is stable, beta-HCG <5000, tubal mass is <3cm, treat with methotrexate.

Admit, consult OB/Gyn

Obtain CBC, BMP, LFT, G&C cultures, coagulation profile, blood type

Treat pain

Question 6

Rx suspected ectopic pregnancy - hemodynamically unstable and/or suspected rupture

Answer 6

Immediate IV access, give normal saline
Type and cross, transfuse as needed
Continuous BP monitoring
PT/PTT/INR
Confirm ectopic by beta-hCG and pelvic US
Consult surgery or Ob/Gyn for possible laparotomy

Question 7

Rx suspected ectopic pregnancy - hemodynamically stable

Answer 7

Monitor for signs of rupture
Obtain beta-hCG quantitative
TV US

If bHCG>1500 + intrauterine pregnancy, ectopic is unlikely -> Rx for abnormal IUP

If bHCG>1500 + no intrauterine pregnancy, EP is likely but unconfirmed - repeat testing in 2 days

If bHCG<1500+no IUP or extrauterine pregnancy on TVS - repeat testing in 2-3 days

If bHCG>1500 + TVS shows adnexal mass - EP confirmed -> proceed

Question 8

Management options for ectopic pregnancy?

Answer 8

MTX if hemodynamically stable, bHCG<5000, tubal mass <3.5 cm, no fetal cardiac activity

Contraindications - renal failure, liver failure, breastfeeding

Laparoscopy is also effective - do in hemodynamically stable patients with bHCG>5000, tubal mass>3.5 cm, and/or fetal cardiac activity

Question 9

What else must patients get?

Answer 9

RH immunoglobulin if RH -

Question 10

Sequence?

Answer 10

Exam (focused)
Order urinary or serum qualitative beta-HCG
Advance clock to next available result
Location: transfer patient to the ward
Order (all stat)
- NPO
- Vitals Q1hr
- IV access
- IV NS
- Complete bedrest
-Quantitative serum beta-hCG
- TV US
- T&C
- Blood group and Rh
-CBC w/Diff
-PT/PTT
-BMP
-LFTs
-Cervical G&C cultures
Advance clock to obtain results of TVS and quantitative HCG

Order: Ob/Gyn, MTX, morphine

Advance to obtain Ob/Gyn recs

Cancel: NPO, vitals, IV access, NSS, and complete bed rest, order rest at home, counseling

Location: home

Appointment: 4 days to monitor HCG level

Final orders: none

Dx: ectopic pregnancy