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An ectopic pregnancy is one that is not within the uterus.
majority occur in the Fallopian tube but can occur in the abdominal cavity, ovary, or cervix
Implantation of the gestational sac in the Fallopian tube may have three results:
- Extrusion (tubal abortion) into the peritoneal cavity
- Spontaneous involution of the pregnancy
- Rupture through the tube causing pain and bleeding
- PV bleeding
- abdominal/pelvic pain
- 6-8 weeks LMP
- shoulder tip pain (large amount of bleeding)
- postural symptoms
- Urinary pregnancy test
- Ultrasound scan – may confirm an extrauterine pregnancy (mass) or show free fluid in the pouch of Douglas. transvaginal scan – early pregnancy because transabdominal scanning may not be sensitive enough.
- Rhesus status (anti-D immunoglobulin may be required)
- Serial β HCG and progesterone – useful if no sac is visualized on ultrasound
- normal pregnancy, the β HCG level doubles every 48 hours.
- In an ectopic the level will fail to rise
- Clotting—due to the risk of disseminated intravascular coagulation (DIC).
Emergency department management
- Two large intravenous cannulae and cross-match blood (6 units).
- Fluid resuscitate
- Give anti-D immunoglobulin if the patient is rhesus negative.
- Urgently refer to the gynaecology team.
- Surgical management
- unstable – require a laparotomy and salpingotomy or salpingectomy
- stable- laparoscopic approach
- Medical management
- methotrexate – minimal symptoms and a β HCG lower than 3000 IU/L.
- Expectant management – minimal symptoms and a pregnancy of unknown location. monitore with serial β HCG and ultrasound scans
Pelvic inflammatory disease
- Sexually transmitted (common) – Chlamydia, Gonorrhoea, Mycoplasma genitalium
- Non-sexually transmitted -E. Coli, Group B Strep, Bacteroides, Gardenella
- lower abdominal pain, vaginal discharge, nausea/vomiting, fever, lower abdominal tenderness, cervical excitation, and adnexal tenderness.
- Fitz-Hugh Curtis syndrome (right-upper quadrant pain associated with perihepatitis)
Empirical treatment (lack of definitive clinical diagnostic criteria) – Delayed treatment increases the risk of complications
- mild to moderate PID
- oral ofloxacin 400 mg bd and oral metronidazole 400 mg bd, for 14 days. or a single intramuscular
injection of ceftriaxone 500 mg, followed by oral doxycycline 100 mg bd and oral metronidazole 400 mg bd, for 14 days.
- oral ofloxacin 400 mg bd and oral metronidazole 400 mg bd, for 14 days. or a single intramuscular
- Inpatient management if :
- Clinically severe disease, with severe symptoms (nausea and vomiting).
- Fever greater than 38°C.
- Tubo-ovarian abscess.
- Signs of pelvic peritonitis.
- PID in pregnancy, when intravenous antimicrobial therapy is indicated to reduce the risk of maternal and foetal morbidity and pre-term delivery.
- Intolerance or lack of response to oral therapy.
- Inpatient Treatment
- intravenous ceftriaxone and doxycycline.
- Surgical drainage may be required for tubo-ovarian abscesses.
- removing an IUCD in patients presenting with PID, especially if symptoms have not resolved within 72 hours.
- Further screening for sexually transmitted infections .
- Sexual partners from the previous six months should be contacted and offered screening via the genitourinary medicine clinic.
- Ectopic pregnancy (fivefold increased risk)
- Chronic pelvic pain
- Abscess formation
- There are many causes of abnormal vaginal bleeding. The differential diagnosis varies according to whether the bleeding is menstrual, intermenstrual, post-menopausal, pregnancy-related, or post-coital.
- The initial priority in the ED is to exclude an ectopic pregnancy or threatened miscarriage.
- Follow-up should be arranged urgently if there is a possibility that the bleeding is caused by a genital tract carcinoma.
- Oral emergency contraception: levonorgestrel or ulipristal acetate ( Available without prescription to women >16 years of age)
- The copper intrauterine contraceptive device (cIUCD)
- single dose (1.5 mg) up to 72 hours after unprotected sexual intercourse. If taken within 24 hours, it prevents 95% ofpregnancies but this diminishes with time to 58% at 72 hours.
- mechanism inhibition of ovulation for 5–7 days.
- single oral dose or 30 mg. It can be taken up to 120 hours after unprotected sexual intercourse and is the only oral emergency contraceptive licensed for use between 72 and 120 hours.
- progesterone receptor modulator- inhibit or delay ovulation.
- It prevents 98% of expected pregnancies and can be inserted up to five days after unprotected sexual intercourse.
- direct toxic effects on sperm and the inhibition of implantation.
- Women should be risk assessed for STD nd offered screening. If the risk of an infection is felt to be high then prophylactic azithromycin should be given on insertion.
- repeat dose of oral medication if vomiting occurs within two hours of taking it.
- Women on hormonal contraception are advised to use additional methods of contraception for seven days post levonogestrel or 14 days post ulipristal actetate.
- Less effective in women taking enzyme-inducing medications (require double dose).
- pregnancy test should be performed if menstruation is five to seven days late, if bleeding or if the patient feels she might be pregnant.
- Medical attention- if lower abdominal pain occurs (ectopic pregnancy)
Under 16s and emergency contraception
Consent to sexual activity
- The legof consent to sexual activity is 16 years in Scotland, England, and Wales.
- Sexual activity under the age of consent is an offence, even if consensual.
- Offences are considered more serious (statutory rape) when the person is less than 13 years oldal age
Consent to medical treatment
- age of 16 years are presumed to be competent to consent to medical treatment.
- Under the age of 16 years, competency to consent to medical treatment must be demonstrated.
- In England and Wales, it is lawful to provide contraceptive advice and treatment to young people without parental consent, provided that the practitioner is satisfied that the Fraser criteria for competence are met.
- The young person understands the practitioner’s advice.
- The young person cannot be persuaded to inform their parents, or will not allow the practitioner to inform the parents, that contraceptive advice has been sought.
- The young person is likely to begin or to continue having intercourse with or without contraceptive treatment.
- Unless she receives contraceptive advice or treatment, the young person’s physical or mental health (or both) is likely to suffer.
- The young person’s best interest requires the practitioner to give contraceptive advice or treatment (or both) without parental consent.
Bleeding in pregnancy
- Miscarriage is the loss of a pregnancy before 24 weeks gestation. Most women present in the first 12 weeks with vaginal bleeding and/or abdominal pain.
- Threatened miscarriage is vaginal bleeding through a closed cervical os—50% proceed to miscarriage.
- Inevitable miscarriage is vaginal bleeding through an open cervical os or passage of some products of conception.
- Incomplete miscarriage is vaginal bleeding but not all products of conception have passed.
- Missed miscarriage occurs when failure of the pregnancy is ‘silent’ and is often first noticed on ultrasound. Miscarriage with infection occurs when retained products become infected.
- Complete miscarriage is once all the products of conception have passed.
- Cervical shock is when the products of conception become stuck in the cervical os, resulting in profound vagal stimulation (hypotension and bradycardia) and severe abdominal pain. Removal of the products of conception from the os if the patient has cervical shock.
- Ergometrine (500 mcg intramuscularly) should be considered if the patient has severe bleeding.
- Gestational trophoblastic disease occurs when a fertilized ovum forms abnormal trophoblastic tissue, but no foetus.
- Antepartum haemorrhage is bleeding after 24 weeks gestation.
- Antepartum haemorrhage should be managed in the resuscitation room. Patients should be aggressively fluid resuscitated and given anti-D immunoglobulin if rhesus negative.
- Kleihauer test—to determine the degree of foetal–maternal haemorrhage
- Patients with antepartum haemorrhage are at risk of massive haemorrhage and DIC. A FBC, clotting, fibrinogen, and cross-match (6 units) should be sent urgently.
Hyperemesis gravidarum – risk of thiamine deficiency. Ensure supplemental thiamine is given- to prevent Wernicke’s encephalathy
Pre-eclampsia and eclampsia
Pre-eclampsia Onset is usually after 20 weeks gestation.
It is classically defined as a triad of:
- Hypertension (systolic >140 mmHg or diastolic >90 mmHg, or a rise above booking BP of systolic >30 mmHg or diastolic >15 mmHg)
- Proteinuria (>0.3g/24 hours)
Clinical features of pre-eclampsia
- Right-upper quadrant and epigastric pain—due to liver oedema and haemorrhage
- Headache, visual disturbance (blurring or flashing before the eyes), and papilloedema—due to cerebral oedema
- Hyperreflexia, clonus
- Convulsions—due to cerebral oedema (heralds the onset of eclampsia)
Investigations for pre-eclampsia
- FBC—risk of thrombocytopenia and haemoconcentration.
- Blood film—should be checked because the patient may develop microangiopathic haemolytic anaemia.
- Clotting screen—should be checked if the patient is thrombocytopenic.
- Renal function—risk of renal failure.
- LFTS—elevated transaminases in haemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.
- Urinary dipstick—≥2 + protein indicates significant proteinuria and the need for 24-hour urine collection.
- Foetal monitoring via ultrasound and cardiotocography.
ED management of pre-eclampsia
- Contact the obstetricians early.
- Manage the patient in the resuscitation room with full monitoring.
- Consider positioning the patient left lateral.
- Control hypertension with oral labetalol.
- Careful fluid management is required. Fluid overload is a significant cause of maternal death due to pulmonary oedema. Limit fluids to approximately 1ml/kg/hr. Urine output should be monitored.
- Magnesium should be considered in women with severe pre-eclampsia (systolic BP ≥170 mmHg or diastolic BP ≥110 mmHg plus significant proteinuria, >1g/L).
- Delivery is the definitive treatment for pre-eclampsia. However, 44% of eclampsia occurs post-partum.
ED Managment of eclampsia
- Intubation should be considered early due to the increased risks of aspiration and ventilatory inadequacy in pregnancy.
- Magnesium is the therapy of choice to control seizures. A loading dose of 4 g intravenously should be given over 5–10 minutes followed by maintenance of 1 g/hour for 24 hours. A further bolus of 2 g can be given if the patient has recurrent seizures.
- Labetalol Stat and infusion
Rhesus prophylaxis—anti-D immunoglobulin
- A rhesus D negative mother exposed to the blood of a rhesus D positive foetus may develop anti-D antibodies
- Anti-D IgG antibodies attack and destroy red blood cells of the foetus resulting in haemolytic disease of the newborn.
Sensitizing episodes before delivery
Sensitizing events likely to be encountered in the ED include:
- Closed abdominal injury (particularly in the third trimester)
- Antepartum haemorrhage
- Intrauterine death
- Ectopic pregnancy ( ? including managed medically )
- Spontaneous miscarriage (all pregnancies >12/40; <12/40 if intervention is required to evacuate the uterus)
- Threatened miscarriage (all pregnancies >12/40; <12/40 if heavy or repeated bleeding, or associated with abdominal pain)
Anti-D immunoglobulin doses
Anti-D immunoglobulin is given intramuscularly and should be given as soon as possible and definitely within 72 hours of the sensitizing episode.
Routine antenatal prophylaxis
- 500 IU should be given at 28 weeks and 34 weeks gestation.
Prophylactic administration following a sensitizing episode
- 250 IU up to 20/40 gestation.
- 500 IU after 20/40 gestation, plus a Kleihauer test to detect large feto-maternal haemorrhage and direct further doses as required.
- 500 iu, plus a Kleihauer test to detect large feto-maternal haemorrhage and direct further doses as required.
- Primary post-partum haemorrhage is blood loss of greater than 500 ml in the first 24 h post-delivery.
- Secondary post-partum haemorrhage is excessive blood loss from the genital tract between 24 h and 12 weeks postnatally.
- The commonest cause of primary post-partum haemorrhage is uterine atony. Stimulation of uterine contraction may reduce bleeding. This can beachieved by bimanual uterine compression (rubbing up the fundus) and/or pharmacologically with oxytocin and ergometrine IV.
- The commonest cause of secondary post-partum haemorrhage is retained products of conception.
- Patients with post-partum haemorrhage may require a massive blood transfusion.
Pregnancy and trauma
Anatomical considerations for trauma in pregnancy
- The enlarged uterus is more prone to injury once it is outside the pelvis (>12/40 gestation) and makes abdominal assessment difficult.
- The bony pelvis is less prone to fracture but retroperitoneal haemorrhage may be massive due to increased vascularity.
- Inferior vena cava (IVC) compression occurs when the patient is supine resulting in hypotension and potential for increased bleeding from lower limb injuries due to increased venous pressure. Decompress the IVC by manual displacement of the uterus or using a ‘Cardiff wedge’ to achieve the left lateral position.
- The diaphragm is higher resulting in decreased residual volume.
- The airway is difficult to control (large breasts, full dentition, neck oedema, and obesity).
- The pituitary is twice its normal size and at risk of infarction if hypovolaemia occurs (Sheehan’s syndrome).
Physiological considerations for trauma in pregnancy
- Pregnant patients can tolerate up to 35% blood loss before showing signs of hypovolaemia. However, the foetus maybe compromised prior to such signs developing.
- The functional residual capacity is reduced and oxygen requirements are increased, resulting in hypoxia developing more quickly.
- Increased risk of aspiration (decreased oesophageal pressure, increased gastric pressure, and prolonged gastric emptying).
- Coagulation can become rapidly deranged especially following an amniotic fluid embolus.
- If the pregnant woman is not immune to VZV and she has had a significant exposure, she should be
offered varicella-zoster immunoglobulin (VZIG) as soon as possible. VZIG is effective when given
up to 10 days after contact (in the case of continuous exposures, this is defined as 10 days from the
appearance of the rash in the index case)
- Non-immune pregnant women who have been exposed to chickenpox should be managed as
potentially infectious from 8–28 days after exposure if they receive VZIG and from 8–21 days after
exposure if they do not receive VZIG.
- Women should avoid contact with potentially susceptible individuals, e.g. other pregnant women
and neonates, until the lesions have crusted over. This is usually about 5 days after the onset of
- Oral aciclovir should be prescribed for pregnant women with chickenpox if they present within 24
hours of the onset of the rash and if they are 20+0 weeks of gestation or beyond. Use of aciclovir
before 20+0 weeks should also be considered.
- Intravenous aciclovir should be given to all pregnant women with severe chickenpox.
- Women should be advised that the risk of spontaneous miscarriage does not appear to be increased
if chickenpox occurs in the first trimester.
If the pregnant woman develops varicella or shows serological conversion in the first 28 weeks of
pregnancy, she has a small risk of fetal varicella syndrome (FVS) and she should be informed of
- Women who develop chickenpox in pregnancy should be referred to a fetal medicine specialist, at
16–20 weeks or 5 weeks after infection, for discussion and detailed ultrasound examination.
- if maternal infection occurs in the last 4 weeks of a woman’s pregnancy, there is a significant risk
of varicella infection of the newborn. A planned delivery should normally be avoided for at least
7 days after the onset of the maternal rash to allow for the passive transfer of antibodies from
mother to child, provided that continuing the pregnancy does not pose any additional risks to the
mother or baby.
- Complications in pregnancy
- Varicella in pregnancy can result in severe chickenpox. The mother is at increased risk of varicella pneumonia and other complications, compared with the general adult population.
- Infection with varicella-zoster during the first 28 weeks of pregnancy can lead to intrauterine infection and fetal varicella syndrome, which is characterised by one or more of:
- Skin scarring in a dermatomal distribution
- Eye defects (for example microphthalmia, chorioretinitis, and cataracts)
- Hypoplasia of the limbs
- Neurological abnormalities (microcephaly, cortical atrophy, learning difficulties, dysfunction of bowel and bladder sphincters)