Question Of The Day #39

question of the day
Abnormal Right Upper Quadrant

Which of the following is the most appropriate next step in management for this patient?

This female patient presents to the Emergency department with atraumatic right shoulder pain, generalized abdominal discomfort, and vaginal bleeding.  She is found to have a positive urine pregnancy test and signs of shock on physical exam (hypotension and tachycardia).  The FAST exam (Focused Assessment with Sonography for Trauma) demonstrates free fluid around the liver.  This quick bedside sonographic exam evaluates the right upper quadrant (liver, right kidney, right lung base), left upper quadrant (spleen, left kidney, left lung base), suprapubic area (bladder), and subxiphoid area (view of heart).  The FAST exam is typically used in the setting of trauma to assess for intra-abdominal bleeding, or “free fluid”.  Fluid on ultrasound appears black, or anechoic.  In the setting of trauma or presumed hemorrhagic shock, free fluid is assumed to be blood.  The hepato-renal recess, also known as Morrison’s pouch, is the most common site for fluid to be seen on a FAST exam.  For this reason, the right upper quadrant should always be viewed first during a FAST exam if there is concern for hemorrhagic shock.  The patient’s right upper quadrant FAST view is annotated below.

This patient is in shock with free fluid in her right upper quadrant FAST view.  In the setting of a pregnancy of unknown origin, shock, and abdominal free fluid, a ruptured ectopic pregnancy is assumed to be the diagnosis.  A cystic adnexal structure and a uterus without a gestational sac can also be noted on ultrasound.  Ectopic pregnancy can present with mild symptoms ranging from abdominal pain and vaginal bleeding to signs of shock with hemoperitoneum as in this patient.  Risk factors for ectopic pregnancy include prior ectopic pregnancies, prior tubal surgeries, prior sexually transmitted infections, tobacco smoking, and use of an intrauterine device (IUD).  Initial Emergency department treatment should include volume resuscitation with blood products, pre-operative laboratory testing, and prompt OB/GYN consultation (Choice C).  Patients who are unstable, show signs of shock, or have large ectopic pregnancies are treated operatively.  Patients with stable vital signs, small ectopic pregnancies, and minimal symptoms are treated medically with Methotrexate (Choice A).   This patient’s hemodynamic instability makes Methotrexate contraindicated in her treatment course.  The patient’s atraumatic shoulder pain is likely from free fluid in the right upper quadrant, causing referred pain to the shoulder from diaphragmatic irritation.  A shoulder X-ray (Choice B) is not indicated in this patient.  Rho(D) immune globulin (RhoGAM) (Choice D) is an important treatment to provide in Rh-negative mothers with ectopic pregnancy.  RhoGAM is indicated in maternal-fetal hemorrhage in order to prevent the maternal immune system from attacking fetal Rh-positive cells in future pregnancies.  RhoGAM is indicated in Rh-negative mothers, not Rh-positive mothers.  The question does not indicate the mother’s blood type or Rh status, however, RhoGAM is not the best initial treatment.  Treatment of the hemorrhagic shock and OB/GYN consultation are the best next steps.  Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #39," in International Emergency Medicine Education Project, May 14, 2021, https://iem-student.org/2021/05/14/question-of-the-day-39/, date accessed: December 2, 2022

Trauma in Pregnancy

Trauma in pregnancy

Trauma remains the leading cause of morbidity and mortality in pregnant women. It increases the risk of preterm delivery, placenta abruption, fetomaternal hemorrhage, and pregnancy loss. Motor Vehicle Accidents (MVAs) account for 70% of blunt abdominal trauma, then comes falls and direct assaults.

Evaluating and managing pregnant trauma patients requires knowing some physiological changes in pregnancy.

Physiological changes in pregnancy

Important actions in pregnant trauma patients

Rhogam (Rh immunoglobulin) and Tetanus Prophylaxis

Administer RhoD (Human Rho(D) immune globulin) to Rh-negative women; 50 mcg for <12 weeks, 300 mcg for >12 weeks. Tetanus prophylaxis is safe but considered as category C.

Images and Radiation Exposure

Do not withhold needed images. The greatest risk to fetal viability from ionizing radiation is within the first 2 weeks after conception and the highest malformation during the embryogenic organogenesis at 2-8 weeks. The risk of central nervous system teratogenesis is highest at 8-16 weeks. A dose of 5 rad is the threshold for human teratogenesis. Plain radiographs is <1 rad. Abdominal CT + Pelvic angio has the highest dose of rad (2.5-3.5). One of the critical problems is the abruption of the placenta, and CT is sensitive for abruption placenta, 86%, and has 98% specificity. The iodine contrast could cross the placenta and causing neonatal hypothyroidism.

Pelvic exam can be done only after performing an ultrasound to determine the placenta location and exclude placenta previa.

Special Tests

Vaginal fluid pH. If the pH is 7, it is amniotic fluid. If the pH is 5, it is vaginal secretions. Ferning on microscope slide = amniotic fluid.

APT ( alkali denaturation) test is qualitative evaluation to determine the presence of fetal Hg in maternal blood.

Kleihauer-Betke test measures fetal hemoglobin transfer to mothers’ blood.

Specific Issues

  • Direct fetal injuries

    It is rare. It can be seen some injuries such as maternal pelvic fractures, direct trauma to the fetal skull.

  • Uterine rupture

    It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.

  • Uterine rupture

    It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.

  • Uterine irritability

    The sign of the onset of preterm labor. Avoid using tocolytics; it causes tachycardia for both mother and fetus.

  • Placental abruption

    1-5% from minor injuries, 40-50% of major injuries. Even simple falls can cause sudden fetal demise. Most sensitive clinical findings; uterine irritability, which can be explained by having more than 3 contractions per hour at the ED.

Fetal viability

The fetus will likely be viable at 24 weeks and above.
The normal fetal heart rate is 120-160 bpm. Heart rate below and above these limits is critical. Because ultrasound may not detect placenta abruption, nor rupture or fetal-placental injuries, high-suspicion and close monitorization are necessary.

Cardiotocography (CTG)

4-6 hours will be enough for most of the cases. Persistent contractions or uterine irritability needs an external CTG for 24 hrs. Fewer than 3 contractions per hour could indicate a safe discharge.

Indication for Emergency C-Section

  • Fetal tachycardia.
  • Lack of beat to beat on long term viability.
  • Late deceleration = fetal distress.

C-section has a 75% survival rate in 26 weeks or above. If the fetal heartbeats are present and the procedure was performed early, the success rate is higher.

References and Further Reading

  • Tintinalli, J., Stapczynski, J., Ma, O. J., Cline, D., Cydulka, R., & Meckler, G. (2010). Tintinalli’s emergency medicine: a comprehensive study guide: a comprehensive study guide. McGraw Hill Professional.

 

Cite this article as: AlHanouv AlQahtani, KSA, "Trauma in Pregnancy," in International Emergency Medicine Education Project, October 25, 2019, https://iem-student.org/2019/10/25/trauma-in-pregnancy/, date accessed: December 2, 2022

You have a baby

Stork_8793

Emergency Delivery chapter written by David F. Toro, Diana V. Yepes, Ryan H. Holzhauer from USA is just uploaded to the Website!

A 24-year-old female with pelvic pain

How ectopic pregnancy should be delivered to the students/interns. 

Clear, to the point! 

Ectopic Pregnancy

by Dan O’Brien, USA

A 24-year-old woman presents to the emergency department with the complaint of lower abdominal pain and vaginal spotting. She has never been pregnant. Her last normal menstrual period was two months ago. She had light spotting last month and states that her period this month is late. Her history is notable for one episode of lower abdominal pain two years ago thought to be the pelvic inflammatory disease that responded to a two-week course of oral antibiotics. She has no medical allergies and is not on any medications. 

Can you show uterus and ectopic pregnancy in the ultrasound?

Review of systems and family history are unremarkable. Her social history is significant in that she is in a monogamous relationship and is not using birth control. Her general appearance is that of a well-developed female with a temperature of 37ºC, a blood pressure of 110/70 mm Hg and a pulse of 90 bpm. An examination of her abdomen reveals normal bowel sounds, no masses, distension, organomegaly or rebound tenderness. She is mildly tender to palpation in the left lower quadrant. Pelvic exam reveals left adnexal tenderness without palpable masses. The rectal exam is normal with hemoccult negative stool. Pertinent lab values: urine dip pregnancy testing is positive, quantitative serum B-hCG is 2000 mIU/mL, hemoglobin 13 gr/dL, hematocrit 40%. She is Rh-positive. A transvaginal ultrasound performed by the emergency physician during the pelvic exam fails to demonstrate an intrauterine pregnancy. There is a small amount of fluid in the rectouterine cul-de-sac. 2 cm ectopic pregnancy was identified. Two large-bore IV’s were started, the patient was crossmatched for blood and OB-GYN was consulted. Treatment options were discussed.