Question Of The Day #34

question of the day
qod34

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

This patient is pregnant in the first trimester presenting to the Emergency department with right lower quadrant pain. Any first trimester pregnant patient with abdominal pain should be evaluated for ectopic pregnancy. Other causes of this symptom include ovarian torsion, ovarian cyst rupture, pelvic inflammatory disease, tubo-ovarian abscess, urinary tract infection, ureterolithiasis, colitis, or appendicitis. An intra-uterine pregnancy is confirmed on transvaginal ultrasound which excludes ectopic pregnancy from the differential. Ovarian pathologies are also investigated on the ultrasound and are not discovered. 

Another common diagnosis based on the patient’s pain location, young age, and markedly tender abdomen is acute appendicitis. The most common presenting symptom in appendicitis is right lower quadrant pain. Other signs include fever, anorexia, nausea, or vomiting.  Pregnant women may present with back or flank pain, rather than right lower quadrant pain, as the uterus may displace the appendix in the abdomen. There is no single symptom or laboratory test that can reliably exclude the diagnosis of appendicitis. The gold standard test for acute appendicitis diagnosis is a CT scan of the abdomen with IV contrast dye. PO or PR contrast are additionally used in some institutions based on preference and protocols.  In children, appendiceal ultrasound is performed first to avoid excessive radiation exposure and financial cost. CT scanning (Choice A) is similarly avoided in first-trimester pregnancy to diagnose appendicitis, although it is the test of choice in non-pregnant adults. MRI imaging of the abdomen and pelvis (Choice C) is another diagnostic option for pregnant patients, but this is not recommended until an ultrasound is performed. IV antibiotics (Choice D) may be needed to treat appendicitis or other abdominal infections, but this patient lacks a definitive diagnosis or signs of sepsis or shock which would support emergent antibiotics. The best next step to further evaluate the cause of this patient’s symptoms is conducting an appendiceal ultrasound (Choice B). If this study is non-conclusive or is not available, an MRI should be performed. 

Emergency department treatment for acute appendicitis is IV antibiotics, IV hydration, and surgical consultation for appendectomy. Immediate surgery may be avoided in patients who present several days after symptom onset or with a ruptured appendix. These cases are treated with IV antibiotics, IV hydration, bowel rest, and close monitoring.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #34," in International Emergency Medicine Education Project, April 9, 2021, https://iem-student.org/2021/04/09/question-of-the-day-34/, date accessed: September 30, 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: September 30, 2022