Scenario: Patient coming with sudden severe left abdominal pain, pain in the left shoulder and PV bleeding. She had amenorrhea for 8 weeks. Her BhCG was 2500 mIU/mL. A transvaginal Ultrasound was done and showed absence intrauterine pregnancy.
– History –
- CC: if presents as abd pain -> use SOCRATES, if bleeding:
- Onset: when? first time? Sudden\gradual? Continuous\intermittent? Getting better\worse?
- Characteristics: amount? Color? Clots? Tissue? Smell?
- Associated sx:
- Constitutional: fever, chills, appetite?
- Anemia: dizziness, syncope, headache, palpitations, SOB?
- Vagina: vaginal bleeding (if yes, ask about anemia sx), clear fluid gush\leak, discharge, itching?
- Urinary sx: dysuria, flank pain?
- Obstetric Hx:
- Gravida? Para? Abortions? Living?
- If prev: mode of delivery? Fetal\maternal complications?
- LMP?
- Last US: when? Results? Singleton or multiple gestation?
- Screening: GBS, GDM, rubella immunization, blood type\Rh immunization?
- Gravida? Para? Abortions? Living?
- Gynecological Hx:
- Menstrual Hx: regular periods? Intermenstrual bleeding?
- Contraception use, IUCD?
- Gynecological procedures, IVF\induction of ovulation?
- PMHx:
- Diseases:
- Chronic ds (HTN, DM\GDM, DLP)
- Cardiac, thyroid, SLE
- Hematological (anemia, APS)
- Gyn (PID, fibroids, uterine anomalies)
- Medications: abx, steroids, anticoagulants, folate, herbal
- Surgery, hospitalization, trauma
- Allergies
- Diseases:
- FMHx:
- Similar complaint?
- Same diseases as in PMHx?
- Social Hx:
- Occupation, marital status, children?
- Smoking, alcohol, recreational drugs?
- Travel Hx
- Diet, exercise
– Physical Exam –
- WIPE, blah blah, chaperone
- Vital signs: pulse, BP, temperature
- General inspection: weight, distress, pallor
- Chest: signs of pneumonia, cardiac diseases\murmurs
- Abdomen:
- Inspection: scars, contours, fetal movements, linea nigra, striae
- Palpation: tenderness, guarding, rebound, uterus, masses, organs, contractions
- Measure fundal height
- Auscultation
- Vaginal:
- Discharge, bleeding, passage of tissue
- Cervix: dilated, lacerations
- Bimanual: motion tenderness, adnexal masses
– Differential Diagnosis –
- Gynecological:
- Ectopic pregnancy, ruptured?
- Abortion
- Molar pregnancy
- Ovarian torsion\cyst
- PID
- Non-gynecological:
- Appendicitis
- Renal colic
- Diverticulitis
– Investigations –
- Quantitative serum B-hCG
- Labs: CBC (WBC for infection, Hg for anemia, PT\PTT, blood type\cross match\Rh), chemistry (renal function, electrolyte), UA\midstream urine sample (to r\out UTI)
- US: transvaginal > abdominal
– Management –
- If unruptured:
- Methotrexate: single dose IM 50 mg, if:
- B-hCG < 5000 mIU\mL
- Pregnancy mass < 3.5 cm
- Absent fetal cardiac activity
- Surgical laparoscopy\laparotomy -> salpigostromy, or salpingectomy if:
- Pregnancy mass > 3.5
- B-hCG > 5000 mIU\mL
- Present fetal cardiac activity
- Recurrent ectopic pregnancies
- No future child bearing is planned
- Rhogam if Rh –
- Methotrexate: single dose IM 50 mg, if:
- If ruptured \ hemodynamically unstable:
- Stabilize
- Immediate laparotomy
- Rhogam if Rh –
– Follow Up –
- Weekly B-hCG levels until undetectable
- Tell the pt it might recur in the other side