Consider ectopic pregnancy in reproductive-age patients with abdominal pain and vaginal bleeding. It is the leading cause of maternal mortality during the first half of pregnancy.
Examination of the cervix may exacerbate hemorrhage in patients with placenta previa.
Placental abruption may present with concealed hemorrhage or vaginal bleeding and typically includes vaginal bleeding, abdominal pain, uterine tenderness, and contractions. Ultrasound is not sensitive for its diagnosis.
The relatively high prevalence of preeclampsia should warrant obtaining a routine blood pressure and consideration of screening for proteinuria.
Recognize the risk factors for deep vein thrombosis (DVT)/pulmonary embolism to improve timely diagnosis and appropriate treatment to assure good outcomes in the pregnant patient.
Shock may be difficult to diagnose in the pregnant patient as blood volume, heart rate, and respiratory rate are physiologically increased during pregnancy.
Although the teen pregnancy rate decreased 40% from 1990 to 2008 due to an increase in the use of contraception, a decrease in sexual activity, and effective pregnancy prevention programs, there are still more than 614,000 teen pregnancies a year.1–3 Pregnancy rates among non-Hispanic black and Hispanic teenagers remain disproportionately high.1 Pregnant teens are less likely to receive prenatal care and are more likely to partake in high-risk behaviors such as smoking and consumption of alcohol during pregnancy.
Bleeding in the first trimester occurs in 25% of patients.4 Common etiologies include ectopic pregnancy, threatened abortion, spontaneous abortion, sexually transmitted infections, and trauma. In later trimesters, the causes include placenta previa and placental abruption.
An ectopic pregnancy is defined as the implantation of the blastocyst outside the endometrial lining of the uterine cavity. Ectopic pregnancy is an important cause of maternal morbidity and mortality during the first half of pregnancy in the United States. There is an overall ectopic pregnancy incidence of 2% with a prevalence of 18% in women presenting to the ED with first trimester bleeding and/or abdominal pain.5 Higher rates of mortality in adolescents are largely due to delays in seeking care. Greater than 97% of ectopic pregnancies are located in the fallopian tube.5 Risk factors include prior ectopic pregnancy, prior tubal surgery, and genital tract infections leading to pelvic inflammatory disease (PID).5
Most cases present within the first 8 weeks of gestation with abdominal pain or abnormal vaginal bleeding. Pelvic or abdominal pain and exquisite tenderness are the most common complaints. Some cases present with a late menstrual cycle and abnormal vaginal bleeding, which can be confused with menses. In the case of a ruptured ectopic with intra-abdominal hemorrhage and hypovolemia, the clinical presentation may include dizziness and/or presyncope.6
The classically described but rare presentation of ectopic pregnancy is tenderness on abdominal examination, shock, and an adnexal mass. More commonly, the abdominal examination may be unremarkable or there may be adnexal and/or cervical motion tenderness. Laboratory and radiographic modalities that aid in the diagnosis are listed in Table 101-1.5
Urine beta-HCG: positive Transvaginal ultrasound showing an empty uterus ± adnexal mass with a serum beta-HCG level greater than 1500–2000 mIU/mL (International Reference Preparation) Serum progesterone: <5 ng/mL → nonviable fetus (ectopic vs. dead fetus)a If ectopic pregnancy is suspected, consider ordering a CBC and ABORh |
In an unruptured ectopic pregnancy, consider methotrexate, a folic acid antagonist, for the medical management of an early ectopic pregnancy. Factors that favor improved success with methotrexate include hemodynamic stability without maternal hemorrhage, beta-HCG <5000 mIU/mL, <3.5 cm gestational sac, and absence of fetal heart tones.5 Contraindications to medical management include unstable vital signs, maternal hemorrhage, tubal rupture, known blood dyscrasias, active gastrointestinal or respiratory disease, liver or renal disease, or other contraindications to methotrexate; if contraindicated or not desired, then surgical management is appropriate. In a patient with a ruptured ectopic pregnancy, assure airway and breathing and cardiovascular stabilization. Manage hypovolemic or hemorrhagic shock in a timely fashion and obtain obstetric consultation for surgical management with transfer of care as necessary.
Placenta previa is defined as a placenta that overlies or is in close proximity to the internal cervical os (Table 101-2)7 and is seen in approximately 0.3% to 0.5% of births in the United States.7 It is the primary cause of painless third trimester bleeding. Risk factors include previous cesarean delivery or uterine surgery, smoking, increased maternal age, multiparity, cocaine use, and a multiple pregnancy.7 It is thought to be caused by scarring of the endometrium.7
| Complete: placenta completely covers internal cervical os |
| Partial: placenta partially covers internal os, typically only found when cervix is dilated |
| Marginal: edge of placenta just reaches the internal os but does not cover it |
| Low lying placenta: extends into the lower uterine segment but does not reach the internal os |
The classic presentation of placenta previa is painless, bright red bleeding from the vagina during the late second or third trimester. The uterus usually remains soft; however, contractions may occur. Examination of the cervix may exacerbate hemorrhage with catastrophic results. Digital examination is contraindicated; use ultrasound to make the diagnosis. Transvaginal ultrasonography is more accurate than transabdominal ultrasonography for diagnosis but should be performed by an experienced individual with careful attention to not place the vaginal probe into the cervix. When placenta previa is diagnosed, especially in women with a history of previous cesarean delivery, consider placenta accreta, invasion of the previa into the myometrium. Evaluate the placenta by transvaginal ultrasonography or if needed by MRI for evidence of placenta accreta.
Manage known placenta previa with no acute bleeding in the ED as expectant: pelvic rest, limit long-distance travel, and maintain a safe hemoglobin level. Stabilize patients with hemorrhage with insertion of two large-bore IV catheters and deliver crystalloid fluids and blood transfusions if needed. At time of delivery, cesarean delivery is required due to increased risk for hemorrhage. Delivery may ultimately lead to a hysterectomy. Thus, initiate early obstetric consultation and transfer to a facility capable of managing the mother and newly born child, as placenta previa is associated with both maternal and neonatal morbidity and mortality.7
Placental abruption is the premature separation (partial or total) of a normally implanted placenta presenting with concealed hemorrhage or vaginal bleeding. It usually occurs during the latter half of pregnancy and is seen in 1% of all pregnancies.8 It has significant perinatal mortality, with 119 deaths per 1000 pregnancies, usually due to preterm delivery.8 Maternal risk factors include previous history of placenta abruption, elevated blood pressure (due to either chronic hypertension or preeclampsia), cocaine use, cigarette smoking, multiple gestation, premature rupture of membranes, oligohydramnios, and chorioamnionitis.8 The classic presentation of placental abruption typically includes vaginal bleeding, abdominal pain, uterine tenderness, and contractions. The amount of bleeding does not correlate with the severity of abruption. In more severe cases of placental abruption, severe hemorrhage, uterine tetany, maternal hypotension, coagulopathy, fetal distress, and fetal death can be seen.8 Ultrasonography is insensitive and unreliable in the diagnosis of placental abruption; in most mild cases, the clinical diagnosis is made and confirmed postpartum on inspection of the placenta.
Stabilize the patient with suspected placenta abruption by assuring an airway, 100% oxygen, two large-bore IV catheters, fluid resuscitation, and careful monitoring of the mother and fetus. Obtain a CBC including a platelet count, coagulation studies, fibrinogen, and type and cross for matched blood.8 Initiate early obstetric consultation and transfer to a facility capable of caring for the mother and newly born child.
Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide and constitute one of the greatest risks of maternal and perinatal morbidity and mortality, with an estimated 50,000 to 60,000 deaths per year worldwide.9 Hypertensive disorders of pregnancy can be classified into four categories: (1) chronic hypertension, (2) pre-eclampsia/eclampsia, (3) chronic hypertension with superimposed pre-eclampsia, and (4) gestational hypertension.
