0071643192.pdf

OBSTETRICS AND GYNECOLOGY

588

TREATMENT

Treatment is guided by the patient’s hemodynamic status, quantitative β-hCG,

and ultrasound findings.

■ Unstable patients: Two large-bore IV lines with rapid infusion of crys-

talloid and/or packed red blood cells should be given to maintain blood

pressure. OB/GYN should be consulted immediately (even before the

ultrasound) for emergent laparotomy in an unstable patient with a posi-

tive pregnancy test. Lab tests including blood count and type and cross

should be sent.

■ Stable patients with ectopic pregnancy: Definitive treatment is deter-

mined by the OB/GYN consultant but may consist of laparoscopy or med-

ical management with methotrexate.

■ Stable patients with indeterminate ultrasound: Patients with a low β-hCG

and indeterminate ultrasound may be discharged with return precautions

and follow-up in 2 days for repeat β-hCG level. Women with viable preg-

nancies should double their serum β-hCG in 48 hours. Patients with persis-

tent symptoms or whose β-hCG rises by <66% over 48 hours require further

evaluation.

FIRST TRIMESTER BLEEDING

CAUSES

The causes of first trimester bleeding include

■ Ectopic pregnancy: The most life-threatening cause of first trimester bleeding

(see “Ectopic Pregnancy”)

■ Spontaneous abortion

■ Gestational trophoblastic disease (GTD)

■ Physiologic bleeding (implantation bleeding)

■ Cervical pathology (eg, cervicitis)

Spontaneous Abortion

Thirty percent of all pregnancies are complicated by first trimester bleeding.

About 50% of these will end in a spontaneous abortion.

Miscarriage occurs when a pregnancy ends spontaneously before the fetus has

reached 20 weeks or 500 g.

TERMINOLOGY

■ Threatened abortion: Abdominal pain or vaginal bleeding in the first 20 weeks

gestation, closed cervixon exam, no passage of fetal tissue by history or

exam. Fetal cardiac activity may be detected.

■ Inevitable abortion: Vaginal bleeding with open cervixbut no passage of

fetal products

■ Incomplete abortion: Incomplete passage of fetal parts, open cervix, pain,

and vaginal bleeding

■ Complete abortion: Complete passage of fetal parts and placenta, closed

cervix, uterus contracted

■ Septic abortion: Infection of the uterus during a miscarriage, usually due

toStaphylococcus aureus; fever, chills, purulent cervical discharge, and

uterine tenderness