Vaginal Bleeding Answers 451However, this patient is hemodynamically compromised and has most likely
ruptured. Surgical intervention is warranted in these cases. Patients with
ectopic pregnancies may also present with back or flank pain, syncope or
peritonitis in cases with significant abdominal hemorrhage. Risk factors also
include previous ectopics, intrauterine devices, PID, sexually transmitted
diseases (STDs), in vitro fertilization, and recent elective abortion. The inci-
dence of a coexisting heterotopic pregnancy is about 1/30,000 but increases
to 1/8000 in women on fertility drugs.
Both gastrointestinal (GI) and gynecological conditions should be
included in the differential diagnosis of women presenting with abdominal
pain, and appendicitis (a)is often at the top of the list. However, its probability
is lowered by the associated vaginal bleeding. PID (b)often presents with
gradual pelvic pain and discharge with other systemic signs of an infectious
etiology, such as fever. Placenta previa (c)usually presents with painless
vaginal bleeding in the second trimester. Abruptio placentae (e)also presents
in the second or third trimester and is painful.
401.The answer is a.(Rosen, pp 230-231.)Uterine rupturepresents as
uterine pain without contraction and vaginal bleeding. It is most prevalent
in women who have had a previous cesarean section, recent cocaine or
prostaglandin use. Cocainecauses extreme vasoconstriction that compromises
blood flow to the uterus and fetus causing friable and necrotic tissue, which
is prone to rupture. This is an obstetric emergency that necessitates surgical
intervention for stabilization of both mother and child.
Normal contractions (b)may be seen at this time as well, however,
they are more commonly seen with a lowered fundal height as the fetus
advances down the vaginal canal. Placenta accreta (c)is usually painless
and associated with brisk, bright-red vaginal bleeding. It is caused by an
indistinct placental cleavage plane and seen in the delivery of the placenta
itself. Vaginal bleeding may be seen with ruptured membranes as in vasa
previa (d), however, this is relatively painlessand rarely seen in the ED
setting. Ruptured ovarian cysts (e)should still be considered in the pregnant
patient and although this may also be painful, it is rarely severe and other
more life-threatening causes should be higher up on the differential diagnosis.
The distinguishing characteristic in this patient is her cocaine use.
402.The answer is b.(Rosen, pp 230-231.)Placenta previais the most
probable etiology for this patient’s vaginal bleedinggiven that it is not painful.
Bleeding is rarely severe and the physical examination is usually unremarkable