Vaginal Bleeding
Answers
399.The answer is c.(Rosen, pp 228-229.)Aβ-hCG should be one of the
first ancillary tests considered in a patient presenting with vaginal bleeding
regardless of their sexual, contraceptive, and menstrual history. In addition
to the initial and timely urine qualitative test, a follow-up serum quantitative
β-hCG is warranted if positive. Patients that present with these symptoms
and a positive β-hCG need follow-up for repeat testing to check trending
levels. Determining if a patient is pregnant may also help distinguish if, for
example, the emergent cause of this patient’s bleeding is an ectopic pregnancy
versus a pathologic cervical lesion.
Although a type and screen (a)may be necessary in patients with
severe vaginal bleeding that causes hemodynamic instability, this patient is
currently stable. A type and screen is indicated, however, if this patient is
pregnant to determine Rh status. A coagulation panel (b)may be considered
later in determining if the vaginal bleeding is induced by conditions such
as von Willebrand disease, a relatively common cause of menorrhagia. A CBC
(d)may also be helpful in distinguishing such conditions as idiopathic
thrombocytopenia purpura. Remember the most important question to answer
initially is if this patient is pregnant.
400.The answer is d.(Rosen, pp 226-231.)This patient has a significant
risk factor for having an ectopic pregnancy.Tubal ligations raise the likelihood
of having an ectopic pregnancy by providing an outlet for improper implan-
tation of an embryo into the abdominal cavity or somewhere outside of the
uterus. Implantation most commonly occurs in the fallopian tubes, 95% of
the time. Again, a β-hCG is crucial in the beginning stages in the workup
of this patient. In a normal pregnancy, the β-hCG doubles every 2 days and
typically only increases by two-thirds in ectopic pregnancies. Progesterone
levels also differ and may be helpful. A transvaginal ultrasound is also
warranted to determine the size and location of the ectopic and any associ-
ated free fluid indicating rupture. β-hCG levels dictate whether a transvaginal
(>1500 mIU/mL) or transabdominal (>6500 mIU/mL) approach should
be used. Smaller, nonruptured ectopics may be treated with methotrexate.
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