452 Emergency Medicine
except for a gravid uterus and bright-red blood in the vaginal vault. Manual
and speculum pelvic examinations should not be done until placenta previa
can be ruled out with an ultrasound, which is often diagnostic. Transvaginal
ultrasound can be done because of the wide angle of the probe and low
probability of penetrating the cervical os. Vaginal examination may then be
performed with awareness that surgical intervention may be necessary to
control bleeding. It is also important to note the stage of pregnancy given
that first-trimester pregnancies more commonly include spontaneous
abortions and ectopics that may present with vaginal spotting.
It is important to emphasize the importance of the patient’s presentation
with regard to painfulorpainlessvaginal bleeding. Although other factors
may alter pain, in general, it is a useful tool in helping to differentiate the
diagnosis. Abruptio placentae (c), uterine rupture (d), and ovarian torsion
(e)are painful etiologies of vaginal bleeding. Ectopic pregnancy (a)is usually
more painful after it ruptures but may present as painless vaginal bleeding
in the first trimester.
403.The answer is c.(Rosen, pp 230-231.)Postpartum bleeding is classified
as early, within 24 to 48 hours of delivery, or late, up to 1 to 2 weeks.
Causes of early postpartum bleeding include uterine atony(most common
cause), genital tract trauma, retained products of conception, and uterine
inversion. Late bleeding episodes may be caused by endometritis or retained
products of conception. Uterine atony is common after prolonged labor and
oxytocin administration. Physical examination will reveal a soft uterus and
blood in the vaginal vault. Treatment consists of bimanual massageand intra-
venous (IV) oxytocin to stimulate uterine contractions. Ergot alkaloids may
be given in refractory cases.
Although genital tract trauma (a)is a possible cause of early postpartum
bleeding, this patient’s physical examination did not reveal any lacerations
or mucosal trauma. As explained above, endometritis (b)is a later manifestation
and accompanied with foul-smelling lochia in addition to a tender, swollen
uterus. This patient is afebrile and did not exhibit any systemic signs of
infection. Ectopic pregnancy (d)is extremely unlikely given this patient’s
recent history of giving birth. Uterine artery rupture (e)is also unlikely and
most commonly occurs at time of delivery followed by a period of extreme
hemodynamic instability.
404.The answer is d.(Rosen, p 2482.)Postpartum bleeding is classified as
early, within 24 to 48 hours of delivery, or late, up to 1 to 2 weeks. Causes of