454 Emergency Medicine
defined as open when one can place more than a fingertip within the cervix.
In these cases, dilation and curettage with full evacuation of the pregnancy
is warranted. Rh immunization may also be needed depending on the status
of the patient; therefore, a type and screen should be obtained. First-trimester
vaginal bleeding occurs in about 40% of pregnancies with approximately
half of them eventually resulting in spontaneous miscarriages.
A threatened abortion (a)is defined by first-trimester vaginal bleeding,
a closed cervical os, and no passage of fetal tissue by history or examination.
Aβ-hCG and ultrasound are needed to confirm an intrauterine pregnancy
and help rule out an ectopic pregnancy. Often times, it will be too early in
the pregnancy to see either on ultrasound evaluation. These patients should
be given close follow-up for a repeat β-hCG and ultrasound within 24 to
48 hours. Patients need to be given bleeding precautions upon discharge
from the ED, given that they are in stable condition. This includes bed rest
for 24 hours and the avoidance of intercourse, tampons, and douching
until the bleeding stops. Complete abortions(b)are defined by the complete
passage of fetal products and placenta. These patients require supportive
management, dilation, and curettage for removal of all potentially retained
products of conception and Rh prophylaxis. Incomplete abortions (d)are
defined by the partial passage of fetal products with an open cervical os.
Dilation and curettage and Rh prophylaxis are also warranted. A missed
abortion(e)is the retention of nonviable fetal products for some time after
the abortion occurred. This may progress to spontaneous abortion with
expulsion or may require a dilation and curettage for removal.
407.The answer is e.(Rosen, pp 2413-2416.)Given that this patient has
aclosed cervical oswithno history of passing tissue,it is most likely a
threatened abortion.This patient will need further ultrasound and β-hCG
evaluation in 1 to 2 days to follow the pregnancy. Progesterone levels can
also aid in distinguishing an ectopic pregnancy. Proper bleeding precautions
should also be given and an Rh status determined.
Placenta previa (a)is unlikely given the early stage of pregnancy. An
inevitable abortion (b)involves an open cervical os. In a complete abortion
(c), a closed cervical os may be observed but there is also a history of the
passage of fetal tissue. A septic abortion (d)is defined as a uterine infection
during any time of an abortion. Patients present with vaginal bleeding and
cramping pain with fever and purulent cervical discharge. Prompt evacuation
is warranted in these cases along with the initiation of antibiotic and Rh
prophylaxis.