458 Emergency Medicine
(d)or endometriosis. If this patient had a history of bleeding before the day of
her presentation, a complete abortion would have to be investigated. Given
her negative β-hCG, an ectopic pregnancy (c)or threatened abortion (a)can
be ruled out. PID (e)presents with fever, abdominal pain, purulent vaginal
discharge, and a positive STD history, not vaginal bleeding.
415.The answer is d.(Rosen, pp 228-229.)Progesterone levelsmay be
helpful in distinguishing ectopic pregnancies. A level of <5 ng/mL is highly
suggestive of an ectopic pregnancy, given that the uterus may not be able to
carry the pregnancy. Higher levels indicate that embryo implantation inside
the uterus is more likely.
Estrogen levels (a)and FSH (b)may prove helpful in distinguishing
menopausal symptoms or aiding infertile women. TSH levels (c)are useful
when reaching a diagnosis in women with irregular menstrual flow. A CBC
(e)is not warranted given that this patient is not hemorrhaging. A type and
screen should be performed to determine Rh status.
416.The answer is c.(Rosen, pp 226-231.)Given that this is a transvaginal
ultrasound, the threshold for visualizing a pregnancy is lower than the
transabdominal approach (β-hCG > 6500 mIU/mL). A transvaginal ultrasound
can typically identify a gestational sac when the β-hCG>1000 mIU/mL, and
the yolk sac when the β-hCG>2500 mIU/mL.
417.The answer is e.(Rosen, pp 230-231.)There is a high probability
that this patient is suffering from a uterine rupture or abruptio placentae.
Monitoringshould be instilled immediately with preparation for delivery.
Emergent obstetrical consultation is warranted for repair and possible
Cesarean-section. Risk factors include trauma, hypertension, recreational
drug use, smoking, multiparity, and advanced maternal age.
Ultrasound(a)is not useful in these cases, given that this is mainly a clin-
ical diagnosis. Tocolytics (c)should not be given to prevent delivery, as this is
often the treatment of choice. In cases of hemodynamic compromise as a
result of excessive blood loss, blood transfusions (d)are indicated. A type and
crossmatch should be done in this case in preparation for such an interven-
tion. A brief external look to examine for vaginal bleeding may be done, but a
complete pelvic examination (b)is not warranted as it may worsen bleeding.
418.The answer is e.(Rosen, pp 2413-2415.)Inthreatened abortion,the
patient has vaginal bleeding with a closed internal os in the first 20 weeks of