Pediatric emergency medicine trisk 2116 2116
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Management
Pregnancy. Once the diagnosis of pregnancy has been made, the goals of the ED
evaluation include (i) dating the pregnancy, (ii) recognizing symptoms that
require immediate referral for obstetric or gynecologic evaluation, (iii) identifying
and treating presenting and potential nonsurgical complications, (iv) assessing
chronic medical conditions, (v) providing appropriate counseling, and (vi)
securing appropriate and timely follow-up. These goals can be tailored to specific
settings, depending on consultant availability and access to close follow-up for
the patient.
The approach to management of patients diagnosed with pregnancy includes
subspecialty consultation, quantitative serum β-hCG levels, serum progesterone
levels, abdominal and/or transvaginal ultrasound, depending on the practice
setting, as well as close follow-up. Ideally, schedule a primary care or adolescent
medicine specialist follow-up visit in 2 to 3 days so that counseling about options
can be repeated in a less rushed, less chaotic environment. It is also important to
review the patient’s medical insurance and link her to eligible coverage/resources.
The need to arrange close follow-up and to facilitate connection to care following
the ED visit should not be underestimated.
In a normal singleton pregnancy, serial serum β-hCG levels should increase by
67% every 48 hours during the first month of pregnancy. Levels that do not rise
or rise more slowly than expected are indicative of an abnormal pregnancy
(usually an ectopic pregnancy or a pregnancy that is destined to spontaneously
abort). Ultrasound is used to visualize the uterine cavity to assess for the presence
of a gestational sac. When the β-hCG level reaches the discriminatory zone, a
gestational sac should be visible within the uterus. The discriminatory zone varies
based on local transvaginal ultrasound expertise, but is generally around a β-HCG
of 2,500, or a gestational age of 6 weeks. If no sac is seen and the β-HCG is
beyond the discriminatory zone, the pregnancy is presumed to be ectopic. If the
discriminatory zone has not been reached or the pregnancy dates (by last
menstrual period, for example) is less than 6 weeks, the patient should have a
repeat β-HCG within 48 hours and the ultrasound repeated if the β-HCG is at or
above the discriminatory zone.
For patients diagnosed with ectopic pregnancy, conservative medical
management may be appropriate in adolescents who are stable, have no evidence
of any bleeding, have a hemoglobin of greater than 8 g/dL and a gestational sac
less than 4 cm, who are not immunocompromised, and do not have a bleeding
diathesis, or liver, or renal disease, and if close follow-up can be secured. As
