An 18-year-old G1P0 presents to the emergency department with a 1-day history of abdominal pain and vaginal bleeding. Her LMP was 7 weeks ago. On examination she is afebrile with a normal blood pressure and pulse. Abdominal examination demonstrates left lower quadrant tenderness with voluntary guarding. Laboratory tests reveal a normal white count, hemoglobin of 10.5 g/dL, and a quantitative b-hCG of 2342 mIU/ml. Ultrasound reveals a 10 × 5 × 6 cm uterus with a normal-appearing 1-cm stripe and no gestation sac or fetal pole. A 2.8-cm complex adnexal mass is noted on the left.
In the treatment of this patient, laparoscopy has what advantage over laparotomy?
Laparoscopic treatment of ectopic pregnancy is the preferred surgical treatment if the patient is stable. Studies suggest that the fertility rates and repeat ectopic pregnancy rates are comparable for laparoscopy and laparotomy. Laparoscopy results in shorter hospital stays, and many patients who undergo laparoscopy may be sent home the same day.
At the time of laparoscopy, she is noted to have an approximately 3 cm mass in the ampulla of the left fallopian tube, consistent with an unruptured ectopic pregnancy. There is no blood in the cul de sac.
What is the best next step in management?
An unruptured ectopic pregnancy in a patient who desires future fertility could be managed with a laparoscopic salpingostomy. These patients have a higher risk of persistent ectopic tissue, and should be followed with serial hCGs. It is not necessary to perform a laparotomy in this stable patient, nor is removal of the entire fallopian tube (salpingectomy) indicated in this 18-year-old. Methotrexate therapy (without surgery) would also be a reasonable option to manage this stable, unruptured ectopic pregnancy if the patient did not have any contraindications such as immunodeficiency, renal or liver disease, or inability to comply with medical therapy follow up. Better outcomes with methotrexate are also seen with hCG values
Which of the following events would be most likely to predispose this patient to ectopic pregnancy?
Any factor delaying transit of the ovum through the fallopian tube may predispose a patient to ectopic pregnancy. The major predisposing factor in the development of ectopic pregnancy is PID, which may cause tubal adhesions. A patient with a history of one episode of salpingitis will have a 9% chance of ectopic pregnancy. Any operative procedure on the fallopian tubes, such as tubal ligation, infertility surgery, or surgical treatment of a previous ectopic, will increase a patient’s risk. Tubal sterilization with laparoscopic fulguration has a higher rate of ectopic pregnancy than tubal ligations performed with clips or rings. Prior ectopic pregnancy, history of DES exposure, and use of assisted reproductive technology all increase the risk of ectopic. IUD use decreases the overall pregnancy rate, but if a patient gets pregnant with an IUD (1/500-1/1000), it has a higher chance of being an ectopic pregnancy.
An 18-year-old G1P0 at 8 weeks’ gestation presents to your office for her first prenatal visit. She reports daily nausea and vomiting over the past week.
Which of the following signs or symptoms would indicate a more serious diagnosis of hyperemesis gravidarum?
Nausea and vomiting of pregnancy is a common condition that affects 70% to 85% of pregnant women. Hyperemesis gravidarum is an extreme version of this that occurs in 0.5% to 2% of pregnancies. The diagnostic criteria include intractable vomiting not related to other causes, a measure of acute starvation (ie, ketonuria), and weight loss (usually at least 5% of body weight). Electrolyte abnormalities such as hypokalemia can also be present due to persistent vomiting. Hyperemesis gravidarum is the most common reason for admission to the hospital during early pregnancy. Patients who have hyperemesis gravidarum are best treated (if the disease is early in its course) with parenteral fluids and electrolytes, sedation, rest, vitamins, and antiemetics if necessary. ACOG recommends antiemetics such as dimenhydrinate, metoclopramide, or promethazine as first line agents, followed by methylprednisolone or ondansetron if this is not effective. Very slow reinstitution of oral feeding is permitted after dehydration and electrolyte disturbances are corrected. The disease usually improves spontaneously as pregnancy progresses.
A 32-year-old G2P0101 presents to labor and delivery at 34 weeks’ gestation with a chief complaint of regular uterine contractions every 5 minutes for the past several hours associated with the passage of clear fluid from her vagina. The external fetal monitor demonstrates a reactive fetal heart rate tracing, with contractions occurring every 3 to 4 minutes. Sterile speculum examination demonstrates a closed cervix with a pool of clear fluid in the vagina. A sample of this fluid is fern and nitrazine-positive. The patient has a temperature of 38.8°C, pulse 102 beats per minute, blood pressure 100/60 mm Hg, and her fundus is tender to palpation. Her admission blood work shows a WBC of 19,000 mcL. The patient is very concerned because she previously delivered a baby at 35 weeks who developed respiratory distress syndrome (RDS). You perform a bedside ultrasound, which shows oligohydramnios, and a fetus whose size is appropriate for gestational age and in cephalic presentation.
Which of the following is the most appropriate next step in the management of this patient?
This patient with preterm, premature rupture of membranes (PPROM) has a physical examination consistent with an intrauterine infection or chorioamnionitis. Chorioamnionitis can be diagnosed clinically by the presence of maternal fever, tachycardia, and uterine tenderness. Leukocyte counts are a nonspecific indicator of infection because they can be elevated with labor and the use of corticosteroids. When chorioamnionitis is diagnosed, fetal and maternal morbidity increases and delivery is indicated regardless of the fetus’s gestational age. In the case described, antibiotics need to be administered to avoid neonatal sepsis. Ampicillin is the drug of choice to treat group B streptococcal infection. Since the fetal heart rate is reactive, there is no indication for cesarean delivery. Induction or augmentation of labor should be instituted as indicated. There is no role for tocolysis in the setting of chorioamnionitis, since delivery is the goal.
There is also no role for the administration of steroids, since delivery is imminent. Steroids are typically not indicated after 34 weeks’ gestation. A cerclage is used to treat an incompetent cervix in the second trimester in the absence of ruptured membranes.
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