Rosen & Barkin's 5-Minute Emergency Medicine Consult (573 page)

• Determine 1st day of last menstrual period (FDLMP)
  
• 40% of women cannot accurately remember their FDLMP
  

Pelvic exam:

• Estimate expected date of delivery by determining uterine fundal height
  
• Centimeters from pubic bone to top of uterus approximates gestational age after 16 wk
  
• Detect abnormal pelvic pain or masses
  

• Pregnancy tests:
  
  • β-subunit of hCG
    
  • Quantitative hCG normally doubles every 2 days until 6–7 wk gestation
    
  • Progesterone
    
• Measurement of β-hCG:
  
  • Most urine pregnancy tests have sensitivity at 25 mIU/mL:
    
    • False-negative tests with dilute urine and high vitamin C intake
      
  • Home pregnancy tests are not that accurate:
    
    • Detect pregnancy 9–12 days post conception
      
  • Positive home pregnancy tests should be confirmed by serum hCG levels.
    
  • Serum level of hCG:
    
    • Detectable 8–11 days post conception
      
  • hCG levels may remain detectable up to 60 days after an abortion.
    
• Serum progesterone level is an indicator of the viability of the pregnancy and may be used to predict the outcome of the pregnancy:
  
  • A serum progesterone level of <5 ng/mL is indicative of a nonviable pregnancy (spontaneous abortion or ectopic pregnancy).
    
  • Progesterone level 25 ng/mL denotes a viable pregnancy.
    

• Ultrasonography is used to confirm pregnancy in the setting of abdominal pain, vaginal bleeding, or some other potential obstetric complication:
  
  • Can estimate gestational age
    
  • Confirm intrauterine or ectopic pregnancy
    
  • Evaluate fetal viability
    
  • Identify fetal abnormalities
    
• Transabdominal US vs. transvaginal US:
  
  • Transvaginal US is more sensitive but more difficult to perform.
    
  • Intrauterine pregnancy seen at 4–5 wk in transvaginal US
    
  • Gestational sac seen at 5.5–6 wk in transabdominal US
    
  • Transvaginal US is contraindicated in the setting of premature rupture of membranes and 3rd-trimester bleeding.
    
• When used in combination with hCG levels, US is a very helpful tool in detecting abnormal/problem pregnancy.
  
• MRI: No significant side effects have been documented.
  
  • Often the study of choice to evaluate for appendicitis in pregnancy
    
• Plain radiography and CT:
  
  • Dose-dependent teratogen
    
  • Slight increase in risk of childhood cancer
    
  • Goal is to not exceed 5,000 mrad fetal dose of radiation:
    
    • CXR with abdominal shield: <1 mrad
      
    • Abdominal plain film: 240 mrad
      
    • Chest CT: <10 mrad
      
    • Head CT: < 10 mrad
      
    • Abdominal CT with and without contrast: 2,000 and 1,000 mrad
      
    • Cardiac catheterization: 1,300 mrad
      
    • VQ scan: <50 mrad
      

Any woman who is of the age to be sexually active who presents to the ED should be assumed to be pregnant until proven otherwise.

TREATMENT

• Assume the patient is pregnant
  
• Administer medications only when necessary to avoid teratogenetic side effects or placental–fetal compromise (e.g., epinephrine)
  
• If >24 wk gestation, transport in left lateral recumbent position
  

• Advanced cardiac life support, advanced trauma life support measures as needed: Oxygen, cardiac monitor, IV access, and fluids:
  
  • 1st objective is to resuscitate mother
    
• If >24 wk gestation, place in the left lateral recumbent position
  

The goal is to optimize maternal condition to improve fetal condition.

• 1st trimester is when organogenesis is occurring.
  
• Fetal malformation continues beyond the 1st trimester.
  
• Before using any drug, refer to its Food and Drug Administration safety classification in pregnancy:
  
  • This classification system categorizes drugs as A, B, C, D, and X, with category A being the safest and category X being the most toxic.
    
• Analgesics: Acetaminophen is the preferred OTC analgesic
  
• Aspirin and NSAIDs are not teratogenic but are best used in consultation with an obstetrician
  
• Oxycodone, codeine, hydrocodone, meperidine, and morphine have no known teratogenic affect and can be used for the control of severe pain in pregnancy for short periods of time (3–4 days).
  
• Antibiotics: Selecting the right antibiotic in a gravid female depends on 3 factors:
  
  • Maternal drug allergies
    
  • Gestational age
    
  • Type of infections and associated pathogens
    
• Consider placing patient on prenatal vitamins
  
• Pain control:
  
  • Acetaminophen: 500 mg PO q6h; do not exceed 4g/d
    
• Antiemetic:
  
  • Ondansetron: 4 mg IM/IV q8h
    
  • Vitamin B
    ₆
    25 mg TID or ginger can also help
    

FOLLOW-UP

• Pregnant women with the following obstetric complications should be admitted to the hospital:
  
  • Hyperemesis gravidarum with inability to tolerate oral fluids
    
  • Complicated UTI
    
  • Ectopic or molar pregnancy
    
  • Septic abortion
    
  • Preterm labor
    
  • Premature rupture of membranes
    
  • Preeclampsia/eclampsia
    
  • Severe pregnancy-induced HTN
    
• Pregnant women with medical conditions that would warrant admission in a nongravid female.
  

Women without the above conditions may be discharged from the ED.

Need OB follow up for prenatal care by 6–8 wk gestation

• All women are considered to be pregnant until proven they are not
  
• Review all medications’ pregnancy safety classifications before administering or prescribing
  
• Minimize radiation exposure to fetus to <5,000 mrad
  

• Dighe M, Cuevas C, Moshiri M, et al. Sonography in first trimester bleeding.
  J Clin Ultrasound
  . 2008;36:352–366.
  
• Ebrahimi N, Maltepe C, Einarson A. Optimal management of nausea and vomiting of pregnancy.
  Int J Womens Health.
  2010;2:241–248.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Moschos E, Twickler DM. Endometrial thickness predicts intrauterine pregnancy in patients with pregnancy of unknown location.
  Ultrasound Obstet Gynecol
  . 2008;32:929–934.
  

CODES

• V22.0 Supervision of normal first pregnancy
  
• V22.1 Supervision of other normal pregnancy
  
• V22.2 Pregnant state, incidental
  

BASICS

• Penile erection (engorgement of corpora cavernosa) in the absence of sexual arousal that is prolonged and frequently painful
  
• Low-flow priapism:
  
  • Most common mechanism
    
  • Poor venous outflow
    
  • Usually painful
    
  • Ischemia and thrombosis from stagnant, hypoxic blood can occur after a few hours.
    
  • Fibrosis and erectile dysfunction are late sequelae.
    
• High-flow priapism:
  
  • Rare
    
  • Penile arterial laceration with uncontrolled inflow of arterial blood
    
  • Usually painless
    
  • Presentation may be later than in low-flow priapism.
    
  • Ischemia and erectile dysfunction are uncommon.
    

• Idiopathic
  
• Pharmacologic agents:
  
  • Intracavernosal injectables for the treatment of erectile dysfunction:
    
    • Prostaglandin E1
      
    • Papaverine
      
    • Phentolamine
      
  • Psychotropics:
    
    • Phenothiazines
      
    • Butyrophenones
      
    • Trazodone
      
    • Sedative–hypnotics
      
    • Selective serotonin uptake inhibitors
      
  • Antihypertensives:
    
    • Prazosin
      
    • Hydralazine
      
    • Phenoxybenzamine
      
    • Guanethidine
      
  • Rarely implicated agents:
    
    • Phosphodiesterase inhibitors: Sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra)
      
    • Anticoagulants
      
    • Cocaine
      
    • Marijuana
      
    • Ethanol
      
    • Androstenedione
      
  • Toxins (Black Widow, Scorpion)
    
• Hematologic disorders predisposing to sludging of blood:
  
  • Sickle cell anemia (most common cause)
    
  • Leukemia
    
  • Multiple myeloma
    
  • Polycythemia
    
• Penile and perineal trauma (arterial laceration and high-flow priapism)
  
• Spinal trauma (loss of inhibitory adrenergic tone)
  
• Rare causes:
  
  • Pelvic neoplasms and infections
    
  • Infiltrative diseases (e.g., amyloidosis)
    
  • Dialysis
    
  • Parenteral nutrition solutions containing a fat emulsion