2. Aims
• Review case presentation
• Clinical work through
• Discuss what we do know
• What else is there to know?
• Emergency differentials
• Questions
3. Overview of child & parent / carer
• 15 yo (F), attended with mother (‘Mary’)
• Pc/ Abdominal pain and nausea
• HPc/
– 14/7 Hx of abdo pain & N&V (*haematemesis)
– Rapid onset, colicky/deep?, alleviated by rest, starts during /
after school, 6/10 severity (currently 1/10)
– Recent UTI treated with 3 day course 200 mg BD Trimethoprim
(completed course)
– No longer has urinary Sx of; increased frequency or dysuria
• PMHx/ None, Dx/ None, NKDA
• SHx/ Lives at home with Mum & Dad, also has 4 sisters
– No alcohol intake, no smoking intake
• GHx - ?Previous incisions or abdominal surgeries (none)
4. Key points from history
• Vomiting – volume, hungry, forceful (projectile)
or effortless (regurgitation);
keeping down solids / liquids?
• Contains? – coffee grounds, bile-stained, fresh
blood, ect
• Painful abdomen – constipation, diarrhoea,
bloating, normal bowel motions? Blood (fresh /
old)
• Urinary symptoms – have they resolved?
• FHx of anything?
5. Overview of assessment and
examination
• Observations: Pulse 95, BP
103/63, RR 14, Sats 98%, GCS
15, T 36.2 – not worried
(tachy?)
• OE/ HEENT normal, *LN, A&O,
pain low at rest, PEARL, low
BMI, CRT <2s centrally, pale
and cold peripheries
• CVS / Resp – all normal
• GI/ Soft abdomen, mild
flinching on palpation (left
adnexae and central), no
uterus palpated and
*organomegaly, BS heard
8. Assessing a teenager
Tanner Staging Female
• Thelarche
– I. None
– II. Breast bud
– III. Further enlargement of areola and
breasts with no separation of contours
– IV. 2. mound of areola and papilla
– V. Areola recessed to general contour
of breast – adult
• Pubarche
– I. None
– II. Downy hair along labia only
– III. Darker/coarse hair extends over
pubis
– IV. Adult type covers smaller area, no
thigh involvement
– V. Adult hair in quantity and type.
Extends over thighs
• Thelarche: breast development
• Pubarche: pubic and axillary hair
development
• Menarche: onset of menses, usually
following peak height velocity
and/or 2 yr following breast budding
9. Anything else?
• Sisters: one of them got pregnant at 16 and went
'off the rails' and she is concerned she will end up the
same
• Took a pregnancy test last week as was asked to by
boyfriend of 5 months duration (also 15 years old?),
because she missed period of two weeks duration
• Her test was positive, yet both daughter and mother
did not believe it could be true as daughter states
‘I have never done anything’, mother thinks the UTI
was to blame..
• Questions: Intermenstrual bleeding, postcoital
bleeding.. When asked described a ‘smelly discharge’
10. Interventions
• Investigations/ PDT – positive
• Urine Dipstix – NAD
• Separate discussion with mother/
Her thoughts, concerns, expectations..
• Why did she come to A&E?..
11. Ideally
• Pelvic U/S: visualize intrauterine preg to r/o
ectopic; if preg., intrauterine not seen, &
– bHCG > discrim. zone → concern for ectopic;
– if bHCG < discrim. zone → follow bHCG;
• Placental position to r/o placenta praevia and
likely severe abruption
• Ectopic pregnancy is life-threatening
diagnosis, ∴ must rule out if Pt pregnant
12.
13. B-hCG
+ve in serum 9 d post-conception
+ve in urine 28 d after first day LMP
Plasma levels double every 1-2 d, peak 8-
10 wk, fall to plateau until delivery
Levels less than expected by dates suggest:
• Ectopic pregnancy
• Abortion
• Inaccurate dates
Levels higher than expected suggest:
• Multiple gestation
• Molar pregnancy
• Trisomy 21
• Inaccurate dates
14. Outcomes & Plan
• Plan/ Discharge and discuss positive test result
with mum and daughter, implications…
• Also engage social services & safeguarding so
they are aware of this case, also let her know
about GP planning so they can do a staging scan
and determine things about the pregnancy, like
how far along it is (Mother: asked whether it is
too late to abort it (if it should come to that)..)
• GP referral – appointment for follow up on smelly
discharge – STI?
18. RUPTURED ECTOPIC PREGNANCY
• Suspect this in women with syncope and abdominal pain or
gynecological symptoms
• 1* cause maternal mortality 1st trimester
• Do a pregnancy test
• Immediate major surgery
• Take patient to OT before anaesthesia, as the loss of
sympathetic tone after the onset of anaesthesia can cause
catastrophic hypotension in a hypovolaemic patient (In
extreme cases, it may be necessary to operate in the ED)
• 1-30,000 1-3,000 with PID…
• It is important to note that rare cases of ruptured ectopic
pregnancies with negative pregnancy tests have been
reported
19. Diagnostic tests
• Urine pregnancy test = +ve
• High resolution transvaginal ultrasound (TVUS) – no
intrauterine pregnancy detected, ectopic visualised
occasionally
• Transabdominal ultrasound – no intrauterine pregnancy
detected
• Serial serum hCG - <53% increase in level over 48 hours or
plateau of level
• Serum progesterone – rules out if 1) <15.9nmol/L, or 2)
>63.6 nmol/L
• Diagnostic laparoscopy
• Dilation and curettage (D&C)
22. Reflection / consideration of
alternative actions etc
• Medical:
• Psychosocial aspects?
– Breaking bad news.. To a child
• Mothers view
• Termination / Continuation of pregnancy?
• How to take history from daughter without
mother
• Importance of collateral history?
23. Guidance
• The 'Changing childbirth' report (Department of
Health 1993) and 'Maternity matters'
(Department of Health 2007) explicitly confirmed
that women should be the focus of maternity
care, with an emphasis on providing choice, easy
access and continuity of care.
• Care during pregnancy should enable a woman to
make informed decisions, based on her needs,
having discussed matters fully with the
healthcare professionals involved.
24. References
• Burns, E., Korn, K. and Whyte, J. (2011) Oxford American Handbook of Clinical
Examination and Practical Skills. New York: Oxford University Press. Practice, 4
• Simon, C., et al (2014) Oxford Handbook of General Practice 5th edition. UK: Oxford
University Press
• Young, A., Vojvodic, M. (2014) Toronto Notes for Medical Students, 30th Edition.
Toronto: Canada
• Public Health England (2013) Teenage Pregnancy Resources. Available at:
http://www.apho.org.uk/resource/view.aspx?RID=116351 (Accessed: 7 May 2015).
• Seeber, B., Barnhart, K. (2006) Suspected Ectopic Pregnancy. Obstet Gynecol
2006;107:399-413 (Accessed: 10 May 2015)
• https://www.nice.org.uk/guidance/cg154/ifp/chapter/Treatment-for-ectopic-
pregnancy
• http://www.nice.org.uk/guidance/cg62/chapter/Aim
• http://www.ahcmedia.com/articles/20867-vaginal-bleeding-in-pregnancy-part-i
15 year old female, attended with mother
Pc/ Abdominal pain and feeling nauseous
HPc/
2 weeks history of abdominal pain & nausea, some episodes of vomiting (*haematemesis)
Colicky in nature, rapid onset, alleviated by rest, starts during / after school, 6/10 severity (currently 1/10)
Recent UTI treated with 3 day course 200 mg BD Trimethoprim (completed course)
No longer has urinary symptoms of increased frequency or dysuria
PMHx/ None, Dx/ None, NKDA
SHx/ Lives at home with Mum & Dad, also has 4 sisters
No alcohol intake, no smoking intake
Observations: Pulse 95, BP 103/63, RR 14, Sats 98%, GCS 15, T 36.2 – not worried (tachy?)
OE/ HEENT normal, *lymphadenopathy, A&O, pain low at rest, PEARL, pale and cold peripheries, low BMI, CRT <2s centrally,
GI/ Soft abdomen, mild flinching on palpation (left adnexae and central abdomen), no uterus palpated and *organomegaly, bowel sounds heard
Investigations/ PDT - positive, Urine Dipstix – NAD
Also signs of infection down below may need to be treated (sounds like a concurrent STI infection?)
(Reference: Image: Surgery at a Glance, 5th Edition)
Labs: FBC, electrolytes, LFTs, amylase/lipase, pregnancy test
Imaging: depends on suspected etiology, may include RUQ U/S for biliary/hepatic disease, KUB for intestinal obstruction, CT for pancreatitis or intestinal disease. Do not delay resuscitation or surgical consultation for ill Pt while waiting for imaging.
Choice of contraceptive method
• Condoms: Most commonly used contraception for adolescents.
Relatively high failure rate—suggest their use in addition to another form of contraception to help prevent STIs
• Long-acting reversible contraception (LARC): Offer IUCD, progestogen implant, injectables, or intrauterine system to all teenagers. Provides high levels of protection against pregnancy with no need for ongoing compliance once fitted / administered. The CSM advises that medroxyprogesterone acetate (Depo-Provera.) should only be used when other methods of contraception are inappropriate as it may increase osteoporosis risk (use alternative if other risk factors and try not to use >2y), menstrual irregularity, and increase weight
• Combined hormonal contraception (pill, patch, or vaginal ring):
Suitable method of contraception for the under 16s. Poor compliance
can be a problem and leads to a relatively high failure rate
• Progestogen-only pill (POP): Suitable for teenagers but has the same compliance problems as combined hormonal contraception and is associated with menstrual irregularity. Useful if the teenager does not want long-acting contraception and CHC is contraindicated
• ‘Morning after pill’ (levonorgestrel 1.5mg <72h or ulipristal acetate 30mg <120h after unprotected intercourse): Not suitable as regular contraception, but valuable in preventing unwanted pregnancy. Provide information on availability and make it easy for teenagers to get urgent same-day appointments to obtain a prescription
Gynaecological disorders presenting to the ED with abdominal pain may be difficult to distinguish from other disorders. Obtain a full history of the pain: sudden onset of severe colicky pain follows ovarian torsion and acute vascular events
More insidious onset and continuous pain occur in infection and inflammation
Radiation of the pain into the back or legs suggests gynaecological origin
Other clues in the history include co-existing symptoms of vaginal discharge, vaginal bleeding, or missed LMP
Abdominal and pelvic pain in early pregnancy may be due to ectopic pregnancy or threatened abortion: both occur in patients who do not realise they are pregnant or who deny the possibility of pregnancy due to embarrassment
1st tests to order
Once pregnancy is confirmed, TVUS is used to determine location of the pregnancy.
If an intrauterine gestation is visualised, which can be either viable or non-viable, the likelihood of having an ectopic pregnancy is extremely low, with the exception of heterotopic pregnancy. [36]
Occasionally, an ectopic pregnancy is visualized on TVUS (either by 'doughnut sign' - presence of an adnexal mass separate from 2 clearly identified ovaries, View imageView image or 'ring of fire' - increased blood flow to the ectopic gestation seen on colour Doppler), and the diagnosis is made directly.
However, in many cases, neither an intrauterine nor an ectopic pregnancy can be visualised on ultrasound, resulting in the so-called pregnancy of unknown location. [37]
Using TVUS, an intrauterine pregnancy should be seen by 5 weeks after the last menstrual period
If an intrauterine pregnancy cannot be confirmed when the discriminatory hCG levels are reached (1500-2000 IU/L or 1500-2000 mIU/mL), there is a high possibility that the pregnancy is ectopic.
no intrauterine pregnancy detected ; ectopic pregnancy visualised occasionally
Less sensitive than transvaginal ultrasound; should detect intrauterine pregnancy by 6 weeks after last menstrual period, or when discriminatory hCG levels are reached (4000-6000 U/L [4000-6500 mU/mL]). If intrauterine location is not identified after discriminatory hCG level is reached, high possibility that pregnancy is ectopic.
Ordered to confirm pregnancy or if TVUS does not confirm an intrauterine pregnancy.
In 99% of viable intrauterine pregnancies, a rise in hCG levels of at least 53% in 2 days can be demonstrated. [38] [39] [40]However, caution is advised when interpreting the result, as one study revealed that up to 27% of women diagnosed with an ectopic pregnancy had hCG curves resembling a normal pregnancy. [41]
When level is well above discriminatory level (1500-2000 U/L or 1500-2000 mU/mL) and there is no sign of intrauterine gestation on TVUS, a viable intrauterine gestation is extremely unlikely, and successive serum quantitative hCG can be used to differentiate between an ectopic pregnancy and a failing (non-viable) intrauterine gestation (miscarriage).
A steady decrease in hCG values (i.e., a decrease of 12% to 35% in 2 days depending on the initial hCG values) suggests a failing intrauterine pregnancy (miscarriage), but it can also be seen with spontaneously resolving ectopic pregnancies. [38] [43]
On the other hand, suboptimal increase (i.e., <53%) or plateauing of hCG values suggests an ectopic pregnancy. [38] [37][40]
A third hCG, in a stable patient, and early ultrasound decrease intrauterine pregnancy misclassification. [47]
<53% increase in level over 48 hours or plateau of level
May rule out ectopic pregnancy if 1) <15.9 nmol/L (<5 ng/mL), as unlikely to be associated with a viable pregnancy, or 2) >63.6 nmol/L (>20 ng/mL), as reasonably excludes ectopic pregnancy. [44]
However, should not be used to affirmatively diagnose ectopic pregnancy between 15.9 and 63.6 nmol/L (5 and 20 ng/mL).
However, should not be used to affirmatively diagnose ectopic pregnancy between 15.9 and 63.6 nmol/L (5 and 20 ng/mL).
Fig. 1. Possible anatomic sites in ectopic pregnancies.
Illustration: John Yanson. Seeber. Suspected Ectopic Pregnancy. Obstet Gynecol 2006.
A fertilised ovum implanting and maturing outside of the uterine endometrial cavity, with the most common site being the fallopian tube (97%), followed by the ovary (3.2%) and the abdomen (1.3%). [1] If undiagnosed or untreated, it may lead to maternal death due to rupture of the implantation site and intraperitoneal haemorrhage. [2]
The 'Changing childbirth' report (Department of Health 1993) and 'Maternity matters' (Department of Health 2007) explicitly confirmed that women should be the focus of maternity care, with an emphasis on providing choice, easy access and continuity of care. Care during pregnancy should enable a woman to make informed decisions, based on her needs, having discussed matters fully with the healthcare professionals involved.
Burns, E., Korn, K. and Whyte, J. (2011) Oxford American Handbook of Clinical Examination and Practical Skills. New York: Oxford University Press.
Public Health England (2013) Teenage Pregnancy Resources. Available at: http://www.apho.org.uk/resource/view.aspx?RID=116351 (Accessed: 7 May 2015).
http://www.nice.org.uk/guidance/ph51
