Chapter 100

#### High-Yield Facts

• Ectopic pregnancy, as the leading cause of maternal mortality during the first half of pregnancy, should be considered in patients with abdominal pain and vaginal bleeding.

• Examination of the cervix may exacerbate hemorrhage in patients with placenta previa.

• Placental abruption may present with concealed hemorrhage or vaginal bleeding and typically includes vaginal bleeding, abdominal pain, uterine tenderness, and contractions. Ultrasound is not sensitive for its diagnosis.

• The relatively high prevalence of preeclampsia should warrant obtaining a routine blood pressure and consideration of screening for proteinuria.

• HELLP syndrome is defined as hemolysis, elevated liver enzymes, and low platelets (<100,000/mm3); lower platelet counts are associated with higher mortality.

• Shock may be difficult to diagnose in the pregnant patient as blood volume, heart rate, and respiratory rate are physiologically increased during pregnancy.

Although the teen pregnancy rate decreased 40% from 1990 to 2008 due to an increase in the use of contraception, a decrease in sexual activity, and effective pregnancy prevention programs, there are still more than 750,000 teen pregnancies a year.13 Pregnancy rates among non-Hispanic black and Hispanic teenagers remain disproportionately high.1 Pregnant teens are less likely to receive prenatal care and are more likely to partake in high-risk behaviors such as smoking and consumption of alcohol during pregnancy. Teen mothers are at risk of not completing their education and living in poverty as compared to their peers.

##### Vaginal Bleeding in Pregnancy

Bleeding in the first trimester occurs in 25% of patients.4 Common etiologies include ectopic pregnancy, threatened abortion, spontaneous abortion, sexually transmitted infections, and trauma. In later trimesters the causes include placenta previa and placental abruption.

#### Ectopic Pregnancy

An ectopic pregnancy is defined as the implantation of the blastocyst outside the endometrial lining of the uterine cavity. Ectopic pregnancy is an important cause of maternal morbidity and mortality during the first half of pregnancy in the United States. There is an overall incidence of 2% and an incidence of 1.8% in women presenting to the emergency department (ED) with either first trimester bleeding and/or abdominal pain.5 Higher rates of mortality in adolescents are largely due to delays in seeking care. Greater than 95% of ectopic pregnancies are located in the fallopian tube.5 Risk factors include prior ectopic pregnancy, prior tubal surgery, genital tract infections leading to pelvic inflammatory disease (PID), and intrauterine device.5

Most cases present within the first 8 weeks of gestation with abdominal pain or abnormal vaginal bleeding. Pelvic or abdominal pain and exquisite tenderness are the most common complaints. Others present with a late menstrual cycle and abnormal vaginal bleeding, which can be confused with menses. In the case of a ruptured ectopic with intra-abdominal hemorrhage and hypovolemia, the clinical presentation may include dizziness and/or presyncope.6

The classically described but rare presentation of ectopic pregnancy ...

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