Chapter 4. Sexual Abuse, Gynecology, and Sexually Transmitted Infections

Clinical Summary

Child sexual abuse occurs when a dominant, more powerful person involves a depending, developmentally immature child or adolescent in sexual activities for his or her own or others’ sexual stimulation or gratification. This includes child pornography and prostitution, and ranges from nontouching abuses to direct genital, anal, or oral-genital contact. About 1% of children experience some form of sexual abuse each year. Perpetrators are usually male (75% to 90%) and usually involve adults or minors known to the child. Abuse by family members or known acquaintances often involves multiple episodes over weeks to years, whereas abuse by strangers tend to be a single episode. Most cases are detected when the child discloses the abuse. Sexually abused children may present with a variety of general and/or nonspecific symptoms and signs (eg, sleep disturbances, abdominal pain, enuresis, encopresis, phobias). Physical findings are often absent even when the perpetrator admits to penetration of the child’s genitalia. Many types of abuse leave no physical evidence, and injuries to the mucosa heal quickly and thus leave no physical evidence in most cases.

Emergency Department Treatment and Disposition

Obtain a history in those older than age 3 years, and avoid leading and suggestive questions or showing strong emotions such as disbelief or shock in the absence of the parent so that their influence or distraction are minimized. Maintain a “tell me more” or “and then what happened approach.” Explain the physical examination to the child before conducting it and avoid any additional emotional trauma. Examination should be immediate if the patient presents within 72 hours of the alleged sexual abuse, and must include checking for acute injury or bleeding, vaginal discharge, possible presence of sexually transmitted infections (STIs) and the possibility of pregnancy in adolescent girls who have reached menarche. If more than 72 hours have passed since the alleged abuse, the exam can be scheduled at the earliest time that is comfortable for the child, the investigative team, and the physician. Perform a thorough physical examination, including mental and emotional status with special attention to areas that are involved in sexual activity. The supine frog-leg position is most often employed and well tolerated by prepubertal girls. It is important also to view the hymen in a second position if a concerning physical finding is seen. The prone knee-chest position often allows better visualization of the hymen, the fossa navicularis, and the posterior fourchette. Do not perform speculum or digital examinations in a prepubertal child. A digital rectal examination is usually not necessary. Conduct universal screening of postpubertal patients for gonorrhea, Chlamydia, syphilis, HIV, or other STIs. In asymptomatic prepubertal patients, the yield of positive cultures is very low, and appropriate cultures and serologic tests are recommended when epidemiologically indicated or when history and/or physical findings suggest oral, genital, or rectal contact. Prophylaxis for STIs is not recommended for asymptomatic prepubertal children being evaluated for possible child sexual abuse. In contrast, adolescents should be encouraged to receive prophylaxis for STIs. Use a multidisciplinary approach involving local or regional child abuse consultants and a social worker. Once sexual abuse is identified, all siblings should be examined and close follow-up arranged within 1 to 2 weeks to detect new infections and to complete counseling and treatment for other STIs. Consider mental health assessment and treatment as necessary.

Pearls

1. A normal physical examination does not exclude abuse; diagnostic findings are seen in 5% of victims.

2. Physical examination should not result in additional emotional trauma.

3. Vaginal, rather than cervical, samples are adequate for testing of STIs in prepubertal children.

4. Diagnosis is often made on the basis of the history; a child’s statement of abuse is often the most important evidence.

5. Presume sexual abuse until proven otherwise in a child presenting with STIs.

The authors acknowledge the special contributions of Binita R. Shah, MD, to prior edition.

Clinical Summary

Condyloma acuminata (genital warts) are skin-colored, fleshy lesions on mucocutaneous junctions and intertriginous areas, which can coalesce to large cauliflower-like lesions. Locations include perianal area, glans penis, scrotum, labia or posterior introitus, vagina, cervix, anus, urethra, mouth, nose, and eyes. Symptoms may include pruritus, burning, bleeding, and pain depending on location and size. Condyloma acuminate is caused by human papillomavirus (HPV), which is prevalent and insidious: >50% of sexually active people are infected and most infections are asymptomatic, unrecognized, or subclinical and self-limited. Transmission, occurs by sexual and nonsexual contact activity. Genital warts in children require careful consideration as about 50% are the result of sexual abuse. Nonsexual acquisition is usually seen in children <3 years old and may be suggested by warts on the hands (with autoinoculation patient transferring warts to mouth, genitals, anal area), a mother with hand warts, sexual play among children, absence of other signs of sexual abuse, and warts distant from the anus or introitus.

Oncogenic or high-risk HPV types (eg, HPV types 16 and 18) cause cervical cancers and other anogenital cancers. Persistent infection is the strongest risk factor for the development of precancers and cancers. HPV types 6 and 11 account for 90% of genital warts. Two HPV vaccines are licensed in the United States: a bivalent vaccine (Cervarix) containing HPV types 16 and 18 and a quadrivalent vaccine (Gardasil) containing HPV types 6, 11, 16, and 18. HPV DNA testing is not recommended as it does not alter clinical management. Differential diagnosis includes condylomata lata, pearly penile papules, and skin tags.

Emergency Department Treatment and Disposition

Untreated, visible warts can resolve on their own, remain unchanged, or increase in size or number. Treatment is aimed at relief of symptoms and many factors influence treatment selection, including size, number, anatomic site, morphology, patient preference, convenience, adverse effects, and provider experience. The response to therapy is influenced by the presence of immunosuppression and compliance with therapy. No treatment has been shown to be superior to any other and no single treatment is ideal for all patients or all warts. Patient-applied therapies and provider-administered therapies are available. Patient-applied treatment regimens for external genital warts include podofilox 0.5% solution or gel or imiquimod 5% cream or sinecatechins 15% ointment. Refer the patient to dermatology if diagnosis is uncertain, immunocompromised patient, warts are fixed, indurated, pigmented, ulcerated, or bleeding. Refer for provider-applied treatment regimens (eg, cryotherapy with liquid nitrogen, surgical removal, curettage, or electrosurgery).

Pearls

1. Examination of sexual partners is not required; partners are usually infected at the time one person is diagnosed with HPV infection even in the absence of visible warts.

2. Exclude sexual abuse in children with genital warts.

3. Consult a specialist for management of intraanal warts as patients may also have warts on the rectal mucosa.

4. Laryngeal papillomatosis has been seen in infants born to mothers with HPV infection, delivered vaginally or by cesarean section.

Clinical Summary

Trichomonas vaginalis infection is almost always sexually transmitted with peak prevalence rates between ages of 16 to 35 years. The most common site of infection is the vagina, followed by periurethral glands and urethra. Patients present with pruritus, dysuria, dyspareunia, lower abdominal pain, vaginal discharge, postcoital bleeding, edema and excoriation of the external genitalia, bartholinitis, and urethritis.

Emergency Department Treatment and Disposition

Obtain vaginal secretions for microscopic detection of Trichomonas (specificity of 60%–70%). Tests like OSOM Trichomonas Rapid Test or AFFIRM VP III (nucleic acid probe test) performed on vaginal secretions have sensitivity of >83% and specificity >97%. Culture of Trichomonas is still the most sensitive and specific method of diagnosis. PCR assay for T vaginalis in vaginal or endocervical swabs, and in urine from both men and women is available (sensitivities ranging from 88% to 97%; specificity from 98% to 99%). T vaginalis has not been found to infect oral sites, and rectal prevalence appears low; therefore, oral and rectal testing is not recommended.

Treat patients with metronidazole (2 g orally in a single dose or 500 mg orally twice a day for 7 days) or Tinidazole (2.0 g orally in a single dose). Both of these regimens have high cure rates of about 95%. Intravaginal or topical metronidazole gel has not been shown to be effective and is not recommended. Certain strains of T vaginalis can have diminished susceptibility to metronidazole. If treatment failure occurs with single-dose metronidazole and reinfection is excluded, treat with metronidazole for a 7-day regimen or tinidazole. Treatment of all sex partners is advisable. Because of the high rate of reinfection among patients in whom trichomoniasis is diagnosed, refer the patient to the primary care physician for follow-up.

Pearls

1. T vaginalis is one of the most common STDs in the United States.

2. Up to 25% to 50% of girls may be asymptomatic, whereas up to 90% of boys are symptomatic.

3. Symptomatic girls typically have diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation.

4. Cervicitis is the most common signs of infection and “strawberry spots” may be seen.

5. Adverse pregnancy outcomes with trichomoniasis include premature rupture of membranes, preterm delivery, and low birth weight.

Clinical Summary

Congenital syphilis occurs in babies born to mothers with untreated or inadequately treated syphilis during pregnancy. Transplacental transmission of spirochetes, Treponema pallidum, can occur at any stage of pregnancy. Congenital syphilis is divided into early (diagnosed at <2 years of age) and late (diagnosed >2 years of age). Clinical manifestations are listed in Table 4.2. Infants may present with congenital syphilis after nursery discharge if the mother has very early untreated and asymptomatic primary syphilis with negative serology at delivery (serology often negative in very early syphilis and becomes positive later) or when the mother’s syphilis status was unknown or not reported. Diagnosis relies on clinical findings and reactive syphilis serology (nontreponemal antibody tests like the Venereal Disease Research Laboratory [VDRL] and rapid plasma reagin [RPR] tests), and confirmed by a treponemal test (fluorescent treponemal antibody, absorbed [FTA-ABS] and Treponema pallidum particle agglutination [TP-PA]). Diagnosis in neonates is difficult, because serologic results in the baby reflect maternal antibody status and lack of clinical findings at birth in many babies. Recommended tests include complete blood count (CBC), cerebrospinal fluid (CSF) examination for VDRL, cell count and chemistry, liver enzymes, long bone x-rays (usually lower extremities), abdominal ultrasound, and an ophthalmologic examination.

Emergency Department Treatment and Disposition

Hospitalize all infants with suspected congenital syphilis for either IV penicillin or IM procaine penicillin therapy to be given for 10 days. Therapy is started in the hospital, though IM procaine penicillin can be continued on outpatient basis after diagnostic tests are completed.

Pearl

1. Most patients with congenital syphilis are asymptomatic at birth, and develop clinical findings within the first 3 months of life.

Clinical Summary

Acquired syphilis is contracted through direct sexual contact with ulcerative lesions of skin or mucous membranes of infected people, and has three stages: primary, secondary, and tertiary. Primary syphilis presents with a round, firm, and painless skin ulcer that has a smooth border and a rubbery base. Chancre occurs at the site of contact 10 to 90 days postexposure and heals spontaneously over 3 to 6 weeks. The lesion is usually on the glans penis, cervix, or vagina and less commonly on the lips, nipple, and tongue. Associated painless regional lymphadenopathy may occur 1 to 2 weeks later. Secondary syphilis presents 4 to 10 weeks after the chancre (primary chancre still present in 10% of patients) usually with a rash that is symmetric and generalized on the trunk, extremities, palms, and soles. Lesions vary and may be polymorphic maculopapular annular, papulopustular, psoriasiform, or follicular; the lesions are often copper colored and nonpruritic. A flu-like syndrome, generalized lymphadenopathy, and splenomegaly may also occur as may condylomata lata (highly infectious raised white/gray lesions in warm moist areas like perineal and anal). Some patients have mucous patches in the mouth, alopecia of beard, scalp, or eyebrows. Lesions resolve in 3 to 12 weeks. Tertiary (or late)-stage infection refers to gumma formation (skin, bone, or viscera) and cardiovascular involvement (aortitis). Neurologic infection can occur with any stage of syphilis. Primary and secondary syphilis are sexually transmitted and may be seen in sexually active adolescents. Diagnosis is based on typical skin lesions and confirmed by scraping moist lesions and immediately examining the sample with darkfield microscopy. If a darkfield microscope is not available, a slide of the moist material can be made and sent to a laboratory for staining with specific T pallidum immunofluorescent antibody. The diagnosis of syphilis requires both nontreponemal (eg, RPR) and treponemal (eg, FTA-ABS) testing. Standard testing is usually a nontreponemal screening test followed by a confirmatory treponemal test if positive. Nontreponemal antibody titer correlates with disease activity and usually become nonreactive after treatment. Most patients with reactive treponemal tests will remain positive for their lifetime regardless of treatment or disease activity. RPR is reactive in only about 80% of patients with primary syphilis at presentation, although darkfield microscopy will be positive. Request test with dilutions of serum in order to prevent a false-negative test due to a prozone phenomenon (most common in secondary syphilis with high titers). False-positive nontreponemal test results may occur due to various medical conditions. All patients who have syphilis should be tested for HIV infection. Diagnosis of primary or secondary syphilis in a young child is evidence of sexual abuse and the child needs to be evaluated for other STDs and treated if necessary.

Emergency Department Treatment and Disposition

Treat primary and secondary syphilis with one dose of IM benzathine penicillin (50,000 units/kg up to a maximum of 2.4 million units). Nonpregnant patients allergic to penicillin are treated with either doxycycline or tetracycline for 14 days (see the Centers for Disease Control and Prevention’s [CDC’s] STD treatment guidelines, 2010). Admit younger children with suspected primary or secondary syphilis for further evaluation including lumbar puncture and review of the birth mother’s medical records to determine if the child has congenital or acquired syphilis. Follow-up requires repeat nontreponemal serologic testing 6 and 12 months after treatment.

Pearls

1. All cutaneous lesions of secondary syphilis are infectious. Relapses can occur up to 1 year after untreated primary infection.

2. Parenteral penicillin is the preferred drug for treatment of all stages of syphilis.

3. Sexual abuse must be suspected in any child with acquired syphilis.

Clinical Summary

Gonorrhea (Gonococcal infections; GC) is one of the most common reportable sexually transmitted diseases (STDs) and is often asymptomatic. Incidence is highest among adolescents. Clinical manifestations are similar to those of Chlamydia trachomatis, and coinfection is frequent. Susceptible sites include mucosal columnar epithelial areas (eg, the cervical transition zone in adolescent girls), pharynx, rectum, and conjunctiva. Infants of mothers with GC infection are at risk for ophthalmia neonatorum, scalp abscesses at sites of fetal monitor sites, rhinitis, pneumonia, or anorectal infections. Disseminated gonococcal infection (DGI) is more prevalent in girls (ratio 4:1), especially those who are pregnant or had menses within the previous 7 days. Other risk factors for DGI include pharyngeal gonorrhea, complement deficiency, and immune system diseases such as systemic lupus erythematosus. Other DGI complications include meningitis, endocarditis, osteomyelitis, pneumonia, and hepatitis.

Emergency Department Treatment and Disposition

Gonorrhea is diagnosed either by Gram stain (gram-negative intracellular diplococci), culture (eg, Thayer-Martin culture plate, chocolate agar), and nucleic acid amplification techniques (NAATs; sensitivities and specificities >95%). Specimen swabs can be taken from nonsterile areas such the urethra, vagina, and cervix. The preferred method of testing from nongenital sites (eg, rectum, pharynx, conjunctiva) is culture because some NAATs can cross-react with nongonococcal Neisseria species in both throat and rectum. NAAT testing can also be done on urine samples. In patients with suspected DIG, obtain blood cultures and culture mucosal surfaces.

Treat according to current CDC STDs guidelines and with azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally twice daily for 7 days), if coinfection with chlamydia is not ruled out. Treat uncomplicated GC with cephalosporins (cefixime 400 mg orally in a single dose or ceftriaxone 250 mg IM in a single dose). Do not use quinolone as there are quinolone-resistant N gonorrhoeae. Admit patients with DGI for IV therapy. Refer to CDC guidelines for the current treatment of complicated gonococcal infections, including extragenital sites, DGI, and infections acquired during pregnancy. Instruct patients to refer their sex partners for evaluation and treatment. Follow-up referrals for counseling and patient education should be provided.

Pearls

1. Treatment failures most often represent reinfection.

2. Many infections are asymptomatic (thus screening is important).

3. Symptomatic boys present with genitourinary infection with dysuria, urinary frequency, and purulent urethral discharge.

4. Symptomatic girls present with abnormal vaginal discharge, intermenstrual bleeding, menorrhagia, or dysuria.

5. DGI is characterized by arthritis/arthralgia, tenosynovitis, and dermatitis (arthritis-dermatitis syndrome).

6. Long-term sequelae in women include tubal scarring, infertility, and ectopic pregnancy.

Clinical Summary

Genital herpes is a chronic lifelong herpes simplex virus (HSV-1 and HSV-2) infection that is sexually transmitted. Approximately 70% to 95% of genital infections are caused by HSV-2. Most patients infected with HSV-2 have not been diagnosed with genital herpes. Many have mild or unrecognized infections and intermittently shed virus into the genital tract. Painful vesicular or ulcerative lesions may be present and viral shedding is highest at this time; however, lesions may not be present and viral shedding can still occur. Recurrences are less symptomatic than primary infections. Incidence of HSV infection increases rapidly after puberty, reaching a peak in the third decade of life.

Emergency Department Treatment and Disposition

Take a history and perform a physical exam with attention to previous episodes, potentially infected partners, and presence of lesions as these may help establish the diagnosis. Obtain cell culture (differentiates between HSV-1 and HSV-2) or PCR for HSV DNA, noting that sensitivity of culture declines as healing of lesions progresses. PCR assays are more sensitive and is the test of choice for detecting HSV in spinal fluid. Failure to detect HSV does not indicate absence of infection, because viral shedding is intermittent. Type-specific HSV serology might be useful for recurrent genital symptoms or atypical symptoms with negative HSV cultures. Treat all patients with a first episode with systemic antiviral drugs such as acyclovir, valacyclovir, or famciclovir. These agents can partially control signs and symptoms when used to treat the first clinical episode or recurrent episodes (when given within 1 day of onset of symptoms) or used as daily suppressive therapy. However, these drugs do not eradicate latent virus and, when stopped, do not affect risk, frequency, or severity of recurrences when medication is stopped. Admit patients with severe disease or complications (eg, disseminated infection, pneumonitis, hepatitis, meningitis, or encephalitis) for IV acyclovir therapy. Inform patients with genital herpes that sexual transmission can occur during asymptomatic periods. Advise patients to abstain from sexual activity with uninfected partner(s) when lesions or prodromal symptoms are present and explain the risk of neonatal HSV infection. Pregnant patients should inform health care providers who care for them during pregnancy, and cesarean section is recommended if genital lesions or prodromal symptoms are present during delivery.

Pearls

1. HSV is the cause of 90% of all vesiculoulcerative lesions of the genitalia.

2. Genital herpes is a recurrent, incurable viral disease.

3. Genital herpes has the ability to become latent and then recur. Latency is lifelong but is interrupted by periods of viral reactivation leading to silent viral shedding.

Clinical Features

Dysfunctional uterine bleeding (DUB) or irregular and/or prolonged vaginal bleeding occurs as a result of endometrial sloughing, in the absence of structural pathology or anomaly and is usually due to anovulation. Up to 80% of menstrual cycles are anovulatory in the first year after menarche and become ovulatory an average of 20 months after menarche. Normal menstrual cycles during adolescence are 21 to 40 days long, with 2 to 8 days of bleeding (20–80 mL of blood loss per cycle). DUB is a common menstrual problem during adolescence, and when severe, can result in life-threatening anemia. Menorrhagia is prolonged or heavy uterine bleeding that occurs at regular intervals. Metrorrhagia is uterine bleeding that occurs at irregular intervals. Menometrorrhagia is prolonged or heavy bleeding that occurs at irregular intervals.

Emergency Department Treatment and Disposition

Obtain a through history focused on menstrual history, sexual history (including past STDs, pelvic inflammatory disease [PID]), history of systemic illness (eg, kidney or liver disease), endocrine history (symptoms of hypothyroidism or hyperthyroidism or hyperandrogenism), use of hormonal contraception or exogenous hormones, family history of polycystic ovarian disease, or bleeding diathesis.

Order a pregnancy test, CBC, STD screening if applicable, thyroid function tests, coagulation profile, liver enzymes, blood urea nitrogen, creatinine, type, and cross-match (if transfusion is anticipated). Obtain pelvic ultrasound to evaluate for possible structural anomalies in a virginal patient who cannot tolerate a pelvic examination or if a mass is palpated on pelvic examination or if the pregnancy test is positive.

Evaluate the patient for hemodynamic stability. Once the bleeding is found to be uterine, the evaluation focuses on determination of its cause. Severe bleeding with hemodynamic instability requires immediate intervention with IV fluids and/or blood transfusions.

Treatment for DUB is based on the level of anemia.

1. Patients with Hgb levels of at least 12 g/dL: Reassure, prescribe multivitamin with iron, advise patient to keep menstrual calendar, and refer to a primary care physician.

2. Patients with Hgb levels between 10 and 12 g/dL: Begin a 35-μg combined oral contraceptive pill to be taken every 6 to 12 hours for 24 to 48 hours until the bleeding stops, along with an antiemetic if necessary for nausea and vomiting. Advise tapering oral contraceptive to one pill daily by day 5. Begin a new 28-day pill packet and inform the patient that a withdrawal bleed is likely when the placebo pills are taken. Patients usually will need combined oral contraceptive pill for 3 to 6 months; thus refer to a primary care physician or adolescent medicine specialist.

3. Patients with Hgb levels less than 10 g/dL: If the patient is hemodynamically stable, reliable, and able to tolerate the oral contraceptive, management is as stated above. Otherwise, hospitalization is indicated until the bleeding stops.

Pearls

1. DUB is a diagnosis of exclusion. Pregnancy, endocrinopathies, blood dyscrasias, STDs, and uterine pathology must be excluded.

2. The most common reason for DUB during adolescence is anovulatory cycles secondary to a physiologically immature hypothalamic-pituitary-gonadal axis.

Clinical Summary

PID is an ascending polymicrobial genital tract infection usually found in sexually active females and includes endometritis, parametritis, pelvic peritonitis, salpingitis, oophoritis, tubo-ovarian abscess (TOA), and perihepatitis. Inflammatory disruption of the cervical barrier facilitates movement of microorganisms from the vagina into the normally sterile environment of the uterus. The risk of PID is highest among sexually active females during adolescence (nearly 33% of all cases of PID); women <25 years of age account for 70% of cases. Risk factors for girls and young women are younger age, multiple sex partners, unprotected sex, younger age at first intercourse, or previous PID. Menstruation or recent uterine instrumentation (eg, abortion) is believed to facilitate ascension of microorganisms into the upper genital tract. Differential diagnosis of PID includes appendicitis, complications of pregnancy, urinary tract infection, reproductive tumors or cysts, adnexal torsion, inflammatory bowel disease, ureteral stones, or calculi.

Emergency Department Treatment and Disposition

Begin empiric treatment with broad-spectrum antibiotics in sexually active young women with pelvic or lower abdominal pain, if no cause other than PID can be identified and one or more of the following minimum criteria are present on pelvic examination: cervical motion tenderness or uterine tenderness or adnexal tenderness. Oral temperature >101°F, abnormal cervical or vaginal mucopurulent discharge, elevated ESR or elevated CRP, laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis also support the diagnosis of PID.

Recommended treatment regimens (refer to CDC STDs guidelines) include IV regimen of cefotetan or cefoxitin plus doxycycline. Metronidazole or clindamycin can be added to this regimen with TOA because it provides more effective anaerobic coverage. An outpatient regimen includes a single-dose IM ceftriaxone plus doxycycline given orally with or without metronidazole. Some recommend that all patients be admitted for IV antibiotics. Those with mild or moderate clinical severity may be treated on an outpatient basis. Admit those in whom surgical emergencies (eg, appendicitis) cannot be excluded, who are pregnant, or do not respond to or are unable to follow or tolerate an oral regimen and those with severe illness, nausea, vomiting, or high fever or TOA.

Pearls

1. All women who have PID should also be tested for HIV infection.

2. Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causative agents of PID, but vaginal and enteric organisms (eg, anaerobes, Escherichia coli, genital mycoplasmas, G vaginalis, Streptococcus agalactiae) contribute to its pathogenesis.

3. Complications of PID include peritonitis, perihepatitis (Fitz-Hugh and Curtis syndrome), TOA, and adhesions leading to infertility, ectopic pregnancy, and chronic pain.

Clinical Summary

Ectopic pregnancy, the implantation of a fertilized egg in the fallopian tube instead of the endometrium (uterus), is the leading cause of maternal morbidity in the first trimester of pregnancy, and the most common risk factors are previous tubal infections (eg, PID), previous ectopic pregnancy, prior tubal surgery, tubal adhesions from previous appendicitis or abdominal pelvic surgery. Patients present with mild vaginal bleeding to massive hemorrhage. Patients with an acutely ruptured ectopic pregnancy present with sudden onset of extreme sharp or stabbing unilateral pain as well as shoulder pain. Other acute symptoms include dizziness or loss of consciousness from acute intraperitoneal hemorrhage. Differential diagnosis of ectopic pregnancy includes threatened or incomplete abortion, molar pregnancy, ruptured corpus luteum cyst, adnexal torsion, urinary tract infection, appendicitis, PID, and ureteral calculi.

Emergency Department Treatment and Disposition

Obtain ultrasound to determine if there is intrauterine pregnancy (IUP), which excludes the diagnosis of ectopic pregnancy in most cases. The appearance of a gestational sac at about 5 weeks of pregnancy is the first significant finding on ultrasound suggestive of an IUP; however, a definitive diagnosis of IUP should be deferred until a yolk sac is present. Serial measurements of serum β-human chorionic gonadotropin (β-hCG) also helps; it will increase by at least 66% every 48 hours in a normal pregnancy within the first 30 days after implantation. If β-hCG levels are unchanged or increasing more slowly than normal, the pregnancy is abnormal (it may be an abnormal IUP or it may be an ectopic pregnancy). Pregnancies that have lower than normal β-hCG levels are more likely to be ectopic.

Ectopic pregnancy is a surgical emergency. Unstable patients require aggressive resuscitation with fluid and blood followed by surgery. Begin transfusion if clinically indicated, but do not delay surgery for transfusion. Emergency surgery is necessary to stop the bleeding and try to preserve at least a portion of the affected fallopian tube, if it is not completely ruptured. Oophorectomy is not indicated unless the ovary is bleeding uncontrollably or has other pathology. If ectopic pregnancy is probable or possible, management depends on presence of risk factors, serial measurements of serum β-hCG levels, and results of transvaginal ultrasound over a period of days. These patients should be followed in consultation with an obstetrician on an outpatient basis.

Pearls

1. Ectopic pregnancies must be considered in pregnant patients with pelvic pain, particularly early in gestation and if associated with abnormal uterine spotting or bleeding.

2. Ectopic pregnancies are diagnosed by transvaginal ultrasound if there is no IUP.