Rosen & Barkin's 5-Minute Emergency Medicine Consult (233 page)

Cautions: Female patients of childbearing age presenting in shock may have unrecognized ruptured ectopic pregnancy

• Vital signs unstable:
  
  • Airway management, resuscitate as needed
    
  • Fluid therapy with 2 large-bore IVs, oxygen, and monitor
    
  • Type specific, or O-negative blood if hypotensive after initial fluid bolus
    
  • Consult gynecology and transport to OR immediately for surgery
    
• Vital signs stable:
  
  • Evidence of ectopic pregnancy on US:
    
    • Obstetric–gynecologic evaluation for surgery vs. outpatient methotrexate treatment
      
    • For patients in whom future fertility is desired, methotrexate is the best option; otherwise surgery is the definitive treatment
      
  • No evidence of ectopic pregnancy (pregnancy of unknown location [PUL]: Early IUP vs. early ectopic):
    
    • Desired pregnancy: Serial β-hCG every 48 hr in stable, reliable patients and in conjunction with obstetrician
      
    • Undesired pregnancy: Dilation and curettage to evacuate uterus and confirm presence of products of conception
      

Methotrexate: Initiated only in conjunction with obstetric consultant and close follow-up:

• Reliable patients with unruptured ectopic pregnancies <3.5 cm
  
• β-hCG levels <6,000–15,000
  
• Contraindications:
  
  • Breast-feeding
    
  • Immunodeficiency
    
  • Pre-existing blood dyscrasia
    
  • Clinically significant anemia
    
  • Known sensitivity to methotrexate
    
  • Active pulmonary disease
    
  • Peptic ulcer disease
    
  • Hepatic dysfunction
    
  • Renal dysfunction
    
  • Alcoholism
    
  • Alcoholic liver disease
    
  • Ectopic mass >3.5 cm (relative contraindication)
    
  • Embryonic cardiac motion (relative contraindication)
    
• Most common dosing, single dose (50 mg/m
  ²
  ); serial β-hCG on days 2, 4, and 7
  
  • If <25% decline in β-hCG from day of 1st injection, 2nd dose is given
    
• Multidose treatment is associated with less treatment failure
  
• Common side effects:
  
  • Worsening abdominal pain
    
  • Nausea, vomiting, and diarrhea
    
• Worsening abdominal pain usually occurs 3–7 days after methotrexate initiation.
  
  • These are usually tubal miscarriages
    
  • Follow-up USs are essential to rule out ectopic rupture
    
• Most common complication, tubal rupture in 4%
  
• Factors associated with methotrexate treatment failure:
  
  • Initial hCG >5,000 mIU (5,000–9,999 mIU/mL—13% failure rate, >15,000 mIU/mL failure rate as high as 32%)
    
  • Moderate to large free peritoneal fluid on US
    
  • Presence of fetal cardiac activity
    
  • Pretreatment increase in serum hCG level of more than 50% over a 48 hr period
    

• Methotrexate: 50 mg/m
  ²
  IM/IV × 1
  
• RhoGAM in Rh-negative women: 50 μg IM in women ≤12 wk pregnant; 300 μg IM in women >12 wk pregnant
  

FOLLOW-UP

• Any patient with confirmed ectopic pregnancy who is hemodynamically unstable
  
• Unreliable patients with increased risk factors, no available US, β-hCG >6,500 with no evidence of IUP should be admitted for observation and serial β-hCG tests
  

• Decision for outpatient management should be made in conjunction with OB/GYN
  
• Hemodynamically stable and reliable patients with workup that cannot rule out ectopic pregnancy:
  
  • Strict follow-up for serial β-hCG tests every 2 days
    
  • Patients should be recorded in logbook with phone numbers to ensure follow-up
    
• Ectopic precautions:
  Patients should return to emergency room immediately for:
  
  • Increasing abdominal pain
    
  • Vaginal bleeding
    
  • Syncope or dizziness
    
  • Patients should not be left alone until diagnosis of ectopic pregnancy can be safely ruled out
    
  • Family and friends should also be instructed on warning signs and symptoms of ruptured/bleeding ectopic pregnancies
    

Phone consultation (at a minimum) with OB/GYN is essential when discharging a possible ectopic pregnancy

All patients with positive pregnancy tests and unconfirmed IUP must be followed by an OB/GYN

• Always obtain a pregnancy test on women of childbearing age
  
• Obtain serum hCG and transvaginal ultrasonography in all women with positive pregnancy test presenting with abdominal pain or vaginal bleeding
  
• Recognize the possibility of heterotopic pregnancies, especially in women undergoing fertility treatment
  
• Secure close follow-up for any patient being evaluated and discharged for ectopic pregnancy
  

• Barnhart KT. Clinical practice. Ectopic pregnancy.
  N Engl J Med.
  2009;361:379–387.
  
• Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: The rational clinical examination systematic review.
  JAMA
  . 2013;309:1722–1729.
  
• Huancahuari N. Emergencies in early pregnancy.
  Emerg Med Clin North Am
  . 2012;30:837–847.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Stein JC, Wang R, Adler N, et al. Emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: A meta-analysis.
  Ann Emerg Med
  . 2010;56:674–683.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Pregnancy, Uncomplicated
  
• Vaginal Bleeding
  

CODES

• 633.00 Abdominal pregnancy without intrauterine pregnancy
  
• 633.10 Tubal pregnancy without intrauterine pregnancy
  
• 633.90 Unspecified ectopic pregnancy without intrauterine pregnancy
  

BASICS

• Atopic dermatitis is the most common cause of eczema and the terms are often used synonymously.
  
  • Associated with allergic diseases such as asthma and allergic rhinitis
    
• Eczema literally means “out boil” and refers to spongiosis, the process where microvesicles form and rupture, leaving erythema, edema, crusting, and oozing
  
• Pruritus is highly characteristic
  
  • Patient rub and scratch skin breakdown with oozing and crusting
    
  • Chronically this causes epidermal hyperplasia and hyperkeratosis
    
• 90% of patients colonize with
  Staphylococcus aureus
  , and are prone to episodes of superinfection
  

• Family history of atopy (asthma, allergic rhinitis) typical
  
• Mutation of the filaggrin protein, part of the epidermal barrier, is strongly associated
  

Atopic dermatitis is caused by a deficit in epidermal integrity that allows foreign substances to enter and trigger immune responses.

DIAGNOSIS

• Rash, pruritus, and atopy traditionally prompt the diagnosis
  
• UK diagnostic criteria = pruritus and 3 of the following:
  
  • Flexural distribution
    
  • Atopic history (asthma or allergic rhinitis)
    
  • History of dry skin
    
  • Onset age <2 yr
    
  • Objective signs of flexural dermatitis
    
• Additional findings:
  
  • Cutaneous infections
    
  • Itch when sweating
    
  • Intolerance to wool and lipid solvents
    
  • Triggered by stress