Vignette 1

A 28-year-old P0010 woman presents to the emergency department with abdominal pain since the past day. She reports a 1-week history of nausea with occasional vomiting. She has noticed some breast tenderness as well. She denies dysuria, vaginal bleeding, or any bowel symptoms. She reports that her last period was 4 weeks ago, but was lighter than normal. She has been using condoms for contraception. On arrival, her vital signs include a temperature of 37°C, BP of 117/68, pulse rate of 78 beats per minute, and respiratory rate of 16 breaths per minute. Cardiovascular and respiratory examinations are normal. She notes some suprapubic abdominal discomfort with palpation, but she does not have rebound tenderness or guarding. A speculum examination reveals a closed cervix without bleeding. A pelvic examination is mildly uncomfortable and reveals a normally sized, anteverted

uterus, and palpably normal adnexa. A urine pregnancy test is positive.

2. The quantitative β-hCG level is 1,300 mIU/mL. The patient reveals that this was an unplanned, but desired pregnancy. What follow-up recommendations do you give this patient?

Vignette 1

A 28-year-old P0010 woman presents to the emergency department with abdominal pain since the past day. She reports a 1-week history of nausea with occasional vomiting. She has noticed some breast tenderness as well. She denies dysuria, vaginal bleeding, or any bowel symptoms. She reports that her last period was 4 weeks ago, but was lighter than normal. She has been using condoms for contraception. On arrival, her vital signs include a temperature of 37°C, BP of 117/68, pulse rate of 78 beats per minute, and respiratory rate of 16 breaths per minute. Cardiovascular and respiratory examinations are normal. She notes some suprapubic abdominal discomfort with palpation, but she does not have rebound tenderness or guarding. A speculum examination reveals a closed cervix without bleeding. A pelvic examination is mildly uncomfortable and reveals a normally sized, anteverted

uterus, and palpably normal adnexa. A urine pregnancy test is positive.

3. The patient returns 48 hours later per your recommendations. She reports that her abdominal pain is worse and is left-sided. Yesterday, she also had a small amount of vaginal bleeding that has since subsided. She has not been lightheaded, short of breath, or had palpations and she has been able to tolerate food and drink without difficulty. Her vital signs remain stable. You repeat a β-hCG and the level is now 1,700 mIU/mL. A pelvic ultrasound

reveals a left adnexal mass and nothing in the uterine cavity. What is the most common site of an ectopic pregnancy?

Vignette 1

A 28-year-old P0010 woman presents to the emergency department with abdominal pain since the past day. She reports a 1-week history of nausea with occasional vomiting. She has noticed some breast tenderness as well. She denies dysuria, vaginal bleeding, or any bowel symptoms. She reports that her last period was 4 weeks ago, but was lighter than normal. She has been using condoms for contraception. On arrival, her vital signs include a temperature of 37°C, BP of 117/68, pulse rate of 78 beats per minute, and respiratory rate of 16 breaths per minute. Cardiovascular and respiratory examinations are normal. She notes some suprapubic abdominal discomfort with palpation, but she does not have rebound tenderness or guarding. A speculum examination reveals a closed cervix without bleeding. A pelvic examination is mildly uncomfortable and reveals a normally sized, anteverted

uterus, and palpably normal adnexa. A urine pregnancy test is positive.

4. You explain to the patient that she most likely has an ectopic pregnancy that requires treatment. She would like to avoid surgery. You draw a type and screen, CBC, and complete metabolic panel. Her blood type is O positive, antibody negative. Her hemoglobin is normal as are her liver enzymes. What is your next recommendation?

Vignette 1

A 28-year-old P0010 woman presents to the emergency department with abdominal pain since the past day. She reports a 1-week history of nausea with occasional vomiting. She has noticed some breast tenderness as well. She denies dysuria, vaginal bleeding, or any bowel symptoms. She reports that her last period was 4 weeks ago, but was lighter than normal. She has been using condoms for contraception. On arrival, her vital signs include a temperature of 37°C, BP of 117/68, pulse rate of 78 beats per minute, and respiratory rate of 16 breaths per minute. Cardiovascular and respiratory examinations are normal. She notes some suprapubic abdominal discomfort with palpation, but she does not have rebound tenderness or guarding. A speculum examination reveals a closed cervix without bleeding. A pelvic examination is mildly uncomfortable and reveals a normally sized, anteverted

uterus, and palpably normal adnexa. A urine pregnancy test is positive.

5. What additional recommendation would you make at this time?

Vignette 2

A 35-year-old G3P0020 woman presents to the hospital with vaginal bleeding and abdominal pain. She appears pale and states that she feels lightheaded when sitting up or standing. She reports that she is currently 9 weeks’ pregnant. On arrival, her temperature is 37°C, BP is 86/50, pulse rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. Abdominal examination reveals a rigid abdomen with rebound tenderness to palpation. Pelvic examination reveals a small amount of vaginal bleeding, a 6-week-size uterus, and fullness at the right adnexa. A urine β-hCG confirms that she is pregnant. The nurse works to obtain IV access and draw blood for laboratory tests.

1. What is your first step?

Vignette 2

A 35-year-old G3P0020 woman presents to the hospital with vaginal bleeding and abdominal pain. She appears pale and states that she feels lightheaded when sitting up or standing. She reports that she is currently 9 weeks’ pregnant. On arrival, her temperature is 37°C, BP is 86/50, pulse rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. Abdominal examination reveals a rigid abdomen with rebound tenderness to palpation. Pelvic examination reveals a small amount of vaginal bleeding, a 6-week-size uterus, and fullness at the right adnexa. A urine β-hCG confirms that she is pregnant. The nurse works to obtain IV access and draw blood for laboratory tests.

2. A pelvic ultrasound reveals a right-sided ectopic pregnancy as well as large amounts of fluid, thought to be blood in the abdomen. She now has IV access and a bolus of IV fluids is being given. Her BP is now 78/45 and her pulse rate is 112 beats per minute. Her hematocrit returns as 27.2%. How will you proceed?

Vignette 2

A 35-year-old G3P0020 woman presents to the hospital with vaginal bleeding and abdominal pain. She appears pale and states that she feels lightheaded when sitting up or standing. She reports that she is currently 9 weeks’ pregnant. On arrival, her temperature is 37°C, BP is 86/50, pulse rate is 110 beats per minute, and respiratory rate is 18 breaths per minute. Abdominal examination reveals a rigid abdomen with rebound tenderness to palpation. Pelvic examination reveals a small amount of vaginal bleeding, a 6-week-size uterus, and fullness at the right adnexa. A urine β-hCG confirms that she is pregnant. The nurse works to obtain IV access and draw blood for laboratory tests.

3. The patient undergoes emergency laparotomy with evacuation of the hematoperitoneum as well as right salpingectomy for removal of the ectopic pregnancy. On postoperative day 1, she explains that this pregnancy was conceived via IVF and was highly desired. What is her risk of having a future ectopic pregnancy?

Vignette 3

A 22-year-old P0 woman presents to the clinic for an annual examination. She reports that her last normal menstrual period was 5 weeks prior. Her menstrual cycles are irregular and she reports that she frequently skips a month between periods. She reports that she is sexually active and uses condoms sporadically for birth control. Pelvic examination reveals a mildly enlarged, anteverted, nontender uterus with palpably normal adnexa bilaterally. The patient consents to a urine pregnancy test that returns as positive. The patient expresses that she is uncertain if this is a desired pregnancy. You perform an in-office transvaginal ultrasound; however, neither an ectopic or IUP are visualized.

1. What step do you take next?

Vignette 3

A 22-year-old P0 woman presents to the clinic for an annual examination. She reports that her last normal menstrual period was 5 weeks prior. Her menstrual cycles are irregular and she reports that she frequently skips a month between periods. She reports that she is sexually active and uses condoms sporadically for birth control. Pelvic examination reveals a mildly enlarged, anteverted, nontender uterus with palpably normal adnexa bilaterally. The patient consents to a urine pregnancy test that returns as positive. The patient expresses that she is uncertain if this is a desired pregnancy. You perform an in-office transvaginal ultrasound; however, neither an ectopic or IUP are visualized.

2. The patient consents to a blood draw before leaving the clinic. Later that day, the patient’s β-hCG level returns at 1,300 mIU/mL. You call the patient with the results and she informs you that she would like to continue the pregnancy. What do you recommend next?

Vignette 3

A 22-year-old P0 woman presents to the clinic for an annual examination. She reports that her last normal menstrual period was 5 weeks prior. Her menstrual cycles are irregular and she reports that she frequently skips a month between periods. She reports that she is sexually active and uses condoms sporadically for birth control. Pelvic examination reveals a mildly enlarged, anteverted, nontender uterus with palpably normal adnexa bilaterally. The patient consents to a urine pregnancy test that returns as positive. The patient expresses that she is uncertain if this is a desired pregnancy. You perform an in-office transvaginal ultrasound; however, neither an ectopic or IUP are visualized.

3. Forty-eight hours later, the patient has a repeat β-hCG level that returns at 2,700 mIU/mL. An office ultrasound reveals an intrauterine gestational sac with yolk sac consistent with a 5-week pregnancy. You prescribe a prenatal vitamin and ask the patient to return in 4 weeks for an official prenatal visit. At 8 weeks’ gestation, she returns to the clinic with vaginal spotting. A pelvic examination reveals minimal old blood in the vagina and closed cervix. What test or procedure do you perform first?

Vignette 3

A 22-year-old P0 woman presents to the clinic for an annual examination. She reports that her last normal menstrual period was 5 weeks prior. Her menstrual cycles are irregular and she reports that she frequently skips a month between periods. She reports that she is sexually active and uses condoms sporadically for birth control. Pelvic examination reveals a mildly enlarged, anteverted, nontender uterus with palpably normal adnexa bilaterally. The patient consents to a urine pregnancy test that returns as positive. The patient expresses that she is uncertain if this is a desired pregnancy. You perform an in-office transvaginal ultrasound; however, neither an ectopic or IUP are visualized.

4. Fetal heart tones are confirmed with an office ultrasound. What test should you obtain next?

Vignette 4

A 34-year-old G3P0020 woman presents to the office at 8 weeks’ gestation for her first prenatal visit. This is a planned and desired pregnancy. Her obstetric history is significant for one prior elective termination and one SAB. It took her and her partner just over 1 year to conceive this pregnancy. She is afebrile, normotensive with a normal pulse. Pelvic examination reveals a 7- to 8-week-sized uterus with normal adnexa. Her cervix is closed and there is no vaginal bleeding. An office ultrasound is performed and an IUP is seen with a crown–rump length consistent with 7 weeks and 2 days gestation. Unfortunately, no fetal heart beat is seen.

1. What is your diagnosis?

Vignette 4

A 34-year-old G3P0020 woman presents to the office at 8 weeks’ gestation for her first prenatal visit. This is a planned and desired pregnancy. Her obstetric history is significant for one prior elective termination and one SAB. It took her and her partner just over 1 year to conceive this pregnancy. She is afebrile, normotensive with a normal pulse. Pelvic examination reveals a 7- to 8-week-sized uterus with normal adnexa. Her cervix is closed and there is no vaginal bleeding. An office ultrasound is performed and an IUP is seen with a crown–rump length consistent with 7 weeks and 2 days gestation. Unfortunately, no fetal heart beat is seen.

2. You offer the patient either medical or surgical management. She opts for medical management and takes mifepristone in the office with the plan to take misoprostol the next day. The following evening, you receive a call that the patient has presented to the emergency department with heavy vaginal bleeding. Her vital signs are as follows: temperature, 37°C; BP, 90/52; pulse rate, 100 beats per minute; respirations, 16 breaths per minute; and 100% oxygen saturation on room air. Pelvic examination reveals active bleeding from an open cervical os. Pelvic ultrasound reveals partial retention of fetal products. What is your new diagnosis?

Vignette 4

A 34-year-old G3P0020 woman presents to the office at 8 weeks’ gestation for her first prenatal visit. This is a planned and desired pregnancy. Her obstetric history is significant for one prior elective termination and one SAB. It took her and her partner just over 1 year to conceive this pregnancy. She is afebrile, normotensive with a normal pulse. Pelvic examination reveals a 7- to 8-week-sized uterus with normal adnexa. Her cervix is closed and there is no vaginal bleeding. An office ultrasound is performed and an IUP is seen with a crown–rump length consistent with 7 weeks and 2 days gestation. Unfortunately, no fetal heart beat is seen.

3. The emergency department team obtains IV access and draws blood for a CBC, type and screen and quantitative β-hCG level. An IV fluid bolus is given. Her hematocrit is 30.6%, she is RH positive, and the β-hCG is pending. What is your next step in the management of this patient?

Vignette 4

A 34-year-old G3P0020 woman presents to the office at 8 weeks’ gestation for her first prenatal visit. This is a planned and desired pregnancy. Her obstetric history is significant for one prior elective termination and one SAB. It took her and her partner just over 1 year to conceive this pregnancy. She is afebrile, normotensive with a normal pulse. Pelvic examination reveals a 7- to 8-week-sized uterus with normal adnexa. Her cervix is closed and there is no vaginal bleeding. An office ultrasound is performed and an IUP is seen with a crown–rump length consistent with 7 weeks and 2 days gestation. Unfortunately, no fetal heart beat is seen.

The patient stabilizes and is discharged. She follows up in your office 1 week later and wants to know why she had a miscarriage as well as her risk of future miscarriages. Which of the following is not true?