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2-3 mo pregnant women complaining of severe abdominal pain and bleeding
POC glu 80
ETA 4-6 mins

any woman that comes in with abdominal pain and bleeding need ectopic on ddx

belly full of blood on ULS with + pregnancy test

fluid collects in morrison's pouch any trauma pt or hypotensive pt will see this space

need type and cross need a surgeon and operating room


Most ectopics happen in the

scarring form STDs cause the fetus to get stuck


blood work up in a pt with ectopic

not especially helpful

Blood  WBC 8K, Hgb 11.9; Urine  WBC 10-20 + LE

in a UA we are looking for undiagnosed UTI not helpful for ectopic

CBC +/- chemistry (if in case pt requires methotrexate later),
UA (check for infxn like undetected pyelo or STI – associated with preterm labor). A lot of preterm labor deliveries we see can be traced back to an infection


how does the cervix differ from the ULS

1. Cervix cant respond to active bleeding – if it is ripped in any way, you will bleed to death (like if you have a pregnancy there)

no hemostasis in the cevix


what are the ectopics we miss

The ectopics that we miss are in the cervical area

fimbriae in the ovary – they are hard to detect b/c on US they are sitting next to a lot of other structures


Ectopics hiding near the uterus will present with

More difficult to diagnose - both can appear intrauterine.

More likely to cause catastrophic bleeding.

iHigher rates in ART patients.


Cornual Ectopic

close to the insertion of the uterine artery


RF for cervical ectopic

prior instrumentation, fibroids, IUDs, IVF, uterine structural abnormalities (Asherman’s Syndrome, DES)


Heterotopic Pregnancy

one is in the uterus and one is not

i. 1 in 4,000 pregnancies
ii. 1 in 100 pregnancies in patients using assisted reproductive technology


endocaveterial ULS

always start with the transabdominal view

2 large bore IV
type and cross
OB on board


ULS pitfalls

i. Make sure you are oriented correctly!
ii. Find the uterine cavity.
iii. Find the endocervical canal.
iv. Always look in the adnexa and ovaries.

Always scan trans-abd AND trans vaginal

When in doubt, get a formal study!


Threatened miscarriage

just have bleeding
closed OS


pain, OS may or may not be closed, bleeding, some tissue left behind

Incomplete miscarriage


labs on pregnant ptds

CDC type and screen

need to know if there is incompatibility
don't want mom to build a response


Quantitative beta hCG

Primarily used to trend an early pregnancy.ii. Indicates when we should see an IUP.

above 7500 -abd uLS

if you have a completely early uterus with a Low HcG --> suspicious .


hcg for

iii. Ectopic pregnancies have been reported from 5-200,000 mIU.

with super high suspect molar pregnancies or multiple gestations


threatened miscarriage

Address the possibility of ectopic pregnancy, and include the patient in this discussion.

Standard labs include CBC, CMP, UA, STI testing, Rh status, and quantitative hCG for trending purposes.

iii. Ultrasound.
iv. 48-hour follow-up either in the ED or with an OB provider.
v. Strict return precautions.


what can you assess in a patient coming 30+ weeks pregnant with blleding and pain

gestational age
looking a

anything outside a labor and delivery suite is precipitous delivery


two placental catastrophes

previa= over the cervix usually painless

abruption= part of the placenta has separated away from the uterine wall


classic abruption and sxs and dx tests

uterine cramping or pain with bleeding. Can occur from sheer forces as well

ULS not very sensitive for abruption
1. CBC, type/crossmatch
2. Coagulation profile
3. Renal function studies

maternal wellness and fetal variability on fetal heart rate strips


RF for abruption

2. Maternal trauma
3. AMA
4. Multiparity
5. Smoking
6. Cocaine use
7. Previous abruptions

can go into DIC


what is the major problem with cord prolapse

deprieving oxygen and blood to the fetus

As uterus is contracting, there are decelerations which means the cord is being squeezed which means there are times baby is not getting O2 so there is a lack of circulation

need to elevate the presenting part


tx of cord prolapse

a. Elevate the foot off the cord and put pt in trendelenberg and take pt to the OR

Infusing the bladder with saline - although not as helpful if a presenting part is visible.


how do you know is the cord isn't in danger

success with pulsations in the cord


you do not want to pull the baby being delivered unitl

2. DO NOT PULL until the umbilicus is delivered.


should be delivered

Infant should deliver face down.

premi more likely to be breeched


presentation of shoulder dystocia

Buddha like faces – very plethoric, can appear purplish

“Turtle sign”

if the head comes out and back in


what could indicate a possible shoulder dystocia

Fetal macrosomia- is used to describe a newborn who's significantly larger than average.

Precipitous delivery
(less than 3 hours)


how to resolve should dystocia

NO fundal pressure/hold pushing until repositioned.

knees to chest in the mom

Want suprapubic pressure and turn the baby to dislodge the shoulder

c section preferred

a. McRobert’s Maneuver
b. Suprapubic pressure
c. Delivering the posterior shoulder
d. Rubin, Woods Corkscrew
e. Zavenelli Maneuver


what are we worried about in houlder dystocia

Worry about brachial plexus injury