Family Medicine 12: 16-year-old female with vaginal bleeding and UCG User: Janessa Pamintuan Email: jpamintuan134@usuniversity.edu Date: March 30, 2024 1:57 AM Learning Objectives The student should be able to: Describe the essential features of a preconception consultation, including how to incorporate this content into any visit. Develop a health promotion plan regarding sexually transmitted infections for a patient of any age or gender. Demonstrate a respectful history taking technique specifically aimed at adolescent patients. Recognize pregnancy and differentiate intrauterine and ectopic conditions. Recognize miscarriage and differentiate intrauterine and ectopic location of pregnancy. Appreciate wide range of responses that patients and their families exhibit upon discovering a pregnancy, and discuss options for an unplanned pregnancy. Discuss a cost-effective approach to initial prenatal labs. Counsel a pregnant patient for healthy behavior, folic acid supplementation, and immunizations. Outline usual normal progression of symptoms and physical exam findings during pregnancy. Demonstrate the management of a miscarriage, including the medical and social follow-up. Demonstrate performance of a focused history and physical examination in newly diagnosed pregnancy. Describe the principles of screening and the characteristics of a good screening test. Discuss who should be screened for chlamydia and gonorrhea depending on gender, age, and risk. Propose a cost-effective diagnostic work-up for a patient presenting with pregnancy including possible complications. Summarize the key features of a patient presenting with first trimester vaginal bleeding, capturing the information essential for differentiating between the common and “don’t miss” etiologies. Find and apply diagnostic criteria and surveillance strategies for normal and abnormal pregnancies. Identify the lifetime risk of intimate partner violence in women. Knowledge Chlamydia: Epidemiology, Course of Disease, and Screening Recommendations Epidemiology Chlamydial infection is the most common sexually transmitted bacterial infection in the United States. In 2021, 1,644,416 chlamydia cases were reported to the CDC, which corresponds to an incidence rate of 495.5 cases per 100,000 people. In 2020 to 2021, chlamydia cases increased in both males and females. Persons aged 15-24 years accounted for 58% of the reported cases in 2021. Course of disease Chlamydia is often insidious and asymptomatic. In women, genital chlamydial infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality. Screening recommendations The USPSTF found fair evidence that nucleic acid amplification tests (NAATs) can identify chlamydial infection in asymptomatic men and women, including asymptomatic pregnant women, with high test specificity. In low prevalence populations, however, a positive test is more likely to be a false positive than a true positive, even with the most accurate tests available. Qualities of a Good Screening Test 1. The condition should be an important health problem and the condition screened for must have a high prevalence in the population. 2. There should be a latent stage of the disease. 3. There should be effective treatment for the condition being screened. 4. Facilities for diagnosis and treatment should be available. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 1/10 5. There should be a test or examination for the condition. 6. The test should be acceptable to the population and the total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. The potential benefits of early detection and treatment of a condition need to be weighed against many factors, including adverse side effects of the screening test, time and effort required (of both the patient and the health care system) to take the test, financial cost of the test, potential psychological and physical harm of false-positive results (such as labeling and overtreatment), and adverse effects of the treatment. 7. The natural history of the disease should be adequately understood. 8. There should be an agreed policy on whom to treat. 9. Case-finding should be a continuous process, not just a "once and for all" project. 10. An effective screening test should have very good sensitivity (identify most or all potential cases) and specificity (label incorrectly as few as possible as potential cases). Even a test with a sensitivity of 95% will lead to a higher proportion of false positives when the prevalence of the condition is very low (a low positive predictive value). United States Preventive Services Task Force Recommendations for Chlamydia Screening The USPSTF recommends screening for chlamydia infection in the following: Grade Rationale: Recommendation All sexually active women age 24 and younger Grade B Sexually active women recommendation age 25 and older who are at increased risk There is direct evidence that screening reduces complications of chlamydial infection in women who are at increased risk, with a moderate magnitude of benefit. Such complications include pelvic inflammatory disease, infertility, and premature delivery (among pregnant women). The USPSTF advises against screening women age 25 and older if not at increased risk, regardless of pregnancy status. Only the above categories are found to have a high enough pretest probability to recommend screening. Low risk women (pregnant or nonpregnant) in general are not recommended for chlamydia screening as the overall benefit of screening would be small, given the low prevalence of infection. Risk factors for chlamydia infection include a history of chlamydia or other sexually transmitted infections, new or multiple sexual partners, inconsistent condom use, and exchanging sex for money or drugs. Risk factors for pregnant women are the same as for nonpregnant women. Guidelines for males 1. The USPSTF states that there is "Insufficient" evidence for or against screening men. 2. The CDC recommends consideration of screening for chlamydia in sexually active young men in settings with high prevalence or in men with high-risk behaviors overall. 3. The American Academy of Pediatrics (AAP) recommends considering annual screening for chlamydia in sexually active males in settings with high prevalence rates, such as jail or juvenile correction facilities, national job training programs, STD clinics, high school clinics, and adolescent clinics (for patients who have a history of multiple partners), as well as routine annual screening for men who have sex with men. Screening for Intimate Partner Violence In 2018, the U.S. Preventive Services Task Force (USPSTF) made a grade B recommendation that clinicians screen women of reproductive age (1446) for intimate partner violence and provide or refer women who screen positive to ongoing support services. As a result of the preponderance of evidence linking chronic illness and poor health to violence exposure and victimization, the Affordable Care Act included screening and intervention for interpersonal and intimate partner violence as part of a no-cost sharing preventive service for women. Adolescent Health Counseling and Screening: Preventing Sexually Transmitted Infection and Unintended Pregnancy Counsel all sexually active adolescents regarding contraception. Options include: oral contraceptives, medroxyprogesterone acetate (Depo-ProveraTM) injections, long-acting reversible contraceptives such as implantable options and intrauterine devices (IUDs), as well as the vaginal ring (NuvaRingTM) and transdermal combined hormonal contraception (patches) Remind patients these options do not protect against sexually transmitted infections Discuss condoms and abstinence Discuss emergency contraception Recommend folic acid supplementation to prevent neural tube defects in the event of pregnancy Preconception Counseling © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 2/10 It can be challenging to find the opportunity to discuss reproductive life planning. Whether it is a walk-in/urgent care visit, sports pre-participation examination, or adolescent well-child exam, it can be helpful to bring this topic up to allow for adequate counseling around pregnancy prevention or preconception planning, as appropriate. Preconception Health Care Checklist: Genetic Folic acid supplement: The USPSTF recommends that all persons planning or capable of pregnancy take a daily supplement containing 400 to 800 mcg of folic acid. The dose is increased for the following high-risk scenarios: A. 1 mg in patients with diabetes or epilepsy B. 4 mg in patients who have had a child with a previous neural tube defect Carrier screening (ethnic background): Sickle cell anemia Thalassemia Tay-Sachs disease Carrier screening (family history): Cystic fibrosis Nonsyndromic hearing loss (connexin-26) Screen for infectious diseases, treat, immunize, counsel HIV Syphilis Hepatitis B immunization Preconception immunizations (rubella, varicella) Toxoplasmosis—avoid cat litter, garden soil, raw meat Cytomegalovirus, parvovirus B19 (fifth disease)—frequent hand washing, universal precautions for child care and health care Environmental toxins Occupational exposures: material safety data sheets from employer Household chemicals: avoid paint thinners and strippers, other solvents, pesticides Smoking cessation: bupropion (Zyban), nicotine patches (Nicoderm) Screen for alcoholism and use of illegal drugs Medical assessment Diabetes: optimize control, folic acid 1 mg per day, off ACE-inhibitors Hypertension: avoid ACE inhibitors, angiotensin II receptor antagonists, thiazide diuretics Epilepsy: optimize control; folic acid 1 mg per day DVT: switch from warfarin (Coumadin) to heparin Depression/anxiety: avoid benzodiazepines Lifestyle Recommend regular moderate exercise Avoid hyperthermia (hot tubs, overheating) Caution against obesity and being underweight Screen for domestic violence Assess the risk of nutritional deficiencies (vegan, pica, milk intolerance, calcium or iron deficiency) Avoid overuse of Vitamin A (recommendations are to 750 mcg (2500 IU per day) with a daily upper intake limit of 3,000 mcg (10,000 IU)) Avoid overuse of Vitamin D (recommendations are 600 IU per day, tolerable upper intake is 4000 IU) Caffeine (limit to the equivalent of two cups of coffee or six glasses of soda per day) Note: The sugar intake in six glasses of soda is not recommended. Folic Acid Supplementation Folic acid supplements have been shown to reduce the risk of neural tube defects. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 3/10 The USPSTF "A" recommendation is that "all persons planning to or who could become pregnant should consume 0.4-0.8 mg (400-800 mcg) of folic acid daily." Persons at high risk, such as a neural tube defect (NTD) in a previous pregnancy, a family history of NTD, or on medications with increased risk of NTD (e.g. carbamazepine, valproic acid ) should take high-dose supplementation, 4 to 5mg daily. Signs and Symptoms of Pregnancy Amenorrhea with fatigue, nausea, and/or vomiting as well as breast changes, including tenderness, are the classic presentations of pregnancy. Urinary frequency can also occur. Although urinary frequency can be a normal symptom of pregnancy, the possibility of a UTI should also be considered. Softening of the cervix is known as Goodell's sign while softening of the uterus is known as Hegar's sign. The bluish-purple hue in the cervix and vaginal walls is known as Chadwick's sign and is caused by hyperemia. Enlargement of the uterus can be detected by an experienced examiner as early as 8 weeks on a bimanual exam. Around 12 weeks, the uterine fundus can be palpated above the symphysis pubis. Between 20 to 36 weeks of gestation, the uterine enlargement, measured in centimeters, approximates gestational age and will become a routinely elicited physical exam finding. Fetal heart tones are typically elicited by hand-held Doppler between 10-12 weeks gestation. Fetal movement or "quickening" is detected by the mother around 18-20 weeks of gestation. Unfortunately, the menstrual history is not an entirely reliable indicator of pregnancy. Only 68% of pregnant adolescents report having missed menses. Conversely, not every adolescent who misses a menses is pregnant because anovulatory cycles are normal in the early postmenarcheal years. Bleeding can occur in early pregnancy around the time of the missed menses as a result of an invasion of the trophoblast into the decidua (implantation bleed). Some adolescents mistake this bleeding for menses, leading to a delay in the diagnosis of pregnancy and potential misdating of the pregnancy. We should also remember that teens who have not yet menstruated but are sexually active may be at risk for pregnancy because ovulation can occasionally occur before the first menstrual period. Reproductive Choice Counseling Continue the pregnancy... Terminate the pregnancy... ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​○ Medically ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​○ Surgically Abortion restrictions in the U.S. vary from state to state, as shown here: https://www.guttmacher.org/state-policy/explore/overview-abortion-laws This excellent resource is updated regularly as the political situation is changing rapidly state by state. Calculating Estimated Gestational Age Calculating the estimated gestational age (EGA) based on the last menstrual period (LMP). Calculating the EGA in this manner is not only convenient but ubiquitous in clinical practice. Keep in mind, however, that the actual embryonic age (e.g., the age of the fetus since the date of conception) will typically be approximately two weeks less than the clinically calculated EGA based on the LMP. The other calculation used in clinical practice—which patients care a great deal about—is the estimated due date. Calculating the estimated due date (EDD) from the last menstrual period is a relatively simple process that can be done with an obstetric "wheel", with an electronic calculator (e.g., http://www.mdcalc.com/pregnancy-due-dates-calculator ) or using Naegele's Rule. Naegele's Rule is commonly described as starting with the first day of the last normal menstrual period, then: Add 1 year Subtract 3 months Add 1 week For example, if a patient's LNMP was 7/10/2020, then: 7/10/2021 (+1 yr) 4/10/2021 (-3 mo) 4/17/2021 (+1 wk) Thus, the EDD is 4/17/2021. There are a variety of error corrections to Naegele's Rule and other ways to calculate the EDD in the first trimester that will be discussed later. Hemodynamic Instability Typically, a significant bleed will first cause the pulse to rise and then the blood pressure to drop. Despite the fact that blood pressure is normal, bleeding can continue for a while before the blood pressure reflects this. This finding really changes how urgently you need to begin to make your assessment and, in some cases, intervene. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 4/10 Rhesus immune globulin (RhoGam) Rho(D) Immune Globulin is a critical part of modern obstetrics. Prior to the clinical use of this medication, Rh-negative mothers with Rh-positive first gestations were at high risk of having subsequent gestations and developing hemolytic anemia, hydrops, and/or fetal death. With every pregnancy, there is some passage of fetal red blood cells into the maternal circulation. This occurs at either miscarriage or delivery and can even occur in small but significant quantities across the otherwise placental barrier. When a mother with an intact immune system detects enough of the fetal Rho-D antigen, she forms antibodies to this antigen. This immune response is usually not robust enough to impact the first gestation, but subsequent gestations are at significant risk of an immune response. When this occurs, the maternal antibodies attack the fetus' red blood cells, causing hemolytic anemia, which can lead to fetal hydrops and even fetal death. Rho(D) Immune Globulin administered at appropriate times interrupts the maternal immunologic process. You can visualize this process by imagining the RhoGAM attaching to all of the fetal Rho-D antigenic load, making it immunologically "invisible" to the maternal immune system. Note: If the 50 mcg dose appropriate for the first trimester is unavailable, the 300 mcg dose used at 28 weeks and post-partum may be administered without consequence. First Trimester Vaginal Bleeding One in four pregnant patients experiences vaginal bleeding during the first trimester. When women have significant bleeding in the first trimester, there is a 25%-50% chance of miscarriage. Ectropion Ectropion: When the mucous-producing endocervical epithelium protrudes through the cervical os onto the face of the cervix, it is called an ectropion. The redness around the cervical os (opening) of an ectropion can be confused with a cervical infection or an erosion. An ectropion is normal and common in younger women and patients who are taking oral contraceptive pills. Cervical Ectropion Estimating Gestational Age Based on Last Known Menstrual Period and Ultrasound Recall that Naegele's rule for estimating the date of delivery (EDD) is to subtract three months and add seven days to the first day of the last menstrual period. Calculating today's estimated gestational age is typically done on a pregnancy calculator, but can be counted from the EDD on any calendar. Ultrasounds have their own extensive nomograms that estimate gestational age from measured fetal size. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 5/10 Trimester Measure Accuracy and Interpretation precision If the EGA & EDD from the ultrasound measurements are within one week of the EGA/EDD estimated from the LMP, today's gestational age and the due date (EGA & EDD) should not change to reflect the ultrasound calculations, as in this case. First crown-rump length trimester +/- 1 week If, however, the ultrasound measurements suggest an EGA & EDD that is greater than seven days from the EGA & EDD calculated from the LMP (or, in some cases, if the LMP is historically inaccurate), then the estimated gestational age today, as well as the estimated due date, should be changed to reflect the ultrasound measurements and estimates. 1. biparietal diameter Second trimester 2. head circumference +/- 2 weeks 3. abdominal circumference Same 4. femur length Fetal size cannot be used accurately to assess EGA or EDD and should not change a due date. Third trimester +/- 3 weeks This is because of the response of the fetus to internal and external insults. During the 1st and 2nd trimesters, many problems that develop result in pregnancy loss and/or teratogenesis. However, during the third trimester, many fetal and maternal challenges manifest themselves in fetal growth. Two examples would be macrosomia due to gestational diabetes or intrauterine growth restriction as a part of the pre-eclampsia syndrome. Additionally, fetal size discrepancies can be either familial or idiopathic. Since the ultrasound estimate of gestational age and due date is based on measurements of fetal size compared to a computerized nomogram, these third-trimester measurements should not be used for dating the EGA or EDD. Spontaneous Abortion: Incidence, Causes, and Recurrence Incidence Bleeding early in pregnancy is common. Approximately 25% of pregnancies, diagnosed or undiagnosed, have bleeding in the first trimester. For some pregnant people, they find out they are pregnant when they have the early bleeding. Not all pregnancies with bleeding indicate a pregnancy loss. Only around 10% to 20% of diagnosed pregnancies end in miscarriage/spontaneous abortion. Causes Individuals who have a spontaneous abortion and their partners frequently struggle with guilt about their role in the loss. Physicians should address the issue of guilt with their patients and allay any concerns that they may have "caused" the spontaneous abortion. There is no proof that stress or physical/sexual activity causes miscarriage. About half of all miscarriages that occur in the first trimester are caused by chromosomal abnormalities. Recurrence Most people (87 percent) who have miscarriages have subsequent normal pregnancies and births. Clinical Skills HEEADSSS Adolescent Interview Pre-participation exams are a great opportunity for prevention and counseling, as otherwise, healthy adolescents may not come in for this routinely. HEEADSSS covers the following issues: Home Education / Employment Eating Activities Drugs Sexuality Suicide / Depression Safety / Violence © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 6/10 Remember that in caring for adolescents, patients should be encouraged to involve parents in their health care decisions. Nevertheless, teens have a right to be interviewed and examined without a parent or guardian in the room. Management Management of Inevitable Abortion In the setting of an inevitable (or similarly, an incomplete) spontaneous abortion, the traditional choices for management are expectant management or surgical management. Legislation has limited options for elective abortion in some states. However, in this case, with a non-viable fetus, all options are available. Expectant management means watchful waiting with precautions regarding unusual amounts of bleeding, pain, or fever, and is effective in over 75% of cases in this setting. The disadvantage of this course of action is that it can take up to a month for the products of conception to be completely expelled. This timeframe might not normally be a problem, but a spontaneous abortion is usually complicated by sadness, grief, and even guilt. Expectant management can delay emotional closure. Nevertheless, this is a viable course of action. Surgical options include dilation and curettage (D&C), with or without vacuum aspiration, or manual or electric vacuum aspiration. These choices depend on a variety of factors, including primarily local resources and the surgeon's preference and experience. The main indication for suction D&C is unusually heavy bleeding and patient preference. The main contraindication is active pelvic infection. Medical management, can be done with several regimens, but, oral mifepristone 200 mg, followed 24 hours later by misoprostol 800 mcg vaginally, is the most effective for medical management of early pregnancy loss and should be recommended over misoprostol alone when available. Success with this method is generally around 97%, and the time to completion is generally three to four days (but may take up to two weeks), as opposed to two to six weeks with expectant management. Finally, confirming the receipt of rhesus immune globulin (RhoGam) in the Rhesus negative patient is advisable. If it was not given previously, it should now be administered. Studies Initial Pregnancy Laboratory Studies CBC is important for detecting various nutritional and congenital anemias and to detect platelet disorders. Hepatitis B surface antigen tests for hepatitis B, which is a major risk to the newborn. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.) HIV status should be checked as the risk of perinatal transmission can be reduced from 15%-40% without treatment to less than 2% with antiretroviral therapy and avoidance of breastfeeding and labor. RPR tests for syphilis, which is of particular concern during pregnancy because of the risk of transplacental infection of the fetus. Congenital infection is associated with several adverse outcomes, including perinatal death, premature delivery, low birth weight, congenital anomalies, and active congenital syphilis in the neonate. Rubella immunity should be tested by assessing the presence of IgG antibodies. If the patient isn't immune, they should receive a postpartum immunization. The Rubella and the MMR vaccine is a live-virus vaccine and should not be used during pregnancy. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.) Blood type to detect rhesus antibody presence. RH(D)-negative women should receive anti (D)-immune globulin to prevent hemolytic disease in the newborn at 28 weeks gestation or with vaginal bleeding during pregnancy. It is probably not necessary to test serum hCG as well as urine hCG to confirm pregnancy, in the setting of a positive urine hCG. However, as early pregnancy urine hCG concentrations are lower than serum hCG concentrations, it is possible to have a positive serum hCG result, even with a negative urine hCG result. Additionally, one must specify a qualitative (positive vs. negative) vs. a quantitative serum hCG. Quantitative serum hCG levels rise at a predictable rate, so serial testing of serum hCG levels can be useful to determine viability or to diagnose an ectopic pregnancy, although one measurement alone is not sufficient to accurately estimate gestational age. An ultrasound would not be the best test to order at an early stage of pregnancy. For example, at five weeks' estimated gestation, only a gestation sac but no embryo would typically not be seen. Furthermore, the results would be difficult to interpret without a serum quantitative beta-human chorionic gonadotropin test (quantitative pregnancy test). Recommended Laboratory Studies to Investigate First Trimester Vaginal Bleeding CBC: The main utility of the CBC is for the hemoglobin/hematocrit. The white blood cell (WBC) count is limited in its usefulness to detect infection (and thus a septic abortion) during pregnancy because most pregnant patients have mild leukocytosis. Nevertheless, if significantly elevated, or associated with a bandemia, this test would need to be factored into the consideration of a septic abortion. Wet mount or DNA testing for trichomonas, as well as PCR testing for gonorrhea and chlamydia: All sexually transmitted infections can cause vaginal bleeding. These tests should be obtained in this clinical context, despite a previously normal recent result. Progesterone: Laboratory testing for progesterone is most useful in extreme situations. If the result is > 25, it is highly associated with a sustainable intrauterine pregnancy. If the result is < 5, it is highly associated with an evolving miscarriage or ectopic pregnancy. Levels between 5 and 25 have minimal diagnostic value in distinguishing intrauterine from ectopic pregnancy. Algorithms for the diagnosis of ectopic pregnancy emphasizing progesterone measurements have been associated with a higher use of surgical management and often miss ectopic © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 7/10 pregnancy since 85% of ectopic pregnancies will have a normal progesterone level. Nevertheless, the test remains valuable because of its positive and negative predictive value at the extremes of the reference range. In many labs, it is a common and quick test, which makes it frequently ordered. Quantitative beta-human chorionic gonadotropin (quant. beta-hCG): This test has enormous significance, and when combined with the pelvic ultrasound, they are the definitive diagnostic modalities. However, in isolation, one beta-hCG can be challenging to interpret, especially without the ultrasound results. Human chorionic gonadotropin is secreted by the trophoblastic cells very early in embryonic life (day 7, postovulation). Additionally, testing for the beta-subunit is exquisitely sensitive (down to 5 mIU/mL) and specific (the placenta is the only normal tissue that excretes beta-hCG). By the expected date of menses, the beta-hCG is usually > or = 100 mIU/mL. In a normal pregnancy, the beta-HCG increases predictably over 48 hours. The beta-hCG should increase about 49% if the beta-hCG is less than 1500 mIU/ml. As the pregnancy progresses, the expected increase in beta-hCG is 40% at 1500-3000 mIU/ml and 33% >3000 mIU/ml. If the betahCG does not increase more than these minimal percentages, a possible ectopic pregnancy or impending pregnancy loss should be considered. 99% of normal pregnancies increase more than the minimum values. The discriminatory value is the serum beta-hCG level above which a gestational sac should be seen on ultrasound when an intrauterine pregnancy is present. According to the American College of Obstetricians and Gynecologists (ACOG), to definitively diagnosis an ectopic pregnancy by ultrasound, the beta-HCG should be high and suggests > 3500 mIU/mL. In both ectopic gestations and spontaneous abortions, hCG levels are usually lower than normal and increase at less-than-normal rates during early gestation. Molar pregnancy and multiple gestations are both associated with higher hCG levels. Not recommended: Type and screen: Knowing the Rhesus status is critical, as all Rh negative women who are pregnant need to be given RhoGam during any episode of bleeding. However, this does not need to be repeated after initial type and screen, especially in a setting that does not appear that this is a major bleed. If the bleeding is of great volume, a type and screen would be warranted both for potential transfusion and for Kleihauer-Betke testing, which helps to estimate the quantitative amount of fetal hemoglobin in the maternal circulation and with dosing RhoGam. Spontaneous Abortion Spontaneous abortion or "miscarriage" is the loss of a pregnancy without outside intervention before 20 weeks gestation. Spontaneous abortions can be subdivided into: Threatened abortion: bleeding before 20 weeks gestation. Threatened abortion is simply a pregnancy complicated by bleeding before 20 weeks gestation, and is, in some ways, a "catch-all" descriptive diagnosis. Inevitable abortion: dilated cervical os. Incomplete abortion: some but not all of the intrauterine contents (or products of conception) have been expelled. Missed abortion: fetal demise without cervical dilatation and/or uterine activity (often found incidentally on ultrasound without a presentation of bleeding). Septic abortion: with intrauterine infection (abdominal tenderness and fever usually present). Complete abortion: the products of conception have been completely expelled from the uterus. Clinical Reasoning Differential of First Trimester Vaginal Bleeding Most Likely Diagnoses There are many important causes of bleeding in early pregnancy, but the three most common are spontaneous abortion, ectopic pregnancy, and idiopathic bleeding in a viable pregnancy. Finding Significance A cervical os dilated with obvious bleeding lends support to the diagnosis of a spontaneous abortion. Physical Exam Findings Quantitative beta-hCG A distended, acute abdomen may turn one's attention to the immediate possibility of a ruptured ectopic pregnancy. However, an unremarkable pelvic exam does not rule out either a spontaneous abortion, ectopic pregnancy, or a normal pregnancy. Neither transabdominal nor transvaginal ultrasound can reliably detect an intrauterine pregnancy at a beta-hCG level less than 1500 mIU/mL. A quantitative beta-hCG slightly less than 1500 mIU/ml does not argue for or against a spontaneous abortion, an ectopic pregnancy, or a normal pregnancy. The quantitative beta-hCG should increase in a normal pregnancy. The velocity of the increase or decrease is a more useful diagnostic modality than the point value in a stable patient. If the patient is stable, 1-2 serial hCG measurement(s) can prove diagnostically useful and often conclusive when combined with a repeat ultrasound. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 8/10 An ovarian cyst is not necessarily abnormal, and a report stating "cannot rule out ectopic pregnancy" is a classic reminder by the radiologist that they simply cannot rule out ectopic pregnancy. Ultrasound One should be neither cavalier that such an ultrasound finding is a benign finding nor overly aggressive in "treating" for a suspected ectopic pregnancy in a stable patient. Better to make the diagnosis more certain. It would be a mistake to assume a confirmed ectopic pregnancy and to begin either medical or surgical treatment for ectopic pregnancy. This may, after all, prove in 48 hours to be the corpus luteum cyst supporting a normal intrauterine pregnancy. Intrauterine contents (e.g., gestational sac, fetal pole, etc.) are not expected to be seen until the quantitative beta-hCG reaches > 1500 IU/L, so a serial reading (in the stable patient) is needed. In a stable patient without active bleeding, serial readings every 48-72 hours would be appropriate. At each lab reassessment, a clinical assessment should be done as well. At any time, a spontaneous abortion can cause hemodynamic instability or a ruptured ectopic can prove life-threatening. If the patient was or has become unstable, a dilation and curettage (for an unstable spontaneous abortion) or a diagnostic laparoscopy or laparotomy (for a suspected ruptured ectopic) would be the most appropriate course of action. Less Likely Diagnoses Gestational trophoblastic disease (GTD), or molar pregnancy, is a heterogeneous constellation of conditions whereby the placenta acts like a tumor. GTDs are usually benign, but can sometimes be malignant. Typically, they have a characteristic appearance on ultrasound and are associated with markedly increased (>100,000 mIU/mL) quantitative hCG levels. Vaginal trauma and cervical pathology are unlikely if nothing abnormal is seen on physical exam. However, these can't be ruled out conclusively until gonorrhea and chlamydia results are obtained. References American College of Obstetricians and Gynecologists. Early pregnancy Loss. ACOG Practice Bulletin No. 200. Obstet Gynecol. 2018;132:e197-207. AAFP. American Academy of Family Physicians. AAFP Policy on Reproductive Decisions. Accessed February 1, 2024 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol. 2018;131(3):e91-e103. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 200: Early Pregnancy Loss. Obstet Gynecol. 2018;132(5):e197-e207. American College of Obstetricians and Gynecologists. Tubal ectopic pregnancy. ACOG Practice Bulletin No. 193. Obstet Gynecol. 2018; 131:e91-103. CDC. Centers for Disease Control and Prevention. Chickenpox Vaccination: What Everyone Should Know . Accessed February 1, 2024 Centers for Disease Control and Prevention. Final Recommendation: Chlamydia and Gonorrhea : Screening Sept 14, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening Accessed January 31, 2024 Centers for Disease Control and Prevention. Reproductive Health: Teen Pregnancy . https://www.cdc.gov/teenpregnancy/health-careproviders/index.htm. Accessed January 30, 2024. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021. https://www.cdc.gov/std/statistics/2021/overview.htm Close ED, Gunn AO, Cooke A. Preconception Counseling and Care. Am Fam Physician. 2023;108(6):605-13. Dobrow MJ, Hagens V, Chafe R, Sullivan T, Rabeneck L. Consolidated principles for screening based on a systematic review and consensus process. CMAJ. 2018;190(14):E422-E429. Gabbe S, Niebyl J, Simpson J. Red Cell Alloimmunization. In: Obstetrics: Normal and Problem Pregnancies . 5th ed. Philadelphia: Churchill Livingstone Elsevier; 2007. Grubb LK, Powers M, Committee on Adolescence. Emerging issues in male adolescent sexual and reproductive health care. Pediatrics (2020) 145 (5): e20200627 Guttmacher Institute. Abortion rules by state. Accessed February 1, 2024. Hendriks E, MacNaughton H, MacKenzie MC. First Trimester Bleeding: Evaluation and Management. Am Fam Physician. 2019;99(3):166-74. Hornberger LL; COMMITTEE ON ADOLESCENCE. Diagnosis of Pregnancy and Providing Options Counseling for the Adolescent Patient. Pediatrics. 2017;140(3):e20172273. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010. NIH. National Institute of Health: Office of Dietary Supplements: NISVS. The National Intimate Partner and Sexual Violence Survey. 2016/2017 Report on Sexual Violence. CDC. 2022. https://www.cdc.gov/violenceprevention/pdf/nisvs/nisvsReportonSexualViolence.pdf. Accessed January 31, 2024. Prasad P, Mori M, Toriello HV; ACMG Professional Practice and Guidelines Committee. Focused Revision: Policy statement on folic acid and neural tube defects. Genet Med. 2021;23(12):2464-6. Reproductive Health Access Project. Resources. First Trimester Bleeding Algorithm. https://www.reproductiveaccess.org/resource/first-trimesterbleeding-algorithm/. November 1, 2017. Accessed February 1, 2024. Reynolds EH, Green R. Valproate and folate: Congenital and developmental risks. Epilepsy Behav 2020 Jul:108:107068. doi: 10.1016/j.yebeh.2020.107068. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 9/10 Thoma BC, Rezeppa TL, Choukas-Bradley S, Salk RH, Marshal MP. Disparities in Childhood Abuse Between Transgender and Cisgender Adolescents. Pediatrics. 2021;148(2):e2020016907. US Preventive Services Task Force. Final Recommendation Statement: Chlamydia and Gonorrhea: Screening. September 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening. Accessed February 7, 2024. US Preventive Services Task Force. Final Recommendation Statement: Folic Acid to Prevent: Preventive Medication. Aug 01, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/folic-acid-for-the-prevention-of-neural-tube-defects-preventive-medication. Accessed Jan 31, 2024. Wilson JMG, Jungner G. (1968) Principles and practice of screening for disease (large pdf). WHO Chronicle Geneva: World Health Organization. 22(11):473. Public Health Papers, #34. https://apps.who.int/iris/bitstream/handle/10665/37650/WHO_PHP_34.pdf?sequence=17 Accessed February 7, 2024. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MWR Recomm Rep. 2021;70(4):1-187. Published 2021 Jul 23. © 2024 Aquifer, Inc. - Janessa Pamintuan (jpamintuan134@usuniversity.edu) - 2024-03-30 01:57 EDT 10/10 1 Aquifer Essay Title Your Name United States University Course name Instructor name Date 2 Aquifer Essay Title The introduction should be a paragraph that provides a brief overview of the case and main diagnosis with rationale and supporting evidence. You do not need to discuss pathophysiology or summarize the entire case. The entire paper should be between one and three pages long. Differential Diagnoses This section will identify your two differentials with the rationale and supporting evidence. Also explain why these differentials were not the main diagnosis. Diagnostics Identify the lab, radiology, or other tests needed for the main diagnosis with supporting evidence. Do not include excessive or non-pertinent testing. Treatment, Education, and Follow-Up This section should include the elements of an initial treatment plan for the main diagnosis. It should include medication names, dosages, frequencies; patient/family education; appropriate follow up plan; and hospitalizations and consults when appropriate. 3 References The supporting evidence for this paper should be derived from at least two primary sources (not Medscape, UpToDate, Epocrates, etc.), including published clinical guidelines or peer-reviewed professional journals that are NOT textbooks. Supporting evidence should be published within the past 5 years, or 10 if the guidelines have not been updated. References should be in APA format. Refer to the APA 7 Manual for specific formatting requirements. 4
Purchase answer to see full attachment