Positive pregnancy tests. Look for the classic triad of unilateral belly pain, amenorrhea (a missed a period, the patient saying, “I didn’t have a period for a while”), and a positive pregnancy test. These people need an ultrasound emergently.

Ectopic Pregnancy

Very few things can kill a person faster than a popped ectopic pregnancy. Just be aware of the pathophysiology. You have a fetus growing in a tube. It won’t happen like that, it’s a slow process. It grows but once they start the pain, it gets worse and worse.

I had a young lady recently that came in. I cannot get an ultrasound at night after 11 until 7 in the morning. I cannot get one, no matter what the scenario is. She came in, positive pregnancy test, unilateral belly pain. The pelvic exam was not diagnostic and she did not look that sick.

She definitely needed an ultrasound, but do I send her home and bring her back in the morning or do I transfer her to a bigger hospital? Or do I hold her in the ER for eight hours. The answer is two out of those three are right, and one is really, really wrong. Do not ever send them home. Do not send them home. You had better keep them right with you. So I said, “Come on, grab a fluffy blanket and a pillow; you are going to sleep right there. I am keeping you around until 7 in the morning so I can do your ultrasound.” They should never, ever go home. They need an ultrasound.

Threatened Miscarriage

This is someone who has vaginal bleeding and a positive pregnancy test, but they have an intrauterine gestation. You do an ultrasound. We have a fetus in the uterus. Okay we’re good. Not a big deal. When someone comes in and they are pregnant and they are bleeding the only big question I have is do they have an IUP or not. Do they have an intrauterine pregnancy or not, because if they do, it is not an ectopic pregnancy. No big emergency here.

If they are exsanguinating bleeding, then that is kind of a big deal, but for the most part I want to know if they bleeding a lot and if they have an intrauterine pregnancy. So when someone comes in, pregnant, bleeding, ask “Have you had an ultrasound with this pregnancy?” If they say “Yes, I had one last week and it was normal,” then you want to get a physical copy of that ultrasound but that is very reassuring that this is not ectopic.

You want to do a quantitative hCG. Remember, one type of pregnancy test, likely over-the-counter, is qualitative. Postitive or negative. The other one is quantitative, generating a pregnancy number. That number in and of itself means nothing. That number though, should double every two days. So you get one number and you have them recheck a quantitative in two days and if that has not doubled, they will miscarriage.

Something that I find it is important to tell parents, moms, is, “You know Mom, there is nothing you could have done to cause this and there is nothing I can do to prevent this. This is a threatened state; you may miscarriage. There is nothing I can do about that. You may go home and do just fine, but you have to go on bedrest, no intercourse. Again, there is nothing you could have done to cause this.” A lot of times I get people that break into tears because of that. Because they think, “Oh, if I would not have lifted that box this would not have happened, if I wouldn’t have done this…”

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