First Trimester Pregnancy Emergencies: Recognition and Management

Points and Pearls Excerpt

• Approximately 25% of pregnant women will experience vaginal bleeding, and 7% to 27% of pregnant women will experience miscarriage.
• In the setting of first trimester bleeding, a pelvic examination is warranted only if you suspect it might change management.
• Half of all patients with ectopic pregnancy have no risk factors for the condition.
• Unstable patients with vaginal bleeding and no intra-uterine pregnancy (IUP) should be assumed to have an ectopic pregnancy until proven otherwise.
• If using a discriminatory zone to confirm an IUP, the American College of Obstetricians and Gynecologists (ACOG) recommends a beta-hCG cutoff of 3500 mIU/mL.
• The beta-hCG typically doubles within 48 hours during the first trimester. It should rise by a minimum of 53%.
• Due to anatomical and physiologic changes in the genitourinary tract during pregnancy, asymptomatic bacteriuria places women at higher risk for pyelonephritis. Although there is no evidence to support routine screening, treat asymptomatic bacteriuria according to local antibiograms.
• Send a urine culture for patients complaining of UTI symptoms even if the urinalysis is negative.
• The most common surgical problem in pregnancy is appendicitis.
• If appendicitis is suspected, MRI is not available, and ultrasound is inconclusive, CT may be warranted. The risk of missing or delaying the diagnosis may outweigh the risk of radiation.
• ACOG recommends using contrast only if absolutely required.
• For stable patients with a pregnancy of unknown location, plan for discharge with follow-up in 48 hours for a repeat beta-hCG and ultrasound.
• Nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum severely impact a pregnant patient's quality of life; one study showed that 25% of women with severe NVP had considered termination and 75% stated they would not want to get pregnant again.
• For NVP, try nonpharmacologic treatments such as acupressure at the P6 point or ginger supplementation. First-line pharmacologic treatment is pyridoxine (vitamin B6). Doxylamine can be added. For severe symptoms requiring IV fluids and medications, see the Clinical Pathway.
• ACOG makes no recommendation on administration of anti-D immune globulin in an Rh-negative patient with threatened miscarriage before 12 weeks. With heavier bleeding and gestational age closer to 12 weeks, administration can be considered.

Most Important References

• Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin no. 189: nausea and vomiting of pregnancy. Obstet Gynecol. 2018;131(1):e15-e30. (ACOG Practice Bulletin) DOI: https://doi.org/10.1097/AOG.0000000000002456
• Committee on Obstetric Practice. Committee Opinion no. 723: guidelines for diagnostic imaging during pregnancy and lactation. Obstet Gynecol. 2017;130(4):e210-e216. (ACOG Committee Opinion) DOI: https://doi.org/10.1097/AOG.0000000000002355
• American College of Radiology. ACR-SPR practice parameter for imaging pregnant or potentially pregnant adolescents and women with ionizing radiation. American College of Radiology. Available at: https://www.acr.org/-/media/ ACR/Files/Practice-Parameters/Pregnant-Pts.pdf Accessed December 10, 2018. (Committee Opinion)
• American College of Emergency Physicians Clinical Policies Subcommittee on Early Pregnancy, Hahn SA, Promes SB, et al. Clinical Policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2017;69(2):241-250. (ACEP Clinical Policy) DOI: https://doi.org/10.1016/j.annemergmed.2016.11.002
• Kazemier BM, Koningstein FN, Schneeberger C, et al. Maternal and neonatal consequences of treated and untreated asymptomatic bacteriuria in pregnancy: a prospective cohort study with an embedded randomised controlled trial. Lancet Infect Dis. 2015;15(11):1324-1333. (Multicenter prospective cohort study; 248 patients with asymptomatic bacteriuria) DOI: https://doi.org/10.1016/S1473-3099(15)00070-5
• Gottlieb M, Wnek K, Moskoff J, et al. Comparison of result times between urine and whole blood point-of-care pregnancy testing. West J Emerg Med. 2016;17(4):449-453. (Prospective observational study; 265 patients) DOI: https://doi.org/10.5811/westjem.2016.5.29989