A 24-year-old primigravida comes to the emergency department for evaluation of pelvic pain. The pain began a week ago as mild cramping but is now constant and severe. The patient had a positive home pregnancy test 3 weeks ago and has also recently had some brown vaginal spotting. She has no chronic medical conditions or previous surgeries. Blood pressure is 110/60 mm Hg and pulse is 108/min. The abdomen is tender to palpation over the left lower quadrant and rebound is present. Initial laboratory results are as follows: Pelvic ultrasound shows a small uterus with a thin endometrium, an 8-week fetal pole in the left adnexa with cardiac motion, and a large amount of free fluid in the pelvis. Laparoscopy confirms hemoperitoneum and a ruptured left fallopian tube; a left salpingectomy is subsequently performed. On postoperative day 1, the patient's blood pressure is 116/78 mm Hg and pulse is 88/min. Repeat laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 24-year-old primigravida comes to the emergency department for evaluation of pelvic pain.  The pain began a week ago as mild cramping but is now constant and severe.  The patient had a positive home pregnancy test 3 weeks ago and has also recently had some brown vaginal spotting.  She has no chronic medical conditions or previous surgeries.  Blood pressure is 110/60 mm Hg and pulse is 108/min.  The abdomen is tender to palpation over the left lower quadrant and rebound is present.  Initial laboratory results are as follows:  Pelvic ultrasound shows a small uterus with a thin endometrium, an 8-week fetal pole in the left adnexa with cardiac motion, and a large amount of free fluid in the pelvis.  Laparoscopy confirms hemoperitoneum and a ruptured left fallopian tube; a left salpingectomy is subsequently performed.  On postoperative day 1, the patient's blood pressure is 116/78 mm Hg and pulse is 88/min.  Repeat laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da84_4102_bc81_11c9efee20e1_MD0003_00 Rh(D) alloimmunization occurs when Rh(D)-negative mothers develop anti-D antibodies due to pregnancy with a Rh(D)-positive fetus. Although most cases of Rh(D) alloimmunization are associated with delivery of a Rh(D)-positive infant, alloimmunization can occur whenever there is significant fetomaternal blood mixing, such as in this patient with a ruptured ectopic pregnancy. Even at an early gestational age, fetal red blood cells carrying the foreign Rh(D) antigen can enter maternal circulation and induce production of maternal anti-D antibodies. In future pregnancies with a Rh(D)-positive fetus, these maternal antibodies can cross the placenta and destroy fetal red blood cells, leading to hemolytic disease of the newborn (ie, hydrops fetalis). hydrops fetalis Therefore, all women with bleeding in pregnancy (eg, ectopic pregnancy) require maternal blood typing. Those who are Rh(D)-negative and have a negative antibody screen (eg, negative Coombs test), such as this patient, are administered anti-D immunoglobulin because the fetal blood type is typically unknown and potentially Rh(D)-positive. Anti-D immunoglobulin masks Rh(D) antigens on fetal red blood cells, thereby preventing maternal anti-D antibody production and alloimmunization (Choice C). ectopic pregnancy (Choice B) Intramuscular methotrexate is used for medical treatment of some ectopic pregnancies (eg, small size, no fetal cardiac motion). It is not administered after salpingectomy because salpingectomy removes the entire fallopian tube containing the ectopic pregnancy. (Choice D) Suction curettage may be indicated for persistent uterine bleeding (eg, incomplete abortion, retained products of conception) but not for an ectopic pregnancy. β-hCG levels remain temporarily elevated in patients after a recent ectopic removal but will decrease and eventually trend to zero. Suction curettage (Choice E) Vaginal misoprostol can be used for medical termination of an intrauterine pregnancy by causing cervical dilation and uterine contractions. It is not used in the management of ectopic pregnancy. Educational objective: Ectopic pregnancies can cause Rh(D) alloimmunization in Rh(D)-negative women due to fetomaternal blood mixing and maternal anti-D antibody production. Therefore, Rh(D)-negative women require anti-D immunoglobulin after an ectopic pregnancy. References: Practice bulletin no. 181: prevention of Rh(D) alloimmunization. (http://www.ncbi.nlm.nih.gov/pubmed/28742673)

A 24-Year-Old Primigravida Comes to the Emergency Department for Evaluation