[##]-year-old female G[#]P[####] at [##] weeks and [##] days gestational age with history and exam consistent with ectopic pregnancy.
Initial consideration in this patient included ectopic pregnancy, inevitable, incomplete, active or threatened spontaneous abortion, septic abortion, subchorionic hemorrhage, hematoma, endometritis, pelvic inflammatory disease (PID), and urinary tract infection (UTI) among others.
Patient presented with [vaginal bleeding/pelvic pain] and [known/unknown] pregnancy. Patient was deemed to be [hemodynamically stable/unstable] on arrival in the ED [and initial resuscitation initiated]. A bedside FAST exam was performed and [noted to be negative/noted to be positive increasing concern for ectopic pregnancy]. Initial labs were obtained to include a urine pregnancy test, a serum quantitative hCG, ]and type and screen/cross/etc.]. A [bedside/formal] ultrasound was obtained [with no clear evidence of intrauterine pregnancy (IUP)/free fluid in pelvis/etc.].
Cervix noted to be closed on exam making inevitable abortion unlikely. No mass or focal tenderness on bimanual or ultrasound. No evidence of brisk active bleeding on pelvic exam in the ED. Patient noted to have [A/B/O +/-] blood type with [no indication for RhoGAM/RhoGAM given prior to discharge from ED].
Doubt septic abortion based on absence of fever, significant uterine tenderness on exam, or evidence of purulent vaginal discharge. Doubt significant ovarian cyst or torsion at this time based on [history/exam/ultrasound]. No evidence of cervical motion tenderness to suggest PID at this time.
Ectopic pregnancy [confirmed/highly suspected] based on findings noted on ultrasound. Quantitative hCG of [###] mIU/mL noted to be [above/below] the discriminatory zone. Case discussed with Dr. [NAME] of Obstetrics with discussion of [plan to evaluate the patient for possible laparotomy given evidence of instability/plan to evaluate the patient for potential medical management with Methotrexate].
[After discussion with Dr. NAME of Obstetrics the patient was felt to be appropriate for outpatient medical management given absence of absolute contraindications (including current breastfeeding, underlying hepatic, renal, hematologic, cardiac or pulmonary disease, or known hypersensitivity) or relative contraindications (adnexal mass >3.5 cm in largest diameter, presence of fetal heart rate, free fluid in the pouch of Douglas, quantitative hCG >5000 mIU/mL). We discussed strict return precautions for worsening pain, syncope, or other symptoms suggestive of ruptured ectopic pregnancy with the patient who demonstrated understanding. We discussed the importance of follow up at 4 and 7 days for repeat hCG levels to ensure satisfactory decline in hCG level (at least 15% between days 4 and 7). Close follow up was planned with Obstetrics prior to discharge.]
Cervix noted to be closed on exam making inevitable abortion unlikely. No mass or focal tenderness on bimanual or ultrasound. No evidence of brisk active bleeding on pelvic exam in the ED. Patient noted to have [A/B/O +/-] blood type with [no indication for RhoGAM/RhoGAM given prior to discharge from ED].
Doubt septic abortion based on absence of fever, significant uterine tenderness on exam, or evidence of purulent vaginal discharge. Doubt significant ovarian cyst or torsion at this time based on [history/exam/ultrasound]. No evidence of cervical motion tenderness to suggest PID at this time.
Ectopic pregnancy [confirmed/highly suspected] based on findings noted on ultrasound. Quantitative hCG of [###] mIU/mL noted to be [above/below] the discriminatory zone. Case discussed with Dr. [NAME] of Obstetrics with discussion of [plan to evaluate the patient for possible laparotomy given evidence of instability/plan to evaluate the patient for potential medical management with Methotrexate].
[After discussion with Dr. NAME of Obstetrics the patient was felt to be appropriate for outpatient medical management given absence of absolute contraindications (including current breastfeeding, underlying hepatic, renal, hematologic, cardiac or pulmonary disease, or known hypersensitivity) or relative contraindications (adnexal mass >3.5 cm in largest diameter, presence of fetal heart rate, free fluid in the pouch of Douglas, quantitative hCG >5000 mIU/mL). We discussed strict return precautions for worsening pain, syncope, or other symptoms suggestive of ruptured ectopic pregnancy with the patient who demonstrated understanding. We discussed the importance of follow up at 4 and 7 days for repeat hCG levels to ensure satisfactory decline in hCG level (at least 15% between days 4 and 7). Close follow up was planned with Obstetrics prior to discharge.]
[After discussion with Dr. NAME of Obstetrics the patient was deemed to be appropriate for operative management. The patient was counseled on the risks, benefits and alternatives to operative management, and demonstrated understanding with planned admission/Given emergent nature of illness and noted instability on presentation, emergency consent was felt to be implied. Crossmatched/Emergency release blood transfusion was initiated in the ED prior to transfer.]
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