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Pediatric emergency medicine trisk 2116 2116

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Management Pregnancy Once the diagnosis of pregnancy has been made, the goals of the ED evaluation include (i) dating the pregnancy, (ii) recognizing symptoms that require immediate referral for obstetric or gynecologic evaluation, (iii) identifying and treating presenting and potential nonsurgical complications, (iv) assessing chronic medical conditions, (v) providing appropriate counseling, and (vi) securing appropriate and timely follow-up These goals can be tailored to specific settings, depending on consultant availability and access to close follow-up for the patient The approach to management of patients diagnosed with pregnancy includes subspecialty consultation, quantitative serum β-hCG levels, serum progesterone levels, abdominal and/or transvaginal ultrasound, depending on the practice setting, as well as close follow-up Ideally, schedule a primary care or adolescent medicine specialist follow-up visit in to days so that counseling about options can be repeated in a less rushed, less chaotic environment It is also important to review the patient’s medical insurance and link her to eligible coverage/resources The need to arrange close follow-up and to facilitate connection to care following the ED visit should not be underestimated In a normal singleton pregnancy, serial serum β-hCG levels should increase by 67% every 48 hours during the first month of pregnancy Levels that not rise or rise more slowly than expected are indicative of an abnormal pregnancy (usually an ectopic pregnancy or a pregnancy that is destined to spontaneously abort) Ultrasound is used to visualize the uterine cavity to assess for the presence of a gestational sac When the β-hCG level reaches the discriminatory zone, a gestational sac should be visible within the uterus The discriminatory zone varies based on local transvaginal ultrasound expertise, but is generally around a β-HCG of 2,500, or a gestational age of weeks If no sac is seen and the β-HCG is beyond the discriminatory zone, the pregnancy is presumed to be ectopic If the discriminatory zone has not been reached or the pregnancy dates (by last menstrual period, for example) is less than weeks, the patient should have a repeat β-HCG within 48 hours and the ultrasound repeated if the β-HCG is at or above the discriminatory zone For patients diagnosed with ectopic pregnancy, conservative medical management may be appropriate in adolescents who are stable, have no evidence of any bleeding, have a hemoglobin of greater than g/dL and a gestational sac less than cm, who are not immunocompromised, and not have a bleeding diathesis, or liver, or renal disease, and if close follow-up can be secured As

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