som
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A 27-year-old woman, gravida 2, para 1, at 13 weeks' gestation comes to the physician because of a dark brown vaginal discharge that appeared the day before. She has soaked two pads since this morning. The past 3 weeks, she has no longer felt sick in the morning. She does not use tobacco, alcohol, or drugs. She has no history of trauma. Her temperature is 37C(98.7F), blood pressure is 110/60 mm of Hg, pulse is 85/min, and respirations are 17/min. Physical examination shows a soft uterus, small for gestational age, and a closed cervix; ecchymosis are present on the left forearm. Fetal heart tones are not heard by Doppler nor seen on real time ultrasonogram. Urine pregnancy test is negative; serum fibrinogen level is decreased. Which of the following is the most appropriate next step in management?
A Dilation and curettage
B.Repeat ultrasound one week later
C.Serial beta-hCG
D.Emergency suction evacuation
E.Reassurance and outpatient follow up
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| msyamp
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Emergency suction evacuation
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| som
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anymore ans here?
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| nadiabarati
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C
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| juanma0
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If the urine pregnancy test is negative, serial BHCG´s are not indicated. Urine HCg is highly sensitive but not specific.
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| wyvern
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D - Decreasing fibrinogen levels + ecchymosis suggest she s developing DIC.
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| yasmeen
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imediate suction and evacuation wehave to removethe cause for dic
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| achilles
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emergency suction and evacuation.
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| som
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this pt had a missed abortion and the fetus is still inside, now she is developing DIC..the fetus has to come out....so this narrows the options to A or D? this depends on the gestational age. this is a snippet from emedicine:
The following methods are available for surgical abortion:
- Manual vacuum aspiration (menstrual extraction) is used at 4-10 weeks of gestation and is 99.2% effective.
Suction curettage is used at 6-12 weeks of gestation.
Sharp curettage is used at 4-12 weeks of gestation but is not currently used because of increased blood loss and retained POC compared to suction.
Dilation and extraction (D&E) is used at 13-24 weeks of gestation.
Intact dilation and extraction (D&X) is used at more than 16 weeks' gestation.
Hysterotomy is used at 12-24 weeks of gestation and is reserved for the rare instances in which all other methods of abortion have failed or are contraindicated.
Hysterectomy is reserved for rare instances in which other gynecological pathology dictates removal of the uterus.
Abortions performed earlier in gestation have a lower risk of morbidity and mortality. In the United States, 88% of abortions are performed at 13 weeks' gestation or less. Ninety-seven percent of abortions are performed using surgical methods. A randomized trial demonstrated comparable acceptability among both patients and physicians of manual vacuum aspiration and suction curettage with regard to procedure time, blood loss, complications, anesthesia requirement, recovery time, pain perception, and overall satisfaction. The only significant factor was noise audibility noted with suction curettage, a distinct advantage of manual vacuum aspiration. In the second trimester, options for abortion include D&E, D&X, labor induction methods, and hysterotomy/hysterectomy. D&E is considered the safest form of abortion in the second trimester. In contrast, D&X is reputed to pose a greater health risk to the mother (increased risk of cervical incompetence, uterine rupture, abruption, amniotic fluid embolism, and uterine trauma) when compared with that of D&E. However, no published data exist regarding the frequency or complication rates for D&X. Further, no prospective trials have been conducted comparing the morbidity or mortality rates of D&E and D&X. A retrospective study has shown comparable complication rates and obstetric outcomes between these 2 procedures when performed by experienced physicians.
guys..u got the ans now i think
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