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Little Adult: A child with a grown up problem

Little Adult: A child with a grown up problem. Interesting Case Rounds March 8, 2007 James Huffman Emergency Medicine Resident, PGY-1. Objectives. β -hCG review Characteristics of the tests (urine/serum) Interpretation of results Travsvaginal Ultrasound review Role

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Little Adult: A child with a grown up problem

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  1. Little Adult:A child with a grown up problem Interesting Case Rounds March 8, 2007 James HuffmanEmergency Medicine Resident, PGY-1

  2. Objectives • β-hCG review • Characteristics of the tests (urine/serum) • Interpretation of results • Travsvaginal Ultrasound review • Role • Logistics of ordering

  3. Case 0037h Triage: 16♀ with low abdo pain, N/V, Vag bleed 37.4°C, 60, 18, 107/44, 98% 0120h Pediatrician: • Abdo pain x 6days w/ vomiting, no diarrhea • Vaginal bleeding – light flow/spotting x 4-5 days • LMP: ended 9/52 ago • Postitive home preg test 2/52 ago

  4. Case On Exam: • Looks well • Eyes N, Ears N, Throat N • Chest: good A/E, CVS N • Abdo: soft/mildly tender RLQ, No invol guarding, no mass, no organomegally “Her belly was as soft as a cucumber. Well, a rotten one”.

  5. Case CBC: N U/A: cloudy with few epithelial cells, nil else Urine β-hCG: Neg, SG=1.020 (N ≤ 1.030) Serum β-hCG: <2 (N 0-5) Booked for Abdominal U/S ?Miscarriage vs Gastroenteritis

  6. Case – return visit 1505h 38.3, 126/59, 82, 18, 96% • ↑RLQ pain, ↓nausea, vaginal bleeding stopped • Denies passing clots/tissue On Exam: • Minimal distress, moves easily • Exquisitely tender RLQ, +invol guarding, +Rovsing’s sign • Vaginal exam deferred as no bleeding currently

  7. Case – return visit Abdo U/S: • No signs of inflammation • Appendix not seen • Ovaries N Repeat Labs: • No changes from previous • LFTs N, Lipase N

  8. Quick summary 16♀ with mild fever, RLQ pain, ?early signs of peritoneal irritation and vaginal bleeding Backgroud of positive home preg test 2/52 ago (now neg urine and serum x2) Normal labs and nil acute seen on abdominal U/S

  9. DDx • Inevitable/incomplete abortion • Dysfunctional uterine bleeding • Ruptured ovarian cyst • PID • Endometritis • Appendicitis • Mesenteric adenitis • Early UTI • (Ectopic pregnancy)

  10. Case Transferred to FMC for TV ultrasound/pelvic exam • Pt left without being seen. Saw WIC, vaginal swabs done:  Negative, as per pt Out patient TV ultrasound done Wednesday:  Results pending

  11. Pregnancy Tests!?But this is a children’s hospital!

  12. Trivia • Youngest person to give birth? • Lina Medina • 5 years, 7 months • Peru • 1939

  13. β-hCG • Glycoprotein consisting of 2 linked subunits • α-subunit is similar in shape to LH, FSH and TSH • No studies specifically looking at pediatric pts Home Pregnancy Tests: • Introduced in 1975 • Immunometric assay of hCG in the urine • Sensitivities vary, but 97% of pregnancies are picked up by 1/52 after first day of missed menses

  14. β-hCG Limitations of urine testing: • Sensitivity is affected by timing/user characteristics • Elevated lipids, high Ig levels and low serum protein can interfere with results • Dilute urine raises the threshold for hCG detection (CHR recommends SG ≥ 1.020) • False positives occur with nonviable intrauterine pregnancy, ectopic, gestational trophoblastic disease and some ovarian tumours

  15. β-hCG - serum • Serum hCG levels rise soon after implantation (7-11 days after ovulation) • Doubling time is 29-53 hrs for days 1-30 • Rule of thumb: • 10 IU/L @ time of missed menses • 100 000 IU/L @ 10 weeks (peak) • 10 000 IU/L @ term *Range is large – hCG levels should not be used for dates

  16. β-hCG - serum Low levels suggest: • Ectopic, abortion, (wrong dates) Higher than expected levels suggest: • Multiple gestation, molar pregnancy, trisomy 21, some ovarian tumors, (wrong dates)

  17. Ultrasound Discriminatory Zone: • The hCG titer at which an intrauterine sac can be seen with transvaginal (TV) ultrasound • CHR – 1200-1500 mIU/L (4-5 weeks) • Abdo U/S – 6500mIU/L (6-8 weeks) TV ultrasound has become the gold standard for non-surgical diagnosis of ectopic pregnancy • If hCG is above DZ level and IUP is not visualized on TVUS, liklihood of ectopic is >90% (*multiple gestation)

  18. Ultrasound Logistics: • The ACH diagnostic imaging department does not perform TV ultrasound • Foothills will, however, they will not directly accept patients • Therefore, you will need to transfer your pt to the FMC ED and have a physician there order the study

  19. Take Home Points • Obstetrical problems not isolated to adult realm • Home pregnancy tests are reasonably sensitive by 1/52 after first day of missed menses, and false positives are rare • Rule of thumb for serum hCG levels • Transvaginal ultrasound if hCG levels are not what are expected for dates

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