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

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

3. Case 0037h 0120h Triage: 16♀ with low abdo pain, N/V, Vag bleed
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 Booked for Abdominal U/S ?Miscarriage vs Gastroenteritis CBC: N
U/A: cloudy with few epithelial cells, nil else
Urine β-hCG: Neg, SG= (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% On Exam:
↑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: Repeat Labs: 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 hrs for days 1-30
Rule of thumb:
10 time of missed menses
weeks (peak)
term
*Range is large – hCG levels should not be used for dates

16. β-hCG - serum Low levels suggest: Higher than expected 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 – 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