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Dump the Myths, Not the Milk: Medication and Imaging Considerations for Lactating Patients in the Emergency Department

lactation myths with medications and imaging
The challenges in lactation are often compounded by outdated beliefs held by clinicians.  Most of the medications we administer in the emergency department (ED) do not warrant any interruption in expression or feeding of breastmilk. Most imaging we perform in the ED is safe in the lactating patient and likewise does not need interruption. Let us convince you to trash the phrase, “Pump and Dump” in the ED.

Most medications commonly given in the ED are safe in lactation

Evidence suggests medication transfer through breast milk is frequently overestimated, with actual infant exposure typically minimal for most medications commonly prescribed in emergency settings [1]. The majority of medications administered in the ED are compatible with continued breastfeeding or pumping without interruption [2]. The practice of “pumping and dumping” is harmful to infants and lactating adults given the many benefits of lactation [3, 4]. It can cause irreparable disruptions in supply, increased parental burden and stress, and is not medically indicated except in very rare circumstances (chemotherapeutics for example) [3, 4]. When uncertainty exists regarding medication safety during lactation, clinicians should consult evidence-based resources such as LactMed or the LactRx app [iphone] to provide informed recommendations. A brief summary table is provided below for quick reference on some common medications.

Medication ClassSafe in LactationCautions in Lactation
Analgesia
  • Acetaminophen [5]
  • Ibuprofen [6]
  • Opioids in routine doses: Oxycodone [7], Morphine [8], Hydromorphone [9],  Fentanyl [10]
  • ⚠️ Caution in very high doses or prolonged infusions of opioids
  • Data on oxycodone shows no adverse effects attributed to oxycodone in maternal doses up to 60 mg/day (~90 MME/day) [11], which is well within the range of typical short-term ED prescribing for acute pain [12]
Sedative Hypnotics
  • Propofol [13]
  • Ketamine [14]
  • Midazolam [15]
  • Safe to feed when awake
  • ⚠️ Caution in infusions and higher doses of long-acting benzodiazepines
Paralytics
  • Succinylcholine [16]
  • Rocuronium [17]
  • Safe to feed when no longer paralyzed; likely safe to feed even on infusions
Opioid Use Disorder
  • Buprenorphine [18]
  • Methadone [19]
  • Recommended to continue feeding
Antibiotics
  • Penicillins [20]
  • Cephalosporins [20]
  • Macrolides [20]
  • Metronidazole [21]
  • Doxycycline (≤21 days) [22]
  • ⚠️ Trimethoprim-sulfamethoxazole (Avoid in premature, ill or jaundiced and those with G6PD) [23]
Anti-hypertensives
  • Labetalol [24]
  • Nifedipine [25]
  • Captopril, Enalapril, Benzapril (Lisinopril—less data) [26]
  • HCTZ [27]
  • Furosemide [28]
  • ⚠️ Diuretics may decrease milk supply if dehydrated
  • ❌ ARBs (Losartan) — No safety data and other alternatives are safe [26]
Antidepressants
  • Sertraline [29]
  • Paroxetine [30]
  • Fluoxetine [31]
  • Citalopram [32]
  • Do not stop an effective antidepressant because of lactation. Risk of depression relapse outweighs the small differences in milk transfer.
  • ⚠️ Bupropion (case reports of infant seizures without causal link) [33]
  • ❌ Doxepin (case reports of infant respiratory depression, hypotonia) [34]
Anticonvulsants
  • Carbamazepine [35]
  • Valproic acid [36]
  • Phenytoin [37]
  • Lamotrigine [38]
  • ⚠️ Levetiracetam (levels can be high, monitor for somnolence) [39]
  • ⚠️ Topiramate (case reports of infant somnolence) [40]
  • ❌ Phenobarbital (Avoid due to high infant exposure and sedation risk) [41]

Most Imaging Performed in the ED is Safe in Lactation

Radiation Exposure

Radiation exposure from diagnostic imaging we typically use in the ED (CT, x-ray) is minimal and there is no need to interrupt nursing/pumping [42].

IV contrast

Iodinated and gadolinium contrast agents are safe and do not require interruption of breastfeeding [43]. Read more in the American College of Radiology 2025 ACR Manual on Contrast Media (start at page 94).

In suspected pulmonary embolism (PE), CT pulmonary angiography (CTPA) is preferred over V/Q scan in lactating patients due to contrast safety (no breastfeeding interruption required), speed and availability, and high rates of indeterminate V/Q scans requiring subsequent CTPA [43, 44].

Exception: In the rare circumstance where contrast is contraindicated (such as anaphylaxis) and a radioactive tracer is indicated (V/Q scan with Tc-99m MAA), the radioactivity does warrant separation from both patient contact and milk for a period of time determined by the rate of decay of the specific agent [45]. Keep expressed milk stored appropriately until radioactivity has been able to decay then it’s safe to feed [46].

References (AMA Format)

  1. Nauwelaerts N, Macente J, Deferm N, Bonan RH, Huang MC, Van Neste M, et al. Generic workflow to predict medicine concentrations in human milk using physiologically-based pharmacokinetic (PBPK) modelling—a contribution from the ConcePTION project. Pharmaceutics. 2023;15(5):1469. doi:10.3390/pharmaceutics15051469
  2. Premer C, Caruso K. Safety profile of the most ordered medications for breastfeeding patients in the emergency department. Am J Emerg Med. 2024;80:1-7. doi:10.1016/j.ajem.2024.02.042
  3. Sachs HC; Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-e809. doi:10.1542/peds.2013-1985
  4. Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988
  5. Acetaminophen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  6. Ibuprofen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  7. Oxycodone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  8. Morphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  9. Hydromorphone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  10. Fentanyl. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  11. FDA drug label. Food and Drug Administration; 2024-2025.
  12. Zhu W, Chernew ME, Sherry TB, Maestas N. Initial opioid prescriptions among US commercially insured patients, 2012-2017. N Engl J Med. 2019;380(11):1043-1052. doi:10.1056/NEJMsa1807069
  13. Propofol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  14. Ketamine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  15. Midazolam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  16. Succinylcholine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  17. Rocuronium. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  18. Buprenorphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  19. Methadone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  20. Spencer JP, Thomas S, Trondsen Pawlowski RH. Medication safety in breastfeeding. Am Fam Physician. 2022;106(6):638-644.
  21. Metronidazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  22. Doxycycline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  23. Trimethoprim-sulfamethoxazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  24. Labetalol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  25. Nifedipine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  26. Park K. Management of women with acquired cardiovascular disease from pre-conception through pregnancy and postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol. 2021.
  27. Hydrochlorothiazide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  28. Furosemide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  29. Sertraline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  30. Paroxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  31. Fluoxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  32. Citalopram. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  33. Bupropion. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  34. Doxepin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  35. Carbamazepine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  36. Valproic acid. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  37. Phenytoin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  38. Lamotrigine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  39. Levetiracetam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  40. Topiramate. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  41. Phenobarbital. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  42. Naseri M, Shahsavan M, Salahshour F, et al. Effective dose for radiological procedures in an emergency department: a cross-sectional study. Radiat Prot Dosimetry. 2020;189(1):63-68. doi:10.1093/rpd/ncaa013
  43. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media. American College of Radiology; 2025.
  44. Falster C, Hellfritzsch M, Gaist TA, et al. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol. 2023;10(11):e922-e935. doi:10.1016/S2352-3026(23)00181-3
  45. El-Sayed Y, Phillips Heine R, Wharton KR, eds. Guidelines for Diagnostic Imaging During Pregnancy and Lactation. American College of Obstetricians and Gynecologists; 2017.
  46. Leide-Svegborn S, Ahlgren L, Johansson L, Mattsson S. Excretion of radionuclides in human breast milk after nuclear medicine examinations: biokinetic and dosimetric data and recommendations on breastfeeding interruption. Eur J Nucl Med Mol Imaging. 2016;43(5):808-821. doi:10.1007/s00259-015-3286-0
By |2026-03-24T13:23:44-07:00Mar 26, 2026|Ob/Gyn, Radiology, Tox & Medications|
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SAEM Clinical Images Series: Bilateral Leg Swelling with a Uterine Twist

The patient is a 40-year-old female who presents to the Emergency Department with bilateral leg swelling. Her symptoms started six days prior and have progressively worsened. Her symptoms are associated with shortness of breath with no chest pain. The patient has taken an over-the-counter diuretic, which has helped with her symptoms. She also reports intermittent vaginal bleeding for the past two months, with a LMP that was two months prior. She is not currently on contraceptives, and does endorse unprotected intercourse over this time. The patient denies headache, blurry vision, nausea or vomiting, abdominal pain, urinary complaints, diarrhea or constipation. She has no other complaints at this time.

 

Vitals: BP 140/86; HR 97; R 14; T 99°F; O2 sat 99% on room air.

General: Well appearing, no acute distress.

Respiratory: Clear to auscultation.

Cardiovascular: Regular rate and rhythm, no murmur.

Abdomen: Soft, nondistended, nontender.

Extremities: Trace bilateral pitting edema. Normal range of motion, neurovascularly intact, equal pulses bilaterally.

Neurological: No focal neurological deficits.

Hgb: 9.6 (previously 13.3 two years prior)

Creatinine: Normal

BNP: 706 pg/mL

Serum ꞵ-HCG: 874,342 mIU/ml

This patient has a complete molar pregnancy.

Molar pregnancy is part of a spectrum of gestational trophoblastic tumors that include benign hydatidiform moles, locally invasive moles, and choriocarcinoma. Patients classically present with painless first or early second trimester vaginal bleeding with uterine size larger than expected gestational age and excessively high β-hcg levels. Some patients develop anemia, hyperemesis gravidarum, clinical hyperthyroidism, and signs of preeclampsia including hypertension, headaches, proteinuria and edema. Acute respiratory distress can occur due to embolization of trophoblastic tissue into the pulmonary vasculature, thyrotoxicosis, or simple fluid overload. Management involves removal of molar tissue through D&C or dilation and suction evacuation. Histopathologic examination of the products of conception is the gold standard for the diagnosis of a molar pregnancy. β-hcg levels are then monitored to ensure complete resolution and to detect any signs of persistent trophoblastic disease. In some cases, adjunct chemotherapy or even hysterectomy may be needed.

Take-Home Points

  • Molar pregnancy can be diagnosed with excessively high β-hcg levels and an ultrasound that shows a classic “snowstorm” or “bunches of grapes” finding.

  • Consider gestational trophoblastic disease in any patient with signs and symptoms of preeclampsia prior to 20 weeks gestation.

  • Cavaliere A, Ermito S, Dinatale A, Pedata R. Management of molar pregnancy. J Prenat Med. 2009 Jan;3(1):15-7. PMID: 22439034; PMCID: PMC3279094.
  • Soper, John T. MD. Gestational Trophoblastic Disease: Current Evaluation and Management. Obstetrics & Gynecology 137(2):p 355-370, February 2021. | DOI: 10.1097/AOG.0000000000004240

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-01-31T19:31:26-08:00Feb 6, 2026|Ob/Gyn, SAEM Clinical Images|
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SAEM Clinical Images Series: A Curious Case of Abdominal Pain

The patient is a 22-year-old G0P0 female who presents to the Emergency Department with two days of left lower quadrant abdominal pain. The patient rates her pain as 10/10 in intensity, sharp in character, and states the pain radiates to her lower back. She notes similar intermittent pain over the past few months, but the pain became persistent over the past two days and has worsened. She also reports decreased appetite with nausea and vomiting. Her pain is exacerbated by movement. She began her menstrual period three days before presentation and denies being sexually active. She was previously prescribed oral contraception for treatment of menorrhagia, but discontinued it five months ago. She denies any fever, chills, chest pain, shortness of breath, urinary frequency, dysuria, vaginal discharge, bleeding, or vaginal pain.

 

Vitals: BP 132/84; HR 89; R 17; T 98.6°F; O2 sat 100% on room air

General: Appears uncomfortable due to pain.

Cardiovascular: Normal rate, regular rhythm.

Abdominal: Soft, non-distended, LLQ tenderness to palpation without rebound or guarding, bowel sounds present.

Genitourinary: No active bleeding or discharge, no signs of infection. No masses palpated.

WBC: 4.8

Hgb: 13.2

BMP: Normal

LFT’s: Normal

Urinalysis: Normal

Urine pregnancy test: Negative

This patient has a mature cystic teratoma (Dermoid Cyst).

Mature cystic teratomas (MCTs), also known as dermoid cysts, are benign ovarian germ cell tumors. While MCTs can occur in women of any age, they are found primarily in patients of reproductive age, with a median age of mid-30s. Patients may present asymptomatically, or with symptoms including nausea/vomiting, abdominal pain, and vaginal bleeding. Pelvic ultrasound or abdominal CT are first-line imaging studies, as well as laboratory testing to include ruling out pregnancy. In this patient with a negative UA and urine pregnancy test, abdominal CT was obtained and showed a large pelvic mass containing bony structures. Intraoperatively, the patient was found to have a large left ovarian dermoid cyst with evidence of torsion. The cyst contained multiple teeth and brown hair, and the diagnosis was confirmed with surgical pathology. Ovarian torsion is a serious complication of MCT and occurs in 3% to 21% of cases. If concomitant ovarian torsion is suspected, emergent gynecologic consultation is warranted.

Take-Home Points

  • Dermoid cysts are benign ovarian germ cell tumors that may grow large, cause significant pain, and often contain teeth and hair.

  • Ovarian torsion is an emergent potential complication of dermoid cysts and may require emergent consultation and surgical intervention.

  • Cong L, Wang S, Yeung SY, et al. Mature Cystic Teratoma: An Integrated Review. Int J Mol Sci. 2023;24(7):6141. doi: 10.3390/ijms24076141. PMID: 37047114.
  • Ahmed A, Lotfollahzadeh S. Cystic Teratoma. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. PMID: 33231995.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-01-31T19:24:41-08:00Feb 2, 2026|Ob/Gyn, SAEM Clinical Images|
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SAEM Clinical Images Series: Alternative Block

A 10-year-old female with a history of constipation presented with intermittent lower abdominal pain with difficulty urinating. Pain was in the suprapubic area. The patient stated she last urinated the morning of presentation and typically urinates 1-2 times a day. She reported that it is sometimes hard to initiate urination and that she has pain at the conclusion of urination. She typically takes MiraLAX daily for constipation but ran out one week ago. She denied fever, chills, nausea or vomiting.

retention

Constitutional: Awake, alert and in no acute distress.

HEENT: PERRLA. Moist mucus membranes.

Cardiovascular: Regular rate and rhythm. No murmur.

Pulmonary: Breath sounds normal. No increased work of breathing.

Abdominal: Abdomen soft. There is tenderness in the suprapubic area. There is no guarding or rebound.

Neurologic: Awake and alert. At neurologic baseline. No focal deficits.

UA: Trace ketones, 100 protein.

Post void residual: 430 cc.

X-ray of the abdomen is normal without obstruction or a significant stool burden. Ultrasound demonstrates a distended fluid-filled vagina.

Imperforate hymen. The opening of the vagina is typically surrounded by a thin membrane with an opening in the center, called the hymen. In the case of an imperforate hymen, the membrane does not have an opening and therefore blocks the vaginal canal. Symptoms of imperforate hymen vary. It can present early in life if normal mucous builds up and causes a bulge of the membrane. Imperforate hymen may not be diagnosed until adolescence when menstruation begins. Symptoms at that time include amenorrhea, back pain, lower abdominal pain, or difficulty with urinating or stooling. In an adolescent with imperforate hymen, physical exam may demonstrate a vaginal bulge with a bluish discoloration, caused by the accumulation of blood in the vagina (hematocolpos). This patient had urinary retention secondary to imperforate hymen and accumulation of blood in the vaginal canal that compressed the urethra. A genitourinary exam was later performed and confirmed the diagnosis. Imperforate hymen is treated with a minor surgical procedure to remove the extra tissue.

Take-Home Points

  • Imperforate hymen occurs when the hymen covers the vaginal entire vaginal opening, therefore blocking it. It may present early in life or later during adolescence.

  • Consider imperforate hymen as a differential diagnosis for female patients who present with lower abdominal or back pain, amenorrhea, or difficulty with urinating or stooling.

  • Diagnosis and management of hymenal variants. ACOG. (2019, May 23). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/06/diagnosis-and-management-of-hymenal-variants

  • Hamouie A, Dietrich JE. Imperforate Hymen: Clinical Pearls and Implications of Management. Clin Obstet Gynecol. 2022 Dec 1;65(4):699-707. doi: 10.1097/GRF.0000000000000703. Epub 2022 Mar 11. PMID: 36260009.

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-02-26T14:55:11-08:00Feb 28, 2025|Ob/Gyn, Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: Unidentified Intrauterine Object

IUP

A 31-year-old female G3P2 presented to the emergency department with vaginal spotting for one week and worsening lower abdominal cramping. She tested positive on a home pregnancy test one day prior to presentation. On the day of presentation, she passed a small blood clot and bled through one pad. She had not yet seen an OB for this pregnancy. Her last menstrual period was one month and three days prior. The current pregnancy is undesired. She denied fevers, chills, urinary symptoms, lightheadedness, palpitations, shortness of breath, nausea, or vomiting.

 

gestational sac

Vitals: BP 95/55; HR 75; Temp 98.4°F; Resp 16; SpO2 100% on room air

Abdomen: Soft; tender to palpation in the suprapubic region, no guarding or rebound tenderness

GU: Scant blood in the vaginal canal, no clots or tissue; os closed, no adnexal tenderness, no cervical motion tenderness

bHCG: 36,966

Rh Factor: Positive

Hgb: 9.2

Ectopic pregnancy needs to be ruled out. This patient has vaginal bleeding, a positive pregnancy test, and abdominal pain. She has not established care with an OB provider and has not had a confirmed intrauterine pregnancy. Specific ultrasound findings for an ectopic pregnancy include a gestational sac with a yolk sac outside of the uterus. Findings suggestive of an ectopic pregnancy include complex adnexal masses, free fluid with debris (suggestive of rupture), and an empty gestational sac within an adnexal mass.

Yes, this is a viable intrauterine pregnancy (IUP). Confirmation can be done with transabdominal ultrasound but in very early pregnancy may require a transvaginal ultrasound. Findings needed to confirm an IUP include a gestational sac containing a yolk sac within a thickened myometrium. The hyperechoic structure seen on transabdominal and transvaginal ultrasounds for this patient is an intra-uterine device (IUD) that is in place. The risk of pregnancy with an IUD in place is <1%; according to a database of 18 million hospital deliveries, the reports of retained IUD at birth was 12 per 100,000 births. For pregnancies with an IUD in place, the rate of ectopic pregnancy is higher. There is also a higher risk of maternal infection, miscarriage, preterm premature rupture of membranes, preterm birth, and intrauterine fetal demise. For desired pregnancies, if the strings are visible, the IUD is removed as soon as possible and a single dose of azithromycin is given due to increased risk of infection during pregnancy. There is limited evidence to guide management for desired pregnancies when strings are not visible. One option is hysteroscopic removal, although this increases the risk of pregnancy loss. More than 50% of pregnancies with in situ IUDs were found to end in spontaneous abortion.

Take-Home Points

  • A definite IUP requires an intrauterine gestational sac with yolk sac and/or embryo (with or without cardiac activity).
  • Pregnancy with an IUD is extremely rare and increases the risk of ectopic pregnancy, maternal infection, miscarriage, PPROM, preterm birth, and fetal demise.
  • Management for desired pregnancies with IUDs in place when IUD strings are visible consists of early IUD removal with a single dose of prophylactic antibiotics.

  • ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011 Jul;118(1):184-196. doi: 10.1097/ AOG.0b013e318227f05e. PMID: 21691183.
  • Ganer H, Levy A, Ohel I, Sheiner E. Pregnancy outcome in women with an intrauterine contraceptive device. Am J Obstet Gynecol. 2009 Oct;201(4):381.e1-5. doi: 10.1016/j.ajog.2009.06.031. Epub 2009 Aug 29. PMID: 19716537.
  • Roline, C.E., Heegaard, W.G. & Anderson, K.S. Early pregnancy with an intrauterine device in place. Crit Ultrasound J 3, 91–92 (2011). https://doi.org/10.1007/s13089-011-0068-1

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Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-09-28T21:27:46-07:00Oct 4, 2024|Ob/Gyn, SAEM Clinical Images, Ultrasound|
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SAEM Clinical Images Series: One Month of Vaginal Bleeding

heterogenous uterus

A 28-year-old female G3P2002 presented to the emergency department for one month of vaginal bleeding. The patient was seen in the emergency department one month earlier for vaginal bleeding in the first trimester of pregnancy. Her estimated gestational age was six weeks by last menstrual period. At the time her beta-hCG was 7225 mlU/mL with no intrauterine pregnancy demonstrated on transvaginal ultrasound. Three days later, the patient had declining b-hCG and transvaginal ultrasound again with no intrauterine pregnancy. The patient was discharged home with a diagnosis of miscarriage. Since discharge, she endorsed an initial slowing of vaginal bleeding but over the last two weeks bleeding had become heavier and continuous; soaking up to eight pads a day. She endorsed worsening nausea and vomiting over the past two weeks. She has been sexually active since her last encounter. She denied abdominal pain, pelvic pain, cramping, dizziness, shortness of breath, or fevers.

 

Vitals: BP 136/70; Pulse 96; Temp 97.8°F; Resp 16; SpO2 100%

Constitutional: No distress

Cardiovascular: Normal rate, regular rhythm, normal heart sounds

Abdomen: Soft and non-tender; Gravid uterus approximately 10 weeks

Pelvic exam: Active vaginal bleeding of dark red blood originating from the cervical os. Cervical os is closed and otherwise normal in appearance. Multiple clots are seen in the vaginal canal and posterior fornix. Vaginal canal and external genitals are normal in appearance.

Beta-HCG: 91,401 mlU/mL

Hemoglobin: 12.8 g/dL

Our patient’s case is convoluted by reporting a miscarriage the month prior, with declining beta-HCG and transvaginal ultrasounds with no intrauterine pregnancy. While her symptoms never fully resolved she endorsed that her vaginal bleeding slowed and only started getting worse after resuming intercourse.

Her physical exam of a gravid uterus of approximately 10 weeks (despite reporting a miscarriage four weeks prior), persistent vaginal bleeding, and intractable nausea and vomiting are concerning for molar pregnancy [1]. Molar pregnancies typically present as abnormal uterine bleeding in the first or second trimester and are accompanied by symptoms of hyperemesis gravida secondary to the increase in beta-hCG [2]. The two main risk factors for gestational trophoblastic disease are the extremes of maternal age and prior molar pregnancy. However, there is an increased risk for molar pregnancy in patients with a history of prior spontaneous abortions and infertility [4]. Beta-hCG are typically greater than > 100,000 mlU/mL signifying excessive trophoblastic growth, however a value < 100,000 mlU/mL does not exclude the diagnosis of molar pregnancy as partial moles tend not to produce as much beta-HCG [3].

These images, taken by point of care ultrasound, show a heterogenic mass with mixed echogenicities within the uterine cavity consistent with gestational trophoblastic disease or molar pregnancy. Obstetrics and Gynecology was consulted for definitive management. The patient was taken to the operating room for dilation and curettage and was discharged the following day.

Take-Home Points

  • Physical exam findings of an enlarged uterus inconsistent with gestational age, vaginal bleeding, and intractable nausea and vomiting should clue you into a possible molar pregnancy.
  • Point-of-care ultrasound is an invaluable tool when assessing vaginal bleeding and will often help the clinician in the management or diagnostic pathway.
  • Beta-hCG < 100,000 mlU/mL does not rule out molar pregnancy. Obtain a good history, perform a thorough physical exam, and pick up your ultrasound probe.

  • Soper, John T. “Gestational Trophoblastic Disease.” Obstetrics & Gynecology, vol. 137, no. 2, 2021, pp. 355–370., https://doi.org/10.1097/aog.0000000000004240.
  • Cline, David, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill Education, 2020.
  • Berkowitz, Ross S., and Donald P. Goldstein. “Molar Pregnancy.” New England Journal of Medicine, vol. 360, no. 16, 2009, pp. 1639–1645., https://doi.org/10.1056/nejmcp0900696.
  • Acaia, Barbara, et al. “Increased Frequency of Complete Hydatidiform Mole in Women with Repeated Abortion.” Gynecologic Oncology, vol. 31, no. 2, 1988, pp. 310–314., https://doi.org/10.1016/s0090-8258(88)80009-x.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2024-02-11T20:06:03-08:00Feb 12, 2024|Ob/Gyn, SAEM Clinical Images|
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SAEM Clinical Images Series: Utility of Bedside Ultrasonography

fitz-hugh-curtis

A 24-year-old G1P0010 female with a PMHx of ovarian cyst (unknown laterality) and emergency contraceptive use 3 months prior presented with sudden onset abdominal pain (upper > lower) that awoke her from sleep four hours prior to presentation with associated nausea and mild lower back pain. The pain is 10/10, sharp, stabbing, and diffuse. Additionally, she reported trace white vaginal discharge at baseline. No acute increase. She had intermittent vaginal bleeding since contraception use over the past two months, which has now resolved. She denied fever, chills, vomiting, chest pain, shortness of breath, diarrhea, or constipation. No pertinent surgical history.

Constitutional: Uncomfortable. Appearing to be in acute pain.

Cardiovascular: Tachycardia. Regular rhythm and normal heart sounds.

Pulmonary: No respiratory distress. Breath sounds normal.

Abdominal: Diffusely tender abdomen with voluntary guarding, otherwise soft. Normoactive bowel sounds. Negative Murphy’s sign.

Pelvic: Scant white vaginal discharge and CMT. No vaginal bleeding, lacerations, or external lesions.

Neurologic: A&O x 3

WBC: 18.9 k/uL

Hgb: 10.5 g/dL

BMP, lipase, Alk phos/Bili/ALT/AST, PT/PTT, and lactate: Unremarkable

Serum HCG: Negative

Urinalysis (UA): Unremarkable

COVID: Negative

An ideal RUQ ultrasound visualizes the liver, Morrison’s pouch, superior and inferior poles of the right kidney, and diaphragm in the coronal plane. Here, we see a thickened hepatic capsule, septations, and trace ascites.

Fitz-Hugh-Curtis syndrome (FHCS) is characterized by perihepatitis in the setting of pelvic inflammatory disease (PID). It traditionally presents with right upper abdominal pain with associated nausea, vomiting, and fever in women of childbearing age. While overall considered a rare manifestation of PID, the true incidence of FHCS is poorly defined in the literature [1]. The pathophysiology of spread is also poorly understood. It is speculated that bacteria (N. gonorrhoeae, C. trachomatis) travel to the liver via blood, lymphatics or peritoneal fluid, causing perihepatitis [1]. Diagnosing FHCS poses a diagnostic challenge to clinicians. Traditionally, the diagnosis is made via laparoscopic exploration of the abdomen with visualization of the characteristic “violin-string” adhesions, with growing evidence also supporting the use of contrast-enhanced CT [1]. Limited evidence exists to support the use of ultrasonography in diagnosing FHCS. One case report published in 1993 used RUQ abdominal ultrasound to identify septations (violin-string adhesions) and ascites to ultimately diagnose FHCS, later confirmed by serologic and operative evidence [2]. Another case report from 2018 used ultrasonography to identify a thickened hepatic capsule in an 18-year-old female with RUQ pain, later confirming FHCS by CT without the need for laparotomy [3]. While more research is needed, identification of FHCS via bedside ultrasonography in the emergency setting followed by appropriate antibiotic therapy can be an effective approach to FHCS, ideally reserving laparoscopy only for lysis of adhesions in refractory cases.

Take-Home Points

  • RUQ abdominal ultrasound findings of a thickened hepatic capsule, ascites, and septations should raise suspicion for Fitz-Hugh-Curtis syndrome in the emergency setting.

  • Moon, Y.H., Kim, J.H., Jeong W.J., Park, S.Y. Ultrasonographic findings in Fitz-Hugh-Curtis syndrome: a thickened or three-layer hepatic capsule. Yeungnam Univ J Med 35(1), 127-129 (2018).
  • Theofanakis, C.P., Kyriakidis, A.V. Fitz-Hugh–Curtis syndrome. Gynecol Surg 8, 129–134 (2011). https://doi.org/10.1007/s10397-010-0642-8
  • van Dongen PW. Diagnosis of Fitz-Hugh-Curtis syndrome by ultrasound. Eur J Obstet Gynecol Reprod Biol. 1993 Jul;50(2):159-62. doi: 10.1016/0028-2243(93)90181-b. PMID: 8405645.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-11-24T21:18:09-08:00Nov 27, 2023|Gastrointestinal, Ob/Gyn, SAEM Clinical Images, Ultrasound|
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