ER - genitourinary

Question 1

Lower abdo pain in fertile aged female
broad ddx (8)

Answer 1

Ectopic
ovarian cyst and/or torsion
UTI
appendicitis
PID
tubo-ovarian abscess
spontaneous abortion, early pregnancy

Question 2

RF for ectopic?

Hint - what changes the anatomy?

Answer 2

previous tubal surgery (even tubal ligation)
prior ectopic pregnancy
intrauterine device use
prior PID
infertility treatments
AMA
smoking
multiple sexual partners
abdominal/pelvic surgeries

Question 3

Emergency blood transfusion in a reproductive age female - what blood type?

Answer 3

O negative

Question 4

If you could order only three blood tests for a woman who you suspect ectopic. what do you order?

Answer 4

CBC, type and screen, and β-hCG

Question 5

What can you do right away to assess for ruptured ectopic?

Answer 5

bedside FAST scan

The combination of a FAST positive for free fluid and positive pregnancy test should be treated as a ruptured ectopic pregnancy until proven otherwise.

Question 6

typical timeframe after menses that an ectopic becomes symptomatic?

Answer 6

6-8 weeks

Question 7

bHCG is <100, can this result safely rule out ectopic?

Answer 7

No.
EP (even ruptured ones) may occur in patients with β-hCG < 100 mIU/mL.
The decision to ultrasound a pregnant patient with abdominal pain and/or vaginal bleeding should not be based on the β-hCG level as it cannot be used to predict the presence of an EP or an IUP

Question 8

Stable patients with EP may be managed medically with what drug?

Answer 8

Methotrexate, must have reliable follow up
- often requires second dose if bHCG not declining as predicted

Laparoscopy if fail medical management

Question 9

Who do you consult for suspected ectopic pregnancy (EP)

Answer 9

ob/gyn

Question 10

Important instructions for someone who is leaving the Emerg with possible ectopic? RTER if…

Answer 10

worsening pain 
vaginal bleeding 
dizziness 
syncope
weakness

Question 11

Bonus Question

At what bHCG levels can an intrauterine pregnancy IUP generally be detected at?
transabdominal?
transvaginal?

Answer 11

The discriminatory zone for ultrasound detection of an IUP is 6000-6500 mIU/mL transabdominally and 1000-2000 mIU/mL transvaginally.

Question 12

Patient is Rh positive, do they require Rhogam?

Answer 12

No.
If Rh neg you worry they will become sensitized, give Rhogam to prevent exposure of Rh+ to prevent maternal production of Rh antibodies

Question 13

PID originates as what?

Answer 13

cervical infection with Neisseria gonorrhea and/or Chlamydia trachomatis

Question 14

RFs on history for PID?

Answer 14

sexually transmitted diseases (STDs)
multiple sexual partners
intrauterine device (IUD)
adolescence (75% of PID cases occur between the ages of 15-25), sexual intercourse at an early age
recent instrumentation of the uterine cavity

Question 15

Two most common physical exam findings for PID?

Two others?

Answer 15

bilateral adnexal tenderness and purulent cervical discharge

Cervical motion and lower abdominal tenderness may also be present

Question 16

Unilateral adnexal tenderness or fullness may suggest what diagnosis?

Answer 16

tuboovarian abscess

Question 17

Most important test to rule in PID?

Answer 17

urine or swabs for chlamydia and gonorrhea

Question 18

Two good reasons to get a pelvic ultrasound in a lower abdo pain where you suspect PID?

Answer 18

1. assess for tubo-ovarian abscess (TOA)
2. rule out other diseases that may present with pelvic pain such as:
   - ruptured ovarian cyst (free fluid in the pouch of Douglas)
   - ovarian torsion (absence of blood flow to one ovary on pelvic ultrasound with doppler).

Question 19

For what reason (other than radiation) might you order an US instead of abdo CT?

Answer 19

CT does not evaluate ovarian blood flow and therefore cannot rule out ovarian torsion.

But CT is frequently ordered in patients to evaluate for appendicitis or other suspected etiology and the scan reveals tuboovarian abscess instead.

Question 20

What if the chlamydia, gonorrhea test is negative? Can they still have a dx of PID?

Answer 20

Up to one-third of women with PID do not have Neisseria or Chlamydia isolated.

PID is a polymicrobial infection despite being most commonly associated with Chlamydia and gonorrhea

Question 21

Minimum clinical criteria for PID? (3)

Answer 21

• history of lower abdominal or pelvic pain
• adnexal, uterine or cervical motion tenderness on exam
• in a patient at risk for STDs with no other discernible cause identified

Because of the potential complications of untreated PID and the prevalence of infection, the Center for Disease Control (CDC) has recommended initiating empiric therapy for all patients who meet minimal clinical criteria for PID.

Question 22

The complications of PID? (6)

Answer 22

chronic pelvic pain
dyspareunia
infertility
ectopic pregnancy
Tubo-ovarian abscess
Fitz-Hugh-Curtis syndrome

Question 23

Instructions/Advice for discharged PID patients? (4)

Answer 23

1. avoid sexual contact until done treatment (at least 7 days)
2. refer their partners for STI treatment and don’t have sex with them until they’re done their treatment
3. further STD testing including HIV, hepatitis, and syphilis.
4. follow up in 72 hours (assess for reassuring exam or indication for further work up), unless their symptoms worsen requiring earlier follow up

Question 24

Which ovary is more likely to tort?

Answer 24

It is more commonly seen in the right ovary due to an increased length of the utero-ovarian ligament on the right and the presence of the sigmoid colon on the left.

Question 25

Biggest RF for ovarian torsion?

Answer 25

ovarian enlargement, typically caused by an ovarian cyst or mass

In reproductive age females the increase in ovarian size is most commonly due to follicular cysts or corpus luteum cysts.

other

• polycystic ovarian syndrome
• people undergoing fertility treatment (ovarian hyperstimulation syndrome.)
• Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum.

Question 26

Classic presentation of ovarian torsion

Answer 26

sudden onset
unilateral 
stabbing
lower abdominal pain 
commonly accompanied by nausea and vomiting. 

Other considerations

• pain may radiate to the groin
• 40% of patients will report gradual pain
• may describe back or flank pain
• intermittent pain episodes over hours, days, or even weeks, if the ovary has been torsing intermittently.

Question 27

How to definitively diagnose ovarian torsion?

Answer 27

OR diagnosis

Absence of vascular flow on US is specific but not sensitive

There is no single finding that can definitively “rule in” or “rule out” ovarian torsion. If all your tests are negative, but you still suspect it, call your gynecologist to discuss taking the patient to the OR for laparoscopy.

Question 28

What presentation/diagnosis should make you also think of ovarian torsion?
eg “stabbing unilateral abdo pain radiating to the groin”

Answer 28

nephrolithiasis