ER - genitourinary Flashcards
Lower abdo pain in fertile aged female broad ddx (8)
Ectopic ovarian cyst and/or torsion UTI appendicitis PID tubo-ovarian abscess spontaneous abortion, early pregnancy
RF for ectopic?
Hint - what changes the anatomy?
previous tubal surgery (even tubal ligation) prior ectopic pregnancy intrauterine device use prior PID infertility treatments AMA smoking multiple sexual partners abdominal/pelvic surgeries
Emergency blood transfusion in a reproductive age female - what blood type?
O negative
If you could order only three blood tests for a woman who you suspect ectopic. what do you order?
CBC, type and screen, and β-hCG
What can you do right away to assess for ruptured ectopic?
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.
typical timeframe after menses that an ectopic becomes symptomatic?
6-8 weeks
bHCG is <100, can this result safely rule out ectopic?
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
Stable patients with EP may be managed medically with what drug?
Methotrexate, must have reliable follow up
- often requires second dose if bHCG not declining as predicted
Laparoscopy if fail medical management
Who do you consult for suspected ectopic pregnancy (EP)
ob/gyn
Important instructions for someone who is leaving the Emerg with possible ectopic? RTER if…
worsening pain vaginal bleeding dizziness syncope weakness
Bonus Question
At what bHCG levels can an intrauterine pregnancy IUP generally be detected at?
transabdominal?
transvaginal?
The discriminatory zone for ultrasound detection of an IUP is 6000-6500 mIU/mL transabdominally and 1000-2000 mIU/mL transvaginally.
Patient is Rh positive, do they require Rhogam?
No.
If Rh neg you worry they will become sensitized, give Rhogam to prevent exposure of Rh+ to prevent maternal production of Rh antibodies
PID originates as what?
cervical infection with Neisseria gonorrhea and/or Chlamydia trachomatis
RFs on history for PID?
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
Two most common physical exam findings for PID?
Two others?
bilateral adnexal tenderness and purulent cervical discharge
Cervical motion and lower abdominal tenderness may also be present
Unilateral adnexal tenderness or fullness may suggest what diagnosis?
tuboovarian abscess
Most important test to rule in PID?
urine or swabs for chlamydia and gonorrhea
Two good reasons to get a pelvic ultrasound in a lower abdo pain where you suspect PID?
- assess for tubo-ovarian abscess (TOA)
- 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).
For what reason (other than radiation) might you order an US instead of abdo CT?
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.
What if the chlamydia, gonorrhea test is negative? Can they still have a dx of PID?
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
Minimum clinical criteria for PID? (3)
- 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.
The complications of PID? (6)
chronic pelvic pain dyspareunia infertility ectopic pregnancy Tubo-ovarian abscess Fitz-Hugh-Curtis syndrome
Instructions/Advice for discharged PID patients? (4)
- avoid sexual contact until done treatment (at least 7 days)
- refer their partners for STI treatment and don’t have sex with them until they’re done their treatment
- further STD testing including HIV, hepatitis, and syphilis.
- follow up in 72 hours (assess for reassuring exam or indication for further work up), unless their symptoms worsen requiring earlier follow up
Which ovary is more likely to tort?
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.
