GU Flashcards
Risk factors for ectopic pregnancy?
Hx PID Hx ectopic pregnancy Tubal surgery including BTL Previous pelvic or abdominal surgery Tubal pathology In utero DES exposure IUD Smoking Infertility/infertility Rx
Classic presentation of ectopic pregnancy?
Abdominal pain, delayed menses, vaginal bleeding
Remember that paradoxic bradycardia can occur in ectopic pregnancy, so vital signs should not be reassuring.
Initial actions and primary survey in ectopic pregnancy?
ABCs Pregnancy test Monitor, 2 large bore IVs CBC, T&S, quantitative beta-hCG Narcotic analgesia Immediate bolus of NS if ill-appearing, severe pain, or abnormal vitals Consider O- transfusion if hypotension FAST exam if concern for rupture Bedside pelvic US
Call Ob-Gyn immediately if +FAST with +pregnancy test
Diagnostic work-up in stable patients with possible ectopic pregnancy?
TVUS to evaluate for the presence or absence of an IUP. If visualized, concurrent ectopic pregnancy is statistically unlikely unless the patient has received fertility treatments.
Beta-hCG
Signs of IUP on TVUS?
Earliest - double decidual sac sign (4.5-5 weeks after LMP) Yolk sac (5-6 weeks) Fetal pole and embryonic cardiac activity (6-7 weeks)
What has a 100% predictive value for IUP?
Yolk sac
Discuss interpretation of quantitative beta-hCG levels in early pregnancy.
Produced by trophoblasts, doubles Q48-72 hours in T1.
Discriminatory zone for when an IUP should be visible on TVUS: 1500-2000 mIU/mL
Ectopic is highly likely if level >1500 with absence of IUP on TVUS
If ectopic pregnancy is not ruled out in the ED, what can be done?
Outpatient OBG - serial US with serial serum quant beta-hCG levels. Rise in level slower than expected is highly suspicious.
Rx ectopic pregnancy?
If unstable - surgery
Fluid and blood resuscitation, pain management, OBG consultation
RhoGAM if Rh-negative
MTX (medical management) - can give 2 doses if 1st dose fails
Contraindications to MTX in ectopic pregnancy?
Hemodynamic instability, inability to follow-up, breastfeeding, immunodeficiency, renal/liver/pulmonary disease, PUD, blood dyscrasias
Initial actions and primary survey in patients with suspected PID?
Pelvic exam Pregnancy test (if pregnant, consider other causes of pelvic pain, as PID is less likely in pregnancy)
Classic presentation of PID?
Bilateral lower abdominal pain
Purulent vaginal discharge (vaginal bleeding less frequently)
Symptoms begin shortly after the start of the menstrual cycle when there are fewer defenses by the mucosal barrier to ascending infections
N/V, general malaise
Hx STDs, multiple sexual partners, IUD use, adolescence, sexual intercourse at an early age, recent instrumentation of the uterine cavity
Bilateral adnexal tenderness, purulent cervical discharge, cervical motion, uterine, lower abdominal tenderness
What physical exam finding suggests tubo-ovarian abscess?
Unilateral adnexal tenderness or fullness with PID symptoms
What physical exam finding suggests Fitz-Hugh-Curtis?
RUQ tenderness with PID symptoms
Dx testing for PID?
UA
CBC with diff
LFTs (if FHC is suspected)
PCR or DNA testing for CG (more sensitive than culture, can be run on cervical secretions or urine, more rapid)
Pelvic US if TOA is suspected or if diagnosis is unclear (r/o other diseases)
CT (not preferred, often ordered if appendicitis or other intraabdominal pathology is suspected)
Diagnose PID?
Negative pregnancy test + elevated WBC with fever, bilateral adnexal tenderness, and mucopurulent cervical discharge -> certain diagnosis
PCR positive for G/C in appropriate clinical setting
Who gets empiric Rx for PID?
All patients who meet minimum clinic criteria for PID (lower abdominal or pelvic pain + adnexal, uterine, or cervical motion tenderness in an at-risk patient with no other discernible cause)
Complications of PID?
Chronic pelvic pain, dyspareunia, infertility, ectopic pregnancy, TOA, FHC syndrome
Rx PID inpatient?
-Cefoxitin or Cefotetan 2g IV Q6hrs with Doxycycline 100 mg PO or IV Q12hrs
OR
-Clindamycin 900 mg IV Q8hrs with Gentamicin (if allergic to cephalosporins)
OR
-Unasyn 3g IV Q6hrs with doxycycline 100 mg PO or IV Q12 hrs
(Always give doxy PO when possible)
Rx PID outpatient?
Ceftriaxone 250 mg IM OR Cefoxitin 2g IM
and
Probenecid 1g PO
and
Doxycycline 100 mg BID for 14 days
Must add metronidazole 500 mg BID for 14 days if more severe infection or history of uterine instrumentation within 3 weeks
Indications for admission in PID?
Suspected TOA or FHC syndrome Intractable vomiting Septic patients Peritonitis Prepubertal children Women with indwelling IUD Pregnant patients
Strongly consider if nulliparous to preserve fertility, as well as women with comorbidities such as DM or HIV/AIDS
IUD removal after initiaiton of ABX
DC instructions for PID treated outpatient?
Avoid sexual contact
Refer partners for treatment
Follow-up in 72 hours unless symptoms worsen
STD testing
Initial actions and primary survey in suspected ovarian torsion?
Vitals and IV access
Focused H&P
US to assess for vascular flow
Consult gynecology early if torsion is suspected
DDx - ovarian torsion?
Ovarian cyst TOA Ectopic pregnancy Appendicitis Kidney stone
Pathophysiology of ovarian torsion?
Ovary (and often the fallopian tube) twist around the vascular pedicle -> obstructs venous flow -> engorgement and edema -> arterial flow compromise -> ischemia and infarction
Classic presentation of ovarian torsion?
Unilateral lower abdominal pain (initial visceral) +/- N/V, may radiate to groin or flank
May have several episodes over hours, days, or even weeks if intermittent torsion
Hx of prior cyst or mass, torsion, current pregnancy should increase suspicion
Lower abdominal tenderness
Adnexal tenderness or mass
Fever is uncommon, usually low-grade if present
Dx testing for ovarian torsion?
Pregnancy test
UA (UTI, nephrolithiasis)
CBC (TOA)
US with Doppler (presence of blood flow does not exclude diagnosis)
CT is non-specific, may be helpful in ruling out DDx
Most common US and CT finding in ovarian torsion?
Enlarged ovary
Rx ovarian torsion
ABCs
IV line, treat pain and nausea
NPO
Surgery (best outcomes within 8 hours)
Pathophysiology of testicular torsion?
Normally, the testicle is anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epidiymis.
Tunica vaginalis consists of a visceral and parietal layer with an interposed potential space which allows the testicle to rotate about the spermatic cord if a firm posterior scrotal attachment is lacking. When the tunica attaches higher up on the cord, the testicle can move and twist within the scrotum (bell-clapper deformity)
Appendix testes are also prone to torsion
Initial actions/primary survey in suspected testicular torsion?
VS, IV access Focused H&P IV pain control US Consult urology early if torsion is suspected
DDx - testicular torsion
Appendix testis torsion Epididymitis Orchitis Renal colic Varicocele Kidney stone Appendicitis Hernia Hydrocele Testicular trauma
Classic presentation of testicular torsion?
Most common in the first year of life and at puberty; can occur at any age
Fairly sudden severe unilateral testicular pain, sometimes radiating to the abdomen, associated with N/V
Urgency, frequency, dysuria
L>R
Possible trauma
Exam: distress, trouble walking, exquisite tenderness/swelling, high-riding in scrotum, may have transverse lie
Absence of cremasteric reflex
Dx testing for testicular torsion?
UA or urethral swab for GC if infectious epididymitis or orchitis is suspected
US with comparison of asymptomatic and symptomatic testes.
Compare the age of presentation of testicular torsion vs. appendage torsion vs. epididymitis.
Bimodal peak (infancy and puberty)
7-14 years
Adult
Compare the features of pain/associated symptoms of presentation of testicular torsion vs. appendage torsion vs. epididymitis.
Entire testicle, onset over hours; assc. with nausea
Upper pole of testicle, onset over hours to days; no assc. symptoms
Epididymis, onset over days; assc. with fever/dysuria
Compare the physical exam findings of testicular torsion vs. appendage torsion vs. epididymitis.
Cremasteric reflex absent, diffusely swollen tender testicle
Cremasteric reflex present
Cremasteric reflex present, epididymal tenderness +/- testicular tenderness
Compare the lab findings of testicular torsion vs. appendage torsion vs. epididymitis.
Not helpful
Not helpful
WBC, LE, nitrites
Compare the US findings of testicular torsion vs. appendage torsion vs. epididymitis.
Affected testicle large and hypoechoic compared to asymptomatic side, decreased flow
Body similar to asymptomatic side with focal hypoechoic area
Body similar to asymptomatic side with hypoechoic epididymis
Compare the Rx of testicular torsion vs. appendage torsion vs. epididymitis.
Surgical detorsion and bilateral orchiopexy
Supportive
ABX
If you anticipate any delay in getting a patient with testicular torsion to the OR, what should be done?
Attempt manual detorsion (rotate away from the midline)
