OB/GYN Emergencies Flashcards
% of patients with surgical or life-threatening illness:
10%
Complications of missed diagnosis of acute abdominal or pelvic pain esp in women:
A missed diagnosis can compromise future fertility, lead to chronic pain or even death
Most common US findings in ovarian torsion:
A. Intraovarian hemorrhage
B. Ovarian enlargement
C. Lack of blood flow through color Doppler imaging
D. Pelvic Free-fluid
Age for ovarian torsion
Most common in reproductive years, avg age mid-20s
Pregnancy and ovarian torsion:
Pregnancy predisposes to adnexal torsion (20% of torsion cases)
Issue with doppler flow with ovarian torsion dx:
~ 50% of surgically confirmed torsion cases will have had normal Doppler flow
Pathophysiology of Ovarian Torsion:
A twisting of the ovary on its vascular pedicle
Most cases due to an underlying ovarian pathology (60% of cases will ultimately reveal a mass–most common = teratoma)
Normal ovaries can undergo torsion, but much lower frequency
Some studies show torsion occurs more often on right side since sigmoid colon in LLQ helps prevent left ovary from twisting
Clinical Presentation of ovarian torsion:
Symptoms often varied and non-specific
“Classic” pain = described as sharp, intermittent, localized
Often associated with vomiting and fever
Physical exam may show tenderness and rebound in RLQ/LLQ associated with/without an adnexal mass
Good and bad dx tests for ovarian torsion:
perks of the different imaging techniques for ovarian torsion:
Lab studies help rule out differentials but not specific
Imaging by Ultrasound is diagnostic and favored over other modalities
US: fast, inexpensive, diagnostic
MRI: better resolution but costly, lengthy study, difficult to obtain
US findings for ov. torsion
Ovarian enlargement is the most commonly associated sonographic finding secondary to obstructed venous drainage
Suspicion of ovarian torsion should be high in the setting of clinical symptoms and ovarian enlargement, regardless of the presence or absence of an ovarian Doppler signal
What can lead to false interpretation of maintained flow in ov. torsion US?
Presence of dual ovarian blood flow
Treatment for ov. torsion:
Definitive surgical management = Salpingo-oophorectomy
Conservative surgical management =
- Gentle untwisting of the pedicle
- Possibly cystectomy
- Oophoropexy
It’s all surgical
A 21 yo female presents to the ED for a “recheck” of her B-HCG level. She was seen by your colleague 2 days ago for lower abdominal pain and vaginal spotting and found to be pregnant. Her B-HCG level at the time was 1350 mIU/mL but her US was not diagnostic. Her pain and bleeding have resolved, and her B-HCG today is 2400 mIU/mL. What is the best next step in management?
Obtain another US to evaluate uterus and adnexa
ß-HCG level needed to be considered as “intra-uterine preg”?
1500
Risk factors for ect preg:
prior ectopic pregnancies (strongest predictor)
hx of PID (most common, ~50% cases)
hx of surgery or instrumentation altering normal tubal or cervical function such as tubal ligation, IUD placement, D&C
Most common site for ectopic preg:
Isthmus of fallopian tube
Clinical presentation of ect preg:
Often asymptomatic, especially with early detection from improved US techniques
Signs and Symptoms are often unreliable and varied
Sign that means an ectopic likely ruptured and why?
Dizziness and syncope
- Causes hemorrhage
DDx for ectopic:
Any 1st trimester bleeding
Common non-GYN / abd complaints
Which type of abortion looks like an ectopic pregnancy:
Complete abortion
Next steps in female patient in child-bearing age presenting with lower abdominal pain +/- vaginal bleeding (dx steps for ect)?
Serum ß-hcg + Pelvic sonogram
Type and screen
Suspected ß-HCG levels for IUP visualized transvaginally? Transabdominally?
Transvaginal visualization of IUP: B-HCG > 1500 mIU/mL
Transabdominal visualization of IUP: B-HCG > 4000 mIU/mL
Management of ectopic preg?
When is each option indicated?
Surgical = Salpingectomy
- No longer Gold Standard for all ectopics
- Indicated if patient is unstable or ruptured
- Laparoscopic preferred over laparotomy
Medical = Methotrexate
- inhibits folic acid synthesis –> inhibits DNA synthesis
- Indications:
• Unruptured adnexal mass < 3.5 cm
• Hemodynamically stable
• Desire for future fertility
• Stable or rising ßhCG < 15,000 mIU/mL
Absolute and relative contraindications to medical tx of ectopic pregancies:
Absolute Contraindications • Breastfeeding • Immunodeficiency • Abnormal creatinine (>1.3 mg/dL), or liver enzymes (AST = twice the normal value) • Alcoholism or liver disease • Preexisting blood dyscrasias • Peptic ulcer disease • Active pulmonary disease • Known sensitivity to methotrexate
Relative Contraindications
• Gestational sac >3.5 cm
• Fetal cardiac activity
It is change of shift in your community hospital, and you notice a 22 y/o 36-week pregnant patient appears quite somnolent. She was signed out as “already treated and nothing to do, awaiting transfer for OB evaluation”. She is minimally responsive, has a decreased respiratory rate and marked decreased deep tendon reflexes.
What is the most likely dx?
What are the next best steps in management?
Pre-Eclampsia
Secure airway + administer IV Mg-SO4
Range of times pre-eclampsia can occur:
20w gestation to 2 weeks post-partum
Clinical criteria for dx of pre-eclampsia:
Blood pressure above 140/90 or an increase in SBP>20 or DBP>10 above baseline, AFTER 20 weeks of gestation, on 2 separate measurements, 6hrs apart
Clinical presentation of severe pre-eclampsia:
SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2 occasions at least 6 hours apart
Proteinuria of more than 5 g in a 24-hour collection with or without LE edema
SOB from pulmonary edema
Oliguria (< 400 mL in 24 h)
Persistent headaches
Epigastric pain and/or impaired liver function
Thrombocytopenia
Oligohydramnios, decreased fetal growth, or placental abruption
Management of patients with pre-eclampsia
Definitive Treatment: Delivery!
Magnesium sulfate used for seizure prophylaxis in severe cases
Anti-hypertensive medications: Hydralazine or labetalol
IV fluid maintenance - pts are intravascularly volume depleted
Signs and Sx of Magnesium toxicity:
How to avoid?
Antidote?
Signs/Sx: decrease or loss of deep tendon reflexes, respiratory depression, bradycardia
“Titrate to reflexes”
Calcium gluconate is antidote
Possible sequelae of pre-eclampsia:
Eclampsia: pre-eclampsia + seizure
HELLP syndrome: a severe variant of pre-eclampsia
- Hemolysis (LDH>600, often seen as schistocytes on smear)
- Elevates Liver enzymes (AST>70)
- Low Platelets (<100,000)
- Epigastric or RUQ abdominal pain
A 17 year old girl presents complaining of dysuria x3 days, she denies fever, abdominal pain, vomiting, and diarrhea. Abdominal exam is normal. Pelvic exam reveals a homogeneous white discharge and coats the vaginal walls. The wet mount features clue cells.
What is the most likely dx?
What is the best treatment?
Candidal vaginosis
Fluconazole 50mg PO once
Etiology / Patho of PID:
Acquired: Chlamydia trachomatis (most common), Neisseria gonorrhoeae
Overgrowth of other natural flora:
- Vaginal flora: Gardnerella vaginalis
- Anaerobes: Bacteroides spp, peptococcus
Ascending infection from cervical infection
Bypass natural barriers to infection
- Cervical mucous may be affected by hormones during ovulation / menstruation
- Monthly endometrial sloughing allows for opening of the cervix
Typical cause of bacterial vaginosis:
Gardnerella vaginalis overgrowth
CDC dx guidelines for PID:
Low abdominal pain without other cause + 1 or more minimum criteria:
- Uterine tenderness
- Adnexal tenderness (95.5% sensitivity)
- Cervical motion tenderness
Very rapid and typically diagnostic test for PID:
Wet-mounts
Management of PID:
Outpatient:
- Ceftriaxone 250mg IM once PLUS
- Doxycycline 100mg BID x14days
- With/Without Metronidazole 500mg BID x14days
Inpatient Admission criteria:
- Inability to tolerate PO
- Severe illness, fever, nausea and vomiting - - Pregnancy
- Failed outpatient therapy
- Tubo-ovarian abscess
DDx for PID:
Trichomoniasis
Bacterial Vaginosis
Candidal Vulvovaginitis
HSV, HPV
**and don’t forget to educate patient on HIV testing!
