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
