OB/GYN Emergencies Flashcards
1st thing to do with any female coming into the ER w/ vaginal bleeding
pregnant or not pregnant
-stable–> ectopic or not or unstable–>OR
Non-pregnant gyn problems
- Ovarian Torsion
- Tubo Ovarian Abscess
- PID
- Cervicitis
- Vaginitis
pregnant gyn problems
- Ectopic Pregnancy
- Threatened/Missed AB
3 Preeclampsia
4 Rh incompatability
5 Endometritis
6 Mastitis
7 Placenta Previa
8 Abruptio Placenta
9 Post Partum Hemorrhage
10 Hyperemesis Gravidarum
HPI for vaginal bleeding
Are you having pain? OPQRST?
- When did the bleeding start?
- Quantity/ how many pads per hour?
- Clots/ tissue/ bright red blood?
- Trauma?
PMH for vaginal bleeding
- LMP,
- G’s P’s Ab’s,
- any chance of pregnancy? Terminations or miscarriages?
- Last sexual encounter, protection?
- dyspareunia, h/o STD’s?
ddx for vaginal bleeding
- Appendicitis
- Ruptured Ectopic
- IBD
- Ovarian cyst or torsion
- PID
- Ureteral colic
- Molar pregnancy
- Normal IUP
- Threatened Ab
- UTI
- Etoh Abuse
- gallbladder
PE for vaginal pain
- vitals
- PEX: hirsute? Thyromegaly? Pale, diaphoretic or benign looking?
- Tachycardic or normal HR?
- Good abdominal exam, masses, inguinal nodes
- Pelvic exam with speculum, bimanual exam (adnexal tenderness), good examination of external genitalia and cervical os
describe the pelvic exam for vaginal bleeding
- Exam Set Up – cotton swabs, chux, speculum, wet prep, GC/Chlam
- Inspect perineum, vulva, urethra, and peri-anal region
- Cervix must be visualized to R/O polyps, ulcers, STD, mass
- May require use of swabs and/or suction to visualize structures
What labs should you get in someone who presents with vaginal bleeding
- Pregnancy test**
- Common tests: CBC, type and screen; chem-7 for renal function
- If pregnant: add quantitative BhCG (marker for how far along you are) and Rh
- If pregnant trauma: Kleihauer-Betke
- If concern for shock: 2 large bore IVs, fluids, Monitor, O2
Always assume ___ in any pregnant female with abdominal pain and or bleeding
an ectopic pregnancy
__% of ectopic pregnancies occur in the fallopian tube
95%
risk factors for ectopic pregnancy
- PID increases risk 6-7 fold- most common risk factor
- Previous ectopic
- IVF
- Tubal Ligation or surgery on the tube
- IUD
- Peri tubal Adhesions from other abdominal surgeries
- Induced Abortions
what is the classic triad for ectopic pregnancy
Vaginal Bleeding (80%) abdominal pain (90%) delayed menses (70%)
presentation for ectopic pregnancy
- History of amenorrhea between 4-12 weeks is common;15% report normal menses
- classic pain of rupture is LATERALIZED, sudden, sharp and severe. May c/o shoulder pain from diaphragm irritation
- Non rupture pain is due to tube distention
- Vaginal bleeding usually light
PE for ectopic pregnancy
- May present in shock if ruptured
- Peritonitis secondary to a hemoperitoneum
- Unruptured ectopic may have adnexal mass and tenderness on bimanual
- Pelvic exam findings may include: bluish cervix, enlarged uterus, blood in the vaginal vault, and cervical motion tenderness
- FHT usually not audible ( too early)
what is chadwick’s sign
bluish hue to cervix w/ pregnancy, from increased blood flow
*no clinical utility
Can hear FHTS using doppler US around __ weeks
12
describe the utility of a pregnancy test
Urine
95% sensitive/specific
+ 2 weeks after ovulation
May get false negative if dilute urine
Serum
+ 7-10 days after ovulation
describe the utility of beta quant “BhCG”
- In normal pregnancy, BhCG doubles approximately 48 hours
- Low HCG levels can suggest EP or “blighted ovum” (anembryonic pregnancy)
- High BhCG suggest GTD (molar pregnancy or choriocarcinoma), multiple pregnancy
- Always, miscalculation of dates may be considered
if BhCG is ____ IU/Ml, gestational sac should be visible on transvaginal US. (4.5-5 weeks)
-____ for a transabdominal US)
over 1500
over 6000
*if over 1500 and don’t see anything but + pregnancy test be worried about ectopic
If BhCG of ___ IU/MI, pregnancy may be too small to be seen on US and requires a repeat level in 48 hours
less than 1500
What is the utility of US w/ pregnancy
- US determines if an IUP is present
- may miss heterotopic pregnancy
A LIVING IUP may be definitively diagnosed when cardiac activity is seen in the uterine cavity (usually seen at ___ weeks)
6-7 weeks
how do you diagnose ectopic pregnancy
- definitive US (empty uterus AND extrauterine cardiac activity) OR
- direct visualization at laparoscopy
Caveat
A negative ultrasound does not rule out an EP just as a negative urine HCG does not rule out pregnancy
Moderate to large amount of free fluid can be suggestive of ___
EP
when is it important to recheck BhCG?
48-72 hrs
describe the management of ectopic preg.
- Consult OB/GYN
- Medical Treatment: Methotrexate (early)
- Indications: no fetal cardiac activity, BhCG less than 5000, less than 3-4 cm sized EP, and hemodynamically stable
- Abdominal pain 3-7 s/p injection is common
- Usually dosed IM; some need second dose - Surgical Management:
- Laparoscopy or laparotomy, +/-salpingectomy, particularly if later in pregnancy or unstable
Evaluation/Management of threatened miscarriage
- Patients can be discharged home with close follow-up
- Recheck Quantitative BhCG in 2-3 days if no confirmatory Ultrasound
- Pelvic rest (no sex)
- Return for increased bleeding, fever, pain, lightheadedness
*Return precautions- if saturating more than 1 pad per hour for 4-6 hours
describe Rh prophylaxis
-Administer RhoGAM to the gravid patient who is Rh (-) and is vaginally bleeding
Exception: when father is known Rh–
*When in doubt treat
1st trimester emergencies
- Ectopic Pregnancy
- Threatened or spontaneous Miscarriage
- Hyperemesis Gravidarum
- GTD – Gestational Trophoblastic Disease
neoplastic disease – can be noninvasive/ hydatidoform mole or choriocarcinoma/ invasive. Have abnormally large uterus and high BhCG
GTD – Gestational Trophoblastic Disease
with spontaneous miscarriages, bleeding occurs in __% of pregnancies, __% go on to a miscarriage
20%
50%
__% of spontaneous miscarriages occur prior to 12 weeks.
80%
*Cardiac activity on US reduces the chances of miscarriage to 5%
spontaneous miscarriages Usually due to
chromosomal abnormalities – nothing the patient did, or can do!
what are types of spontaneous miscarriages
Threatened - vaginal bleeding with a closed cervical os and benign PEX
Inevitable- vaginal bleeding with cervical dilation; cervical os is open
Incomplete- passage of only parts of products of conception (POC), usually occurs at 6-14 weeks; cervical os is open
Complete- passage of all POC and fetal tissue prior to 20 weeks. Os is closed.
Septic- evidence of infection during any stage of Abortion induced or spontaneous
describe the exam for a spontaneous miscarriage
- Consider use of yankower suction if significant bleeding. You must visualize the cervix
- Material protruding from the os should be removed carefully as it may represent a cervical ectopic pregnancy
**All POC, clot or other unidentifiable material should be sent for pathology
what dx tests do you get with spontaneous evaluation
US is used to R/O ectopic pregnancy, as a prognostic tool for fetal viability, and to diagnose retained POC
what dx tests do you get with spontaneous evaluation
US is used to R/O ectopic pregnancy, as a prognostic tool for fetal viability, and to diagnose retained POC
what type of miscarriage?
vaginal bleeding with a closed cervical os and benign PEX
threatened
what type of miscarriage?
vaginal bleeding with cervical dilation; cervical os is open
inevitable
what type of miscarriage?
passage of only parts of products of conception (POC), usually occurs at 6-14 weeks; cervical os is open
incomplete
what type of miscarriage?
passage of all POC and fetal tissue prior to 20 weeks. Os is closed
complete
what type of miscarriage?
evidence of infection during any stage of Abortion induced or spontaneous.
septic
A true gestation sac is surrounded by
two layers of tissue, forming the “double decidual” sign - an inner and outer layer
Yolk sac seen at about __ weeks; fetal pole is seen at about __ weeks; cardiac activity should be seen at about __ weeks
5
5-6
7
treatment of spontaneous miscarriages
- Monitor vital signs, may require fluid resuscitation
- Rhogam IM if Rh negative
- Oxytocin IV for inevitable Ab with massive bleeding
- Consult GYN for possible D and C or discharge home if less than 8 weeks to complete miscarriage
managment of septic miscarriage
- OB consult for urgent D and C
- blood and cervical cultures and gram stains
- Broad spectrum antibiotics: ie, Unasyn or Clindamycin PLUS gentamycin
when does Hyperemesis Gravidarum common happen
Primarily first trimester; usually starts by 5-6 weeks
evaluation/work up of Hyperemesis Gravidarum
- Good history; r/o other pathology
Evaluation:
- Vital signs – hypotension? tachycardia?
- CBC/BMP (to evaluate severity)
- FHTs (doppler or US)
- Urine (protein, infection, ketones)
treatment of Hyperemesis Gravidarum
- IV Fluids – 1-2 liters
Meds
- Antiemetics: Reglan, Phenergan; Zofran?
- Antihistamines: Benadryl
- Usually can disposition home after fluid hydration and PO challenge
- May recommend Unisom or Pyridoxine
**Zofran no longer indicated in first trimester; increased risk of heart defects
Second/Third Trimester Emergencies
- Placenta abruption
- Placenta previa
- Uterine rupture
- Preterm Labor
- Preeclampsia
describe the presentation of abruptio placenta
- Painful Dark Red Vaginal bleeding
- Abdominal pain (67%)
- Back pain
- Uterine tenderness/ irritability (33%)
- Uterus is FIRM - Fetal distress
- Hypotension
- DIC
what is abruptio placenta
- (Painful) Premature separation of placenta from the uterine wall
- Accounts for 30% of bleeding in the second half of pregnancy
- May be complete, partial or concealed
- Concealed abruption may not have vaginal bleeding
risk factors for abruptio placenta
- Trauma
Spontaneous
- Hypertension- most common risk factor
- Advanced maternal age
- Multiparity
- Smoking
- Cocaine use
- Previous abruptions
what is the evaluation and tx of abruptio placenta
- CBC, renal functions, coagulation profile, T&S for possible tranfusion
- Aggressive fluid resuscitation and or blood products – two large bore IVs
- Emergent OB consult
- US for diagnosis
- possible emergency delivery
what is placenta previa
- Implantation of the placenta over the lower segment of the uterus within the zone of effacement and dilatation of the cervix (4.8/1,000 pregnancies)
- Accounts for 20% of bleeding in the second half of pregnancy
risk factors for previa
- Smoking
- Advanced maternal age
- Increased parity
- Previous C-section
- Minority race
- Increased altitude
- Previous termination of pregnancy
Presentation of previa
- Painless bright red vaginal bleeding
- Recurrent episodes, increasing in severity
- Frequently diagnosed early in pregnancy, followed by US; often resolves
- Uterus –soft, nontender, relaxed
describe the evaluation and tx of previa
- NO SPECULUM OR DIGITAL EXAM until you have done a U/S as it may disrupt the placenta causing catastrophic bleeding
- Evaluate by US; 95-97% sensitive
- Emergent OB/GYN consult; C section if unstable
what is the number 1 risk factor for uterine rutputure
previous C section
some signs of impending rupture (although not reliable)
- Sudden onset abdominal pain
- Gross hematuria
- Uterine irritability
- Vaginal bleeding little to massive
what is the treatment for uterine rupture
- Maternal resuscitation – 2 large bore IVs, fluids, transfer to OR
- Emergent OB consult
- Surgery-hysterectomy
complications of uterine rupture
- shock,
- infection,
- DIC
*Maternal mortality 10-30%
what is the presentation of PROM
Clinically, a sudden rush of clear of pale yellow fluid from the vagina
-May be continuous leakage
how do you diagnose PROM
- Direct observation of amniotic fluid leaking or pooling in posterior fornix
- Sterile speculum exam
amniotic fluid has a ph over7.0 (dark blue) on nitrazine paper - FERNING** on smear
After ___, pelvis no longer shields the uterus
12 weeks
After ___, uterus is at the level of the umbilicus
-More blood flow, so maternal hemorrhage more likely
20 weeks
___, bladder is displaced cephalad by enlarging uterus, more likely to be injured
3rd trimester
injuries to pregnant trauma patient
- Placental Abruption
- Uterine rupture
- Maternal fetal hemorrhage
- Preterm labor (less than 37 weeks)
evaluatio nof the pregnant trauma patient
- Keep the patient in left lateral decubitus** position
- OB and Trauma consult
- Two large bore IV’s , supplemental O2
- Rhogam
- Fetal Heart Tones
Uterus compresses __ when supine, causing supine hypotension
IVC
describe the Kleihauer-Betke Assay test
- A blood test performed on maternal blood to quantify fetal maternal blood mixing, if abdominal trauma
- Should be performed on all Rh negative women followed by Rhogam
- But, if you suspect abdominal trauma, just give 300mcg Rhogam
treatment goals for a pregnant trauma patient
- Pelvic exam:
- Looks for trauma, VB, rupture of membranes
- do not perform if blood is present on external inspection - FHT’s and minimum 4-6 hours of fetal monitoring on labor deck
- If high acuity, patient is being transferred or trauma taking over
describe a perimortem C section
- Perform WITHIN 5 minutes of maternal cardiac arrest
- Continue ongoing maternal resuscitation
- Viable gestational age approx 24 weeks (+) FHT
causes of post partum hemorrhage
Uterine atony (90%) uterine rupture uterine inversion retained placenta Coagulopathy Endometritis
evaluation of post partum hemorrhage
- Depends on cause
- Uterus feels boggy on abdominal exam
- Bimanual fundal massage of uterus (manual contraction)
- Nursing to stimulate the nipples
- CBC, type and cross, coagulation studies
- Ultrasound to ID retained material
tx of post partum hemorrhage
- IV fluids, blood products, O2
- Remove placenta, suture lacerations
- Bimanual compression
- Oxytocin for uterine contraction
- OB consult
presentation of mastitis
- Can present with fever,
- tachycardia,
- myalgias
*most commonly caused by breastfeeding
evaluation and tx of mastitis
- May need Ultrasound to r/o abscess–> requires surgery
Tx: Keflex or Diclox, pain meds, and cont. breastfeeding
what is HELLP
Hemolysis; Elevated Liver Enzymes; Low Platelets
*associated w/ Hypertension, proteinuria
usually 3rd trimester (28-36 weeks)
tx of HELLP
Mag Sulfate to prevent seizures; emergency delivery
The Non-Pregnant Vaginal Bleeder Differential Diagnosis premenopausal
- PID
- cervicitis
- cervical polyps
- fibroids
- endometrial or Cervical CA
- coagulopathy
- DUB
- local trauma/assault
- foreign body
- endometriosis
*usually infectious
The Non-Pregnant Vaginal Bleeder Differential Diagnosis post- menopausal
- Exogenous estrogens
- Atrophic vaginitis
- Endometrial CA (15%)
- Fibroids
Diagnosis and treatment of Non-Pregnant Vaginal Bleede
- Need to rule out Emergency Diagnoses (infection, bleeding diathesis, sexual assault)
- US only if it makes a difference today
- Treatment guided by GYN may include hormonal treatment
- No hormones in suspected malignancies
how do you dx and tx dysfunctional uterine bleeding (DUB)
- diagnosis of exclusion.
- Treat with Provera, 10mg daily for 10D. (help w/ bleeding)
- Or may initiate OCP to regulate cycle or as a pulse and then taper
ddx of ER Non Pregnant Pelvic Pain
- Pelvic Inflammatory Disease/Tubo-Ovarian Abscess
- Ovarian Torsion
- Ruptured Ovarian Cyst
- Vaginitis
1 Gynecological complaint to the ED
PID
__% of untreated cervicitis leads to PID
20%
risk factors for PID
- multiple partners
- HIV/ other STDs
- IUD use
- Frequent douching
- Young age
what organisms commonly cause PID
- Primary causes are Neisseria gonorrhea and
- chlamydia trachomatis;
- up to 40% polymicrobial
PID can lead to
Tubo-Ovarian Abscess or Peritonitis (Fitz Hugh Curtis Syndrome)
what is Fitz Hugh Curtis Syndrome? (FHC)
perihepatic inflammation leads to adhesions; severe RUQ pain with PID
how do you dx PID
*clinical dx
1. Lower pelvic pain plus Cervical, adnexal or uterine tenderness 2. Additional findings to support your dx: 3. Fever 4. Abnormal discharge 5. WBCs on wet prep 6. Lab confirmed chlamydia or gonorrhea
evaluation of PID
- Line, labs, pain meds; preg test!
- Pelvic exam, with Wet Prep and Cultures
- Ultrasound to look for TOA (secondary abscess)
tx of PID
- Ceftriaxone 250 mg IM plus
- Doxycycline 100mg po BID 14d, +/-
- Flagyl 500mg po BID 14d
sx of vulvovaginitis (BV)
- Asymptomatic often
- Occasionally vaginal irritation, excoriation
- Thin, gray/white discharge; fishy odor*
dx and tx of BV
clue cells on wet prep
tx: Flagyl
sx of vulvovaginitis (candida)
- ‘cottage cheese’ discharge,
- itchy,
- dyspareunia,
- dysuria
how do you dx and tx vulvovaginitis (candida)
Dx: yeast, hyphae, on wet prep
Treat with Diflucan 150 mg po
sx of vulvovaginitis- Trichomoniasis
- 50% asymptomatic
- Pelvic pain,
- spotting,
- dysuria;
- frothy malodorous discharge
*assciated w/ other STDs
dx and tx of vulvovaginitis- Trichomoniasis
Dx: motile flagellated organisms on wet prep
Treat with Flagyl
how do you dx and tx ovarian torsion
- Diagnosis is with an Ultrasound to evaluate for blood flow
- May be nondiagnostic – treat the clinical picture
tx: surgery/OB consult
sx of ovarian torsion
- Sudden onset, colicky unilateral pelvic pain (90%)
- Nausea and Vomiting (50-70%)
- Adnexal Mass (90%)
- Usually 4-6 cm in size to torse
*often in someone w/ hx of ovarian cysts
___ is preferred over ___ in hemodynamically stable patients for ruptured EP
Laparoscopy
laparotomy
*Laparoscopy has less bleeding, adhesion formation, narcotic requirements, and a shorter hospital stay
__ procedure for patients desiring no further pregnancies
Salpingectomy
