OBGYN Flashcards
Young female complaining of “urinary tract infection”.
BP 120/63 mmHg; HR 71; RR 18; SaO2 100% RA; Temp 37°C (98.6°F).
Nurse triage note states: “Patient presents today with 3 weeks of dysuria, urinary frequency, and lower abdominal pain despite a full course of nitrofurantoin prescribed by a local urgent care clinic, followed by a full course of ciprofloxacin prescribed by her primary care provider.”
When you examine the patient, she claims mild improvement in her symptoms 2 days prior, but now has persistent dysuria again. Initial physical exam is positive only for mild suprapubic discomfort with palpation.
Urinalysis (-) pregnancy test, (+) small leukocyte esterase, and(-) nitrite.
You wonder whether to prescribe a third antibiotic and send a urine culture, or if there is something else you should be considering . . .
Initially treated inappropriately for UTI
Pelvic exam: mucopurulent discharge and friable cervical mucosa
Gc/Chl and trich NAAT swabs obtained
Repeat U/A, U-HCG, and urine culture obtained
Treated her empirically for gonorrhea/chlamydia
Referred her to GYN
3 days later she was +chlamydia, informed her of results, abstain from intercourse 2 weeks, inform partners
Follow up 2 weeks later showed resolution of symptoms
cervicitis and urethritis
-MC organisms:
-Gonorrhea
-Chlamydia
-Trichomoniasis
-History:
-Sometimes asymptomatic
-Discharge
-Dysuria
-Absence of lymphadenopathy and genital ulcers
-Female patients: dyspareunia, post-coital bleeding, or abnormal spotting
-Often co-infection! w/ gonorrhea and chlamydia
-Difficult to distinguish based off PE
-Use APTIMA swabs for NAAT -> can take 24-48hrs
-High sensitivity and specificity
-Endocervical swab
-Urethral swab
-Urine swab (first void)
-Oropharyngeal swab
-Rectal swab
-!!!!!!!!!if results are pending, and you are concerned, treat for both gonorrhea and chlamydia
gonococcal infection
->300,000 cases in the US annually
-Organism: NEISSERIA GONORRHEA
-Humans are the only reservoir
-Male pts will have copious discharge
-thick yellow discharge with no irritation around penile opening
-Female pts are more likely to be asymptomatic
-Present once the infection has ascended
-Can also cause:
-Pharyngitis
-Disseminated infection
-Septic arthritis
-Tenosynovitis
-Conjunctivitis
-Proctitis
chlamydia infection
-MC reported STI in the US
-High rates of asymptomatic infection
-Less discharge than gonorrhea
-More thin, clear and straw-colored than gonorrhea
-Untreated can also progress to upper tract infection:
-Women: PID
-Men: epididymitis, orchitis, prostatitis, proctitis
-chlamydia conjunctivitis
-chlamydial cervicitis
gonorrhea tx (need to know doses)
-CEFTRIAXONE 500mg IM once* (1g if >150kg)
-If allergy: Gentamicin 240mg IM x 1 dose + Azithromycin 2g PO x 1 dose
-Expedited partner therapy (EPT): Cefixime 800mg PO once
-if over 150 kgs -> double the dose
chlamydia tx
-DOXYCYCLINE 100 mg PO BID x 7 days* - treatment of choice
OR
-AZITHROMYCIN 1g PO once (pregnancy)
gonorrhea and chlamydia discharge instruction
-Educate! Non-judgemental approach!
-Minimize disease transmission:
-Abstain from sexual activity for 7 days after treatment AND
Abstain until all sex partners are tested and treated for 7 days
-Obtain additional STI testing
-Offer HIV PrEP initiation
-Test of cure:
-Unnecessary in uncomplicated urogenital or rectal GC/CHL
-Recommended 10-14 day test of cure for PHARYNGEAL!!!! gonorrhea
-Retesting recommended 3 months after tx
trichomonas vaginalis
-MC curable STI worldwide
-Most men are asymptomatic
-Vaginitis symptoms:
Pruritis, dysuria, frequency, dyspareunia
-Cervical exam:
Malodorous, greenish, frothy discharge
-“Strawberry cervix”
-Wet prep exam will show flagellated protozoa and WBCs
-Treatment:
-Metronidazole (Flagyl) PO
-Disulfram-like reaction warning
mycoplasma genialium
-Cause of non-gonococcal urethritis in men
-Cause of non-gonococcal cervicitis or PID in women
-!!!!Consider in patients with recurrent signs and symptoms of STI with negative testing (esp recurrent UTI in men)
-TX: Azithromycin 500mg PO x 1 dose + 250mg PO once daily x 4 days
A 23-year-old G2P1011 presents to the emergency department complaining of lower abdominal pain and vaginal discharge for the past week. She also noticed some spotting over the last 2 weeks. Her BP is 128/76, HR 86, RR 16, Temp 98.8F. The patient appears well and in no distress.
Pelvic inflammatory disease(PID)
An elusive diagnosis
Polymicrobial infection that ascends to the uterus, fallopian tubes and ovaries.
pelvic inflammatory ds
-ascending tract infection:
-endometritis
-salpingitis
-oophoritis
-myometritis
-causative organisms:
-polymicrobial!!!
-STI 22-50%
-anaerobes (BV)
-enteric organisms
-short term complications:
-TOA
-peritonitis
-pyosalpinx
-perihepatitis- Fitz-huge-Curtis- need to do laparoscopy- violin strings
-long term complications:
-infertility
-chronic pelvic pain
-dyspareunia
-ectopic pregnancy
PID hx and PE
-Sx range from mild to severe
-!!Midline lower abdominal pain (MC)
-!!Vaginal discharge, dysuria, dyspareunia
-Abnormal bleeding
-Fever, N/V, general malaise
-RFs to ask about:
-Prior STI, # of sexual partners, IUD, recent cervix instrumentation
-PE:
-!!Lower abdominal tenderness
-!!Cervical motion tenderness (CMT)- chandelier sign
-!!Adnexal tenderness
-If worse on one side, suggests TOA
-Purulent cervical os discharge
-Friable cervix
-RUQ tenderness - Suggests Fitz-Hugh-Curtis syndrome
PID dx
-Clinical diagnosis!
-Send the following routinely :
-!NAAT for gonorrhea and chlamydia
-Wet mount for BV/Candida/Trich
-Pregnancy test
-!Strongly consider HIV, syphilis tests
-US to assess for assoc TOA
-Can find ruptured ovarian cyst, ovarian torsion
-CT can also show TOA
-Can also evaluate for appendicitis
TOA on US
-Tuboovarian abscess is a walled-off abscess that originates in the infected fallopian tube and extends to involve the ovary.
-complications of PID
-appear ill, and will often have severe !!unilateral adnexal tenderness and fullness!! on bimanual pelvic exam
-fever
-Rupture can cause severe sepsis
-Ultrasound will show a complex, thick-walled, adnexal structure.
PID tx
-CDC recommends empiric PID tx in:
-SA young woman with
-lower abdominal/pelvic pain
and no other identifiable cause of illness other than PID
+ 1 or more of the following:
-1. cervical motion tenderness
-2. uterine tenderness
-3. adnexal tenderness
-Outpt care is often appropriate
-Remind pt to avoid sexual contact, to refer their partners for tx, and f/u in 72 hrs, unless sx worsen
-Admit if:
-Pregnant, prepubertal, person has an IUD
-TOA, Fitz-huge-Curtis ± operating room
-Intractable vomiting, sepsis, peritonitis
-MC tx:
-Ceftriaxone 500mg IM
+
-Doxycycline 100mg PO BID x 14 days
+
-Metronidazole 500mg BID x 14 days
-Alternatives:
-Cefotetan + Doxycycline
-Cefoxitin + Doxycycline
-Clindamycin + gentamicin
-Ampicillin-sulbactam + doxy
pelvic exam
-Provider collected and self-collected vaginal swabs both have high sensitivity and specificity for detecting STI
-Great for asymptomatic screening tests!
-Sx = speculum and bimanual examination
-Broad differentials for vaginal discharge, including PID, which you might miss!
sexual assault screening
-Tests and tx are similar to PID plus a few extra things
-Test for: HIV, syphilis, Hep B, Gonorrhea, Chlamydia, Trichomonas
-Sexual Offense Evidence Collection Kit (SOECK) -> Collects DNA evidence
-Drug Facilitated Sexual Assault (DFSA) kit -> Drug facilitated SA
-Forensic evidence can be given to police immediately, or, held in storage w/o investigation for up to 20 years in NYC
-Treatment:
-Ceftriaxone 500mg IM single dose
-Doxycycline 100mg PO BIG x 7 days
-Metronidazole 500mg PO BID x 7 days (not in males)
-Valacyclovir 1gm PO QID x 5 days (not typically done)
-Emergency contraception
-HIV PEP with Truvada (if <72 hour post exposure)
A 25 year-old female presents to the ED with a chief complaint of RLQ abdominal pain. She tells the triage nurse that she has had intermittent episodes of the pain but over the past 45 minutes the pain has become unbearable and excruciating. She complains of persistent nausea and multiple episodes of vomiting. She denies fever, vaginal bleeding, discharge, dysuria or change in bowel habits. She has no past medical history, is a social alcohol drinker, and does not use tobacco products.
On exam she is clearly in distress, clutching her right lower abdomen.
Vital signs reveal BP 145/90, HR 110, RR 21, Tmax 98.9 SpO2 99%RA.
She is slightly obese but is otherwise well-appearing. She is mildly tachycardic with intact distal pulses and has clear equal breath sounds.
Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly.
A pelvic exam demonstrates right adnexal fullness and significant pain on exam without bleeding or discharge.
ovarian torsion
-Point of Care urine pregnancy test and urinalysis were negative.
A bedside transabdominal ultrasound was obtained to evaluate for possible free abdominal/pelvic fluid. The bedside ultrasound was inconclusive.
A consultative transvaginal ultrasound was obtained which demonstrated a decreased Doppler flow to the right ovary.
Gynecology was emergently consulted who recommended proceeding to the OR for laparoscopy.
A large fluid filled cyst was located on the right ovary. The surrounding fallopian tube was dusky and ischemic appearing. The cyst was decompressed and the pedicle of the right ovary was detorsed causing return of blood flow. The patient was closed and taken to recovery where she had resolution of her symptoms.
ovarian torsion
-Ovary and fallopian tube twists upon its blood supply
-Initially venous and lymphatic obstruction, then arterial obstruction
-MC in reproductive age due to development of cysts
-MC in ovaries >5cm, ovarian tumors, or cysts
-Right > left
-Assoc w/ infertility tx
due to enlargement of ovary
-Inquire about hx of: Infertility tx, cysts, torsion, pregnancy
-Classic presentation
-Sudden onset
-Severe, stabbing, unilateral lower abdominal pain
-Assoc w/ N/V
± radiation to the groin
-Atypical presentations
-40% will report gradual pain or intermittent pain (intermittent torsing)
-Infants and children will present with feeding intolerance, distension, vomiting, irritability, and/or a palpable pelvic mass
ovarian torsion PE and dx
-Abdominal exam:
Lower abdominal tenderness
Peritoneal signs are concerning for ovarian necrosis
-Bimanual exam:
Unilateral adnexal tenderness
Palpable adnexal mass (rarely)
-Pregnancy test
-!!!US (transvaginal) -> modality of choice
-Enlarged ovary
-absent flow
-Cyst or mass
-CT scan
-Evaluate for other possible diagnosis
-Enlarged ovary or mass may be seen
-Normal appearing ovary is reassuring
-Laparoscopy is gold standard for definitive dx
-Low threshold for consultation with OBGYN
-Labs cant dx, but are more useful to point towards alternate dx
-!!!!!!!no single finding can definitively rule in or out -> If all tests are neg and still suspect -> call gynecologist to discuss taking pt to OR for laparoscopy
ovarian torsion diff dx
Other ovarian pathology
Ovarian cysts ± hemorrhage
TOA
Other gynecologic pathology
PID
Ectopic pregnancy*
Appendicitis
Diverticulitis
Kidney stone
UTI
transvaginal US for ovarian torsions
-modality of choice
-Asymmetric enlarged ovaries is MC finding
-Mass or cyst may be present
-Absence of blood flow is highly specific
-Doppler findings inconsistent
-60% with surgically proven torsion had blood flow on doppler
-Ovaries have dual blood supply (ovarian and uterine artery)
-Cut off from one supply leaves another showing +doppler flow
-Decreased venous flow occurs early
-Later stages can show free pelvic fluid indicating hemorrhag
-no color (blood flow) over the torsed ovary
ovarian torsion tx
-Pain control
-Antiemetics
-IVF rehydration
-NPO for OR
-STAT gyn consult
-Ovarian salvage time is 36 hours
vaginal bleeding
-LMP, frequency and amount of bleeding
-Contraception use
-If currently SA
-Sex and # of partners
-Dyspareunia
-Hx of STI and whether they were treated
-Previous pregnancies and delivery method
-Previous gynecologic procedures
-Bleeding more than 6 days in a row and/or changing a pad at least every 3 hours is associated with significant blood loss
-Look for S&S of:
-Hemodynamic compromise
-Symptoms of anemia
-Trauma, sexual abuse, infection, suspected bleeding diathesis, and foreign bodies are conditions that should be ruled out in the ED through a combination of history and exam
