1.14.4 Female GU/OB Emergencies

Question 1

Your female patient presents with abdominal pain.

• Specific history you will gather
• Focus of physical exam

Answer 1

• Specific history you will gather
  
  • First day of last normal menstrual period
    
    • Regularity of period?
  • Sexual history
  • Prior pregnancies (GPTAL)
    
    • Gravida, Term, Preterm, Abortions, Live children
  • Hx STIs +/- treatment for STIs
  • Use of contraception; reliability of contraception
  • GYN conditions
    
    • Ovarian cysts, endometriosis, fibroids
  • Fertility tx?
• Focus of physical exam
  
  • Orthostatic VS - blood loss d/t ruptured ectopic preg?
  • Complete abd exam
  • Bimanual/speculum exam
    
    • Differentiate gyn vs. GI etiologies
    • Diagnosis of PID relies on exam
      
      • Cervicitis, cervical motion tenderness, purulent discharge from cervix
    • Assess source/severity of vaginal bleeding
      
      • Cervix? Vaginal laceration?
    • Assess cervical os in pregnancy and/or miscarriage

Question 2

Your female patient c/o abdominal pain.

• Gynecologic DDx
• Non-Gyn DDx
• Initial Labs
• Imaging Selection

Answer 2

• Gynecologic DDx
  
  • Ovarian torsion
  • Ovarian cyst
  • PID
  • Tubo-ovarian abscess
  • Fibroid disease
  • Dysmenorrhea/menhorrhagia
  • Malpositioned IUD
  • Endometriosis
• Non-Gyn DDx
  
  • Appendicitis
  • Nephrolithiasis
  • Hernia
  • Diverticulitis
  • SBO
  • Cystitis/UTI
  • Adhesions/functional abd pain
  • MSK pain
• Initial Labs
  
  • Urine or serum b-HCG
  • UA with Culture
  • Wet prep: yeast, bacterial vaginosis, trichomonas
  • Clamydia and Gonorrhea PCR
    
    • Urine vs endocervical/vaginal
    • Provider or patient can do swab
  • CBC, BMP
  • LFT, Lipase
• Imaging Selection
  
  • Overall, transvaginal and transabdominal US for suspected GYN/OB etiology
    
    • No radiation, cost effective
  • Overall, CT w/ or w/o contrast for Non-GYN etiology
    
    • With f/u US if CT suggests GYN etiology

Question 3

Your patient has pelvic pain. You’re concerned for ectopic pregnancy.

• Definition
• Epi
• Risk factors
• S/s
• Diagnostics
• Definitive diagnosis
• Treatment

Answer 3

• Definition
  
  • Extrauterine pregnancy
• Epi
  
  • 2% of all reported pregnancies
  • 18% of ED patients with 1st trimester bleeding and pain
  • 90% of ectopic preg’s are in fallopian tube
• Risk factors
  
  • Previous EP
  • Fallopian tube surgery
  • In vitro fertilization and embryo txf
  • Hx of PID - d/t scarring
  • Smoking
  • Age >35
  • IUD (low risk of preg, but if preg higher risk for EP)
• S/s
  
  • Abd or pelvic pain, cramping
  • Low back pain
  • Vaginal bleeding
  • Syncope/dizziness
  • Shoulder pain (if blood from rupture reaches diaphragm)
  • Asx if early
• Diagnosistics
  
  • Bedside US to rule out intrauterine pregnancy, extrauterine mass, free fluid
  • Quantitative HCG
  • Transvaginal US
  • ABO/Rh - if (+) and ectopic, give rhogam
  • CBC, CMP
• Diagnosis
  
  • Diagnostic = Gestational sac with yolk sac/embryo in adnexa, not in uterus
  • Suspicious = Hypoechoic adnexal mass, normal US with + HCG
• Treatment
  
  • Non-surgical
    
    • Criteria: hemodynamically stable, no rupture, fetus < 4cm, no cardiac activity, HCG < 3500
    • Methotrexate: single dose in hospital, then at home
    • OB f/u for serial HCG until 0
  • Surgical
    
    • HD unstable, rupture/free fluid, cardiac activity

Question 4

You’ve ruled out ectopic pregnancy and are concerned for ovarian torsion.

• Definition
• Epi
• Risk factors
• S/s
• Diagnostics
• Definitive Dx

Answer 4

• Definition
  
  • Twisting of ovary around ovarian ligament and fallopian tube, cutting off blood supply
• Epi
  
  • 2.7% of acute GYN complaints
• Risk factors
  
  • Younger age < 30 (70-75% of ovarian torsion), adolescents
  • 20% of cases are during pregnancy
  • Adnexal mass/ovarian cyst
  • Tubal ligation -> adhesions -> twisting
• S/s
  
  • Sudden onset unilateral pelvic pain (75%)
    
    • 25% is bilateral
  • Pain is sharp, stabbing, severe
  • N/V
  • Pain may resolve if torsion spontaneously resolves
  • Fever = LATE finding
  • Adnexal tenderness/maxx
• Diagnostics
  
  • Clinical suspicion
  • Pregnancy test - r/o EP
  • TV US with doppler
    
    • Decreased flow is 100% Se and 97% Sp
    • CT abd/pelvis vs MRI
• Definitive Dx
  
  • Made in OR
  • Emergent OB/GYN surgical consult

Question 5

You’ve ruled out ectopic pregnancy and ovarian torsion and are concerned for PID.

• Definition & complications
• Pathogens
• Incidence
• Risk factors
• S/s
• Diagnostic criteria
• Diagnostics

Answer 5

• Definition
  
  • Ascending infxn of female upper genital tract
  • Complications include tubo-ovarian abscess, peritonitis, Fitz-Hugh-Curtis syndrome (liver infxn)
• Pathogens
  
  • <50% STIs (clamid, gon)
  • Polymicrobial (Gardnerella vaginalis, H influenzae, Peptococcus, Bacteroides)
• Incidence
  
  • 4-5% of women age 18-44
• Risk factors
  
  • Reproductive age, younger age
  • IUD insertion
  • Multiple sex partners
  • Hx of pelvic infxn
  • Recent GYN procedure
• S/s
  
  • Pelvic pain
  • Abnormal bleeding, discharge
  • N/V, fever
• Diagnostic criteria (CDC)
  
  • Expanded: sexually active young woman with pelvic pain PLUS
    
    • cervical motion tenderness, uterine tenderness OR adnexal tenderness
  • More specific: adnexal tenderness, fever, and elevated ESR
    
    • Treat for PID in this case
• Diagnostics
  
  • CBC, ESR/CRP, vaginal cultures
  • Imaging to exclude other causes

Question 6

Your patient has heavy vaginal bleeding.

• Emergent stabilization
• Evaluation
• Treatment

Answer 6

• Emergent stabilization
  
  • IVF, uncrossed blood
  • Reverse coagulopathy
• Evaluation
  
  • Determine pregnancy status - is this a rupture EP?
  • Physical exam, speculum exam
    
    • Source ID, and volume estimate
  • Orthostatic VS
  • H/H, type and screen, CT/GC PCR
• Treatment
  
  • OB/GYN consult - medical vs surgical mgmt
  • Provera - progesterone oral contraceptive
  • Tranexamic acid - prevents breakdown of clots
  • Txfn?
    
    • HD stable, Hb< 7 = transfuse
    • Symptomatic, active bleed Hb< 8 = txf

Question 7

In general, what should you remember about managing the pregnant patient?

What are the do-not-miss OB emergencies?

Answer 7

• Mgmt of pregnant patient
  
  • Team approach - med, crit care, OB
  • Health of mother is priority
  • Viability = 24wk
  • Emergent OB consult
    
    • Preterm labor
    • Active labor
    • Fetal monitoring
    • Life-threatening condition to mother or baby
    • Need for med/surg mgmt
  • Consider risks/benefits of imaging and meds
  • Do not miss non-pregnancy DDx
  • High-risk, vulnerable population
    
    • Screen for IPV
• Emergencies
  
  • Preterm labor (24-38wk)
  • Eclampsia, pre-eclampsia
  • HELLP
  • DIC, DVT, PE
  • Post-partum cardiomyopathy
  • Placental abruption
  • Hyperemesis
  • Miscarriage with hemorrhage
  • Sepsis
    
    • Retained products
    • Septic abortion
    • Pyelonephritis
    • Endometritis