Emergency Medicine - Vagina Problems

Question 1

What are the four steps to working up gynecologic complaints?

Answer 1

1. Is she pregnant - Serum/Urine HcG?
2. UA - Nitrites/Leuko/Blood?
3. Pelvic Exam - Discharge/Blood?
4. Ultrasound (not always necessary, but great for issues with uterus/ovaries)

Question 2

Most common pelvic infection?

Answer 2

Chlamydia trachomatis

Question 3

Easiest test for Pelvic Infection?

Answer 3

Wet Mount

Question 4

Source of PID?

Answer 4

Ascending infection from cervical infection

Question 5

CDC Guidelines for PID diagnosis?

Answer 5

Low abdominal pain without any other cause plus…
Uterine tenderness… OR
Adnexal tenderness (95.5% sensitivity)… OR
Cervical motion tenderness!

Question 6

Outpatient treatment for PID?

Answer 6

Ceftriaxone 250mg IM once PLUS!
Doxycycline 100mg BID x14days!
With/Without Metronidazole 500mg BID x14days!

Question 7

Concerning PID finding that would lead to hospital admission (5)?

Answer 7

Tubo-ovarian abscess.
Inability to tolerate PO.
Severe illness. Pregnancy.
Failed outpatient therapy.

Question 8

A 25 year old female patient presents with sharp, intermittent, localized in the lower abdomen, along with vomiting and fever? Is an adnexal mass always noted on exam?

Answer 8

Ovarian Torsion. No.

Question 9

Most common mass found in ovarian torsion?

Answer 9

Teratoma (60% of the time).

Question 10

What side does ovarian torsion more often occur on?

Answer 10

Right side.

Question 11

Does pregnancy increase or decrease the likelihood of developing enlarged ovaries that can produce torsion?

Answer 11

Increase.

Question 12

Best diagnostic test for ovarian torsion? Importance of doppler signal?

Answer 12

Ultrasound. ~ 50% of surgically confirmed torsion cases will have had normal Doppler flow.

Question 13

Most common diagnostic finding on ultrasound for ovarian torsion? Second most common finding?

Answer 13

Ovarian enlargement. Obstructed venous drainage.

Question 14

Although more conservative methods can be used, such as untwisting the ovary or oophorexy, what is the definitive treatment of Ovarian Torsion?

Answer 14

Salpingo-oophorectomy.

Question 15

What is the most common risk factor for ectopic pregnancy? What is the strongest predictor of having an ectopic pregnancy.

Answer 15

PID. Prior ectopic pregnancy.

Question 16

How to diagnose ectopic pregnancy? Any additional actions if patient is bleeding?

Answer 16

Serum B-HCG + Pelvic Sonogram.

send Type and Screen

Question 17

Most common symptoms (>70%) of Ectopic Pregnancy (5)?

Answer 17

Abdominal Pain/Tenderness, CMT, Adnexal Tenderness, Amenorrhea, Vaginal Bleeding.

Question 18

Two discriminatory zones for ectopic pregnancy on ultrasound?

Answer 18

Transvaginal visualization of IUP: B-HCG > 1500 mIU/mL.

Transabdominal visualization of IUP: B-HCG > 4000 mIU/mL.

Question 19

When is surgical management of ectopic pregnancy warranted?

Answer 19

Laparoscopic surgical management is warranted if patient is unstable or ectopic sac has ruptured.

Question 20

What is the medical management of ectopic pregnancies? When is it warranted (4)?

Answer 20

Methotrexate.
Unruptured adnexal mass < 3.5 cm, 
Hemodynamically stable, 
Desire for future fertility, 
Stable or rising β-hCG < 15,000 mIU/mL.

Question 21

What aged women need to get pregnancy tests to rule out a gynecologic emergency? What if they say they are not sexually active?

Answer 21

10-55. Test them anyway.

Question 22

A 22 year old, 36-week pregnant patient appears quite somnolent. She has a BP of 150/100, but she usually tests 130/90.She is minimally responsive, and has a decreased respiratory rate and marked decreased deep tendon reflexes? What would be found on UA? Definitive treatment? Cause of respiratory depression and loss of deep tendon reflexes? How to treat this complication?

Answer 22

Pre-ecclampsia. Protein (>5g in 24 hour collection). Delivery (do it after 34 weeks). Magnesium toxicity (used for seizure prophylaxis). Calcium gluconate.

Question 23

What is HELPP Syndrome (4)?

Answer 23

A severe variant of pre-eclampsia!
•  Hemolysis (LDH>600, often seen as schistocytes on smear).
•  Elevated Liver enzymes (AST>70)
•  Low Platelets (<100,000)
•  Epigastric or RUQ abdominal pain

Question 24

Difference between eclampsia and pre-eclampsia?

Answer 24

Eclampsia has seizures (up to 4 weeks postpartum)

Question 25

How to treat the dehydration and hypertension from pre-eclampsia?

Answer 25

IV fluids and labetalol (or Hydralazine).

Question 26

Agent for seizure prophylaxis in pre-eclampsia?

Answer 26

Magnesium sulfate

Question 27

Important test to preform in abdominal trauma to a pregnant mother?

Answer 27

Kleihauer-Betke testing (assess if fetal hemoglobin has transferred to mother’s bloodstream).

Question 28

What side should pregnant trauma patient be kept on?

Answer 28

Left side?

Question 29

How long should fetal monitoring go on after mother (who suffered trauma) is stable?

Answer 29

4 hours.

Question 30

If the mom has been dead on the trauma table for less than 10 minutes, what can you do to save the baby? What factors lead to higher chances for survival (2)?

Answer 30

Peri-mortem C section.

Fetus >28wks and maternal death <15mins prior to delivery.

Question 31

Bacterial vaginosis

Answer 31

Overgrowth of natural flora: vaginal flora gardnerella vaginalis; anaerobes bacteroides spp, peptococcus