Critical Concepts 2013-2014

1. Critical Concepts 2013-2014 Guidelines for Treating Acute GYN Illnesses LSU Department of OBGYN

2. A 24 year old female presents to the emergency department complaining of vaginal bleeding. In triage, her vital signs are stable and the nurse calls to tell you that she is in the exam room. What initial information do you want about this patient?

3. TRIAGE VITAL SIGNS: Temperature 98.8 Blood Pressure 110/70 Pulse 95 Respirations 12 Weight 220 pounds Height 5’5’’ Urine Pregnancy Test is Positive

4. Take a Complete History HPI: What do you want to know about her presenting complaint of vaginal bleeding?? Other symptoms to ask about?? What else in your history taking will be important to know?

5. Take a Complete History Initial Presentation - - - • Patient’s LMP was about 7 weeks ago but she can’t remember the date; has not received any prenatal care yet • Present Illness – bleeding started 3 days ago but the amount of bleeding got worse today so she decided to come to the ER • Associated Symptoms – feeling tired and having some cramping in her belly over the past several hours

6. Take a Complete History What else in your history taking will be important to know? What questions do you want to ask the patient?

7. Take a Complete History • Medical History – no medical problems • Surgical History - none • Medicines – Ibuprofen • Allergies – no known drug allergies; allergic to latex • Social History – tobacco use, social alcohol, no drugs

8. Take a Complete History • OB History – G1: SVD at 34 weeks G2: miscarriage early in the pregnancy (what are her G/P’s??) • GYN History – past treatment for gonorrhea and chlamydia non-compliant with OCP’s no history of abnormal pap smears

9. First Trimester Bleeding What’s your differential diagnosis?

10. Differential Diagnosis 1. Physiologic: normal intrauterine pregnancy, implantation bleeding, ruptured corpus luteum cyst 2. Ectopic Pregnancy 3. Miscarriage • Pathology – vagina, cervix, uterus - vaginal laceration/foreign body - cervicitis/cervical mass - fibroids/polyps

11. Physical Examination – Patient #1 • vital signs: BP 95/60 HR 100 • abdominal exam –midline tenderness to palpation, no rebound no guarding • pelvic exam - use the speculum to visualize the cervix: no gross lesions moderate blood in the vault with active bleeding at the cervical os - bimanual exam: 8 week size uterus tender to palpation cervical os dilated 2 cm

12. What do you want next???

13. What do you want next??? LABS: - quantitative βhCG - Type and Screen - CBC - +/- CMP pelvic ultrasound (remember to order with transvaginal images)

14. Results • LABS: - quantitative βhCG = 5000 - Type and Screen = O negative, antibody negative - CBC = 8 9 250 26

15. Results • Ultrasound report: uterus 8x4x3cm, irregular shaped gestational sac, fetus measuring approximately 7 weeks with no fetal cardiac activity noted Final diagnosis??

16. Spontaneous/Incomplete Abortion • Gestational Sac – structure can be seen but may be irregular in shape • Yolk Sac – may or may not be present • Fetal cardiac activity will help to define type of miscarriage

17. Intrauterine Pregnancy • Gestational Sac – ring structure seen by 5 weeks embedded into the decidua • Yolk Sac – appears at 5-6 weeks and disappears by 10 weeks • Fetal cardiac activity usually seen by 6 weeks

18. Incomplete Abortion Options for management: • Conservative management with/without prostaglandins to complete abortion • Surgical therapy with suction D&C Other considerations: • Blood type – does this patient need RhoGam? • Antibiotics if uterus was instrumented during examination

19. Abortion Definitions Complete: all POC are expelled from uterine cavity, cervix closed Incomplete: partial expulsion of POC from uterine cavity with dilated cervical os Threatened: all POC in uterine cavity, with heartbeat, cervix closed, bleeding present Missed: all POC in uterine cavity, no heartbeat, cervix closed

20. Spontaneous Abortion Incidence: about 10-15% of clinically recognized pregnancies; nearly 80% before 12 weeks gestation Risk Factors: • Advanced maternal age • Previous spontaneous abortion (20% after 1, 40% after 3 consecutive) • Smoking • Excess alcohol and caffeine intake • Maternal weight: BMI <18 or >25 - Etiology: chromosome abnormalities account for about 50% of 1st trimester losses (nearly 90% of those 8 weeks or less)

21. Questions??

22. Physical Examination – Patient #2 • vital signs: BP 95/60 HR 100 • abdominal exam – significant for right lower quadrant tenderness to palpation, no rebound, voluntary guarding • pelvic exam - use the speculum to visualize the cervix: no gross lesions minimal blood in the vault - bimanual exam: palpable mass in the right lower quadrant with significant tenderness to palpation; 8 week size uterus

23. What do you want next???

24. What do you want next??? LABS: - quantitative βhCG - Type and Screen - CBC - +/- CMP pelvic ultrasound (remember to order with transvaginal images)

25. Results • LABS: - quantitative βhCG = 5000 - Type and Screen = O negative, antibody negative - CBC = 8 9 250 26 - CMP shows that electrolytes and liver functions are within normal limits

26. Results • Ultrasound report: uterus 8x4x3cm, no intrauterine pregnancy seen, ring-like structure seen near the right adnexa, measuring 3x3 cm with yolk sac present - no cardiac activity, moderate free fluid in pelvis Final diagnosis??

27. Ectopic Pregnancy • Diagnosis of ectopic pregnancy is made by physical exam and ultrasound findings • Classic signs are: amenorrhea, abdominal pain, and vaginal bleeding • Definitive Diagnosis: • (in adnexal region) • cardiac activity • fetal pole/fetus • yolk sac

28. Ectopic Pregnancy - Management Contraindications to Methotrexate: - hemodynamic instability/risk of rupture - abnormal renal or liver functions - active peptic ulcer disease or pulmonary disease - allergy to MTX - breastfeeding - inability to follow-up Relative contraindications: - beta >10,000 - size >3.5cm - cardiac activity - free fluid in the pelvis

29. Ectopic Pregnancy If MTX is contraindicated – proceed with surgical removal of ectopic by salpingostomy or salpingectomy Other considerations: • If hemodynamic instability/potential rupture: does the patient need 2nd IV site, PRBC’s, exlap for emergent therapy? • Blood type – does this patient need RhoGam?

30. Ectopic Pregnancy Risk Factors: • Pelvic inflammatory disease • Previous ectopic pregnancy • Previous tubal or pelvic surgery • Smoking • Current use of an intrauterine device • Increasing age Must have transvaginal ultrasound and quant beta hCG levels to accurately diagnose.

31. What if her beta was only 1400?? • Beta hCG level: rises in the first trimester and plateaus after about 10 weeks gestation • doubling of level occurs about every 1.6-2.1 days • majority of pregnancies will increase 66% every 48 hours • abnormal rise or plateau is correlated with abnormal pregnancy • Discriminatory zone: correlates the level of hCG with the ability to see a gestational sac • 1500-2000 with transvaginal images • REPEAT IN 48 HOURS

32. Questions??