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Ob-Gyn Emergencies

Ob-Gyn Emergencies. Denver Health Residency in Emergency Medicine. 1. Case 1. EMS Report: 26 y/o female s/p syncopal episode at work, complaining of lower abdominal pain. Progressively anxious and diaphoretic Field Vitals : 121 98/74 18 PMH : none LMP : expecting this week

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Ob-Gyn Emergencies

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  1. Ob-Gyn Emergencies Denver Health Residency in Emergency Medicine 1

  2. Case 1 • EMS Report: 26 y/o female s/p syncopal episode at work, complaining of lower abdominal pain. Progressively anxious and diaphoretic • Field Vitals: 121 98/74 18 • PMH: none • LMP: expecting this week • Paramedic: “Doc, what do you think is going on?”

  3. Case 1 • What is your initial management of this patient? • Place on monitor • Supplemental O2 • 2 large bore peripheral IVs (18G or larger) • IVF

  4. Case 1 • Nurse: “What do you want next?” • Ultrasound: BEDSIDE • Look for free fluid • + Fluid in Pouch of Douglass....why would she have this? • Send UPT/quantitative (beta) HCG • Positive! • Note: beta HCG in ectopic often low! • Type & Crossmatch Blood, RH status • Consultative Transvaginal U/S • Only if bedside nondiagnostic and patient stable!

  5. Case 1 • What is your presumptive diagnosis? ECTOPIC PREGNANCY

  6. Ectopic Pregnancy • Ruptured ectopic pregnancy: • leading cause of maternal death in first trimester pregnancy • Overall: 10% – 15% of maternal deaths • Incidence of ectopic pregnancies have increased 4 fold in the past 30 years (Why?) • Between 1:100 and 1:200 pregnancies

  7. Ectopic Pregnancy • Risk factors: • PID • Previous ectopic • Endometriosis • Previous tubal/pelvic surgery • Infertility treatment • Cigarette smoking

  8. Ectopic Pregnancy • Treatment: to be determined by OB/GYN • Surgical • Especially if ruptured/impending rupture • Medical (Methotrexate) • For stable, low-risk patients • (Gestation <3.5cm)

  9. Case 2 • Triage Note: 23 y/o G2P1 presents with 3 days lower abdominal cramping and vaginal spotting that started this morning • Has used 2 pads in the last 12 hours • No clots/tissue • Not lightheaded

  10. Case 2: Pertinent Exam • Vitals normal • Mild suprapubic TTP • On pelvic exam, scant bloody discharge from closed os • No adnexal TTP or masses • Nurse: “What are you planning to do? Any orders?”

  11. Case 2: Bedside U/S • 8 week IUP, FHT’s 150’s • What is your diagnosis?

  12. Threatened Miscarriage • Pregnant + Abd pain OR Vaginal Bleeding, <20 wks • Cervical os is closed • Has not passed any fetal products by hx/exam • Confirmed IUP OR indeterminate ultrasound (if very early in pregnancy)

  13. Threatened Miscarriage • Stable patients may be discharged with a non-diagnostic ultrasound • But gosh, could it be an ectopic?! • Repeat beta-hCG quantitative testing is recommended in 2-3 days • Necessary if no definitive IUP identified

  14. Miscarriage: Education for Patients • Greater than 50% of all pregnancies end in miscarriage, most before clinical recognition • 30% of all Pregnancies have 1st Trimester bleeding...overall ~50% of these will end in a Spontaneous Abortion • After pregnancy is confirmed by U/S, about 15% end in miscarriage

  15. Miscarriage: Terminology • Inevitable abortion • Open os with vaginal bleeding • No passage of fetal products yet • Treatment: D&C vs. watchful waiting +/- misoprostol • Incomplete abortion • Open os • Passage of fetal products • Treatment: D&C (unless all POC passed by exam or ultrasound)

  16. Miscarriage • Missed abortion (aka IUFD) • Nonviable fetus in uterus • Closed os • Complications: septic abortion, +/- DIC!! • Treament: D&C • Complete abortion • All POC have passed and os closed • Uterus firm and nontender • Bleeding (nearly) stopped • Treatment: confirm all POC passed by exam or ultrasound, if not, D&C

  17. Before she goes...RH Status? • Why do we check/care? • Rh-negative women • If fetus Rh+, may result in production of maternal antibodies to foreign Rh antigen • Rh(D) immune globulin 300µg or 50µg if <13wk gestation

  18. Case 3 • Triage Note: 19 y/o female presents with dysuria and increased white malodorous discharge for the past week. Has one new sexual partner, use condoms “sometimes” • Vitals normal • Exam significant only for friable, inflammed cervix, no purulence from os • No CMT or abdominal pain

  19. Case 3 • Patient: “What do you think??” http://knol.google.com/k/gonorrhea#

  20. Case 3: Differential for Cervicitis • Infectious • Gonorrhea & Chlamydia most common • HSV & trich also can cause • Noninfectious • normal pregnant cervix • increased mucous discharge @ time of ovulation • Neoplastic • when was her last pap smear?! Encourage f/u!

  21. Cervicitis • Common presentation: • vaginal discharge +/- dysuria • Diagnosis: • Clinical -- Enough to empirically treat! • Wet prep • increased leukocytes suggestive • dx & tx trichomonas/candida/BV • Culture GC/chlamydia (results take 24hrs)

  22. Cervicitis • Treatment: • Must cover for both chlamydia and gonorrhea • Ceftriaxone 125mg IM x 1 (gonorrhea) • Azithromycin 1gm PO (chlamydia) • If trichomonads present • Flagyl 2g PO x1 or 500mg BID x 7d (may make nauseated, also warn Disulfiram rxn) • Partner must also be treated!

  23. When is it PID? • PID is an ascending GU infection • spectrum: endometritis...salpingitis...TOA • Diagnosis (must have all 3): • Lower abdominal tenderness • Adnexal tenderness (most often bilateral) • CMT = Chandelier Sign • Add’l Criteria that increase specificity: • fever • leukocytosis • abnormal vaginal discharge or purulence from os

  24. PID: Treatment • Outpatient Treatment: • Ceftriaxone 250mg IM PLUS • Doxycycline 100mg PO BID x 14d • When to admit? • pregnant • e/o SIRS/sepsis • associated TOA • inability to tolerate PO • immunosuppression • Inpatient Treatment: • Doxy + Cefoxitin/Cefotetan/Unasyn OR • Clinda + Gent • Complications: Fitz-Hugh-Curtis, increased risk ectopic or chronic pain

  25. “What If” Game... • What if our patient had instead come in with sharp RLQ pain? • What would be our differential then, given what we know now? • And what do we need to tease out the diagnosis?

  26. “What If” Game...Female RLQ Pain • Ectopic • UPT + • bedside U/S +/- consultative if needed • TOA • exam c/w PID & unilateral TTP on bimanual • consultative pelvic ultrasound • Adnexal torsion • Acute onset, unilateral; may have hx ovarian cysts • unilateral TTP on bimanual • consultative pelvic ultrasound • Appendicitis • RLQ pain without pelvic findings/complaints • Clinical +/- CT abdomen/pelvis

  27. Case 4 • EMS Report: Called to a home with report of patient seizing. She is 36 wks pregnant, unknown if she’s had prenatal care. Everyone in the house was Spanish-speaking , no other history obtained. Estimated seizure time 7 min. • PMH: 36 wks pregnant, unk prenatal care • No meds/allergies • Attending asks you: “What do you want to do?”

  28. Case 4 • I need vitals! • VS 189/93 122 20 98% NRB 37.9R • OK… now what? Patient is still seizing • ABC’s – Place on monitor • Airway intact, presently sats OK with NRB • Bilateral breath sounds • Hypertensive

  29. Eclampsia Medications: Seizure management • Magnesium: 4-6g over 5-15min • antiepileptic and antihypertensive • Signs of magnesium toxicity: • Respiratory depression • Bradydysrhythmias • Loss of DTRs • What if you see signs of toxicity?? • Calcium gluconate (1gm slow IVP)

  30. Eclampsia Medications: BP management • Hydralazine: • For DBP >110 • 5-10mg IV q 20min • Labetolol (3rd line) • 20mg IV up to 300mg • Definitive management?? • Delivery! • Get OB involved with first EMS call

  31. Eclampsia • May occur up to 10 days postpartum • Definition:symptoms of pre-eclampsia + sz • HTN (>140/90) • Proteinuria (300mg/24hrs) • Dispo: • Admission to OB service for definitive care

  32. Take Home Points • Vaginal bleeding in pregnancy • ECTOPIC until proven otherwise! • Educate re: miscarriage—this is emotional news! • Cervicitis/PID • Requires high level of clinical suspicion • Low threshold to treat empirically, minimizes complic. • Eclampsia • Magnesium Sulfate 1st line, involve Ob early • Dispo instructions are important • OB-Gyn follow-up? (repeat Quant? Pap smear?) • Treat partners, use protection in interim!

  33. What did you see on shift today? • Ectopic Pregnancy • Threatened Miscarriage (& other variations) • Cervicitis (& PID) • Eclampsia 33

  34. Questions?

  35. References Le T. et al. First Aid for the Emergency Medicine Boards. McGraw-Hill: New York. 2009. Rivers C.S., et al. Preparing for the Written Board Exam. Emergency Medicine Educational Enterprises, Inc. 2006

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