EM E1: OBGYN

When do ALL clinicians NEED a chaperone in the room?

when completing any GU exam

What is the MCC of vaginal bleeding during a women's reproductive years?

Abnormal uterine bleeding (AUB)

What is heavy prolonged menstrual flow?

Menorrhagia

What is bleeding that occurs at any time between menstrual periods?

Metrorrhagia

What is heavy bleeding at irregular intervals?

Menometrorrhagia

What is no uterine bleeding for 6 months or longer?

Amenorrhea

What typically causes mid-cycle spotting?

drop in estrogen just before ovulation

What is the #1 lab study for evaluation of abnormal uterine bleeding?

Urine or serum HCG

*assume everyone is pregnant

What imaging is used for evaluation of abnormal uterine bleeding?

US

What cannot be done in the ED for tx of AUB?

procedures -must admit (biopsy, hysterectomy, endometrial ablation)

What is generally effective for tx of abnormal uterine bleeding & dysmenorrhea?

NSAIDs

*Tranexamic acid (TXA) has growing use

In addition to a pregnancy test, what labs should you order for abd or pelvic pain?

CBC, UA, STD culture and wet prep

What is the gold standard imaging study for PID/adnexal masses?

diagnostic laparoscopy

What is a pelvic/transvaginal US used for?

PID, abscess, leiomyoma, cysts

What is the dx study for ovarian torsion?

Pelvic/transvaginal US with doppler

Which test can help differentiate appendicitis vs GYN cases?

CT

What is the most important part of managing pts w/ abd/pelvic pain?

pain management

What is the MCC of PID?

Gonorrhea & Chlamydia

What is a complication of long-term PID?

Infertility

What is PID?

ascending infection from the cervix & vagina

What is a key sign of PID found on PE?

Chandelier sign

What is the inpatient tx for PID?

IV Cefoxitin or Ceftriaxone + Doxycycline

What is the outpatient tx for PID?

IM Ceftriaxone + PO Doxycycline or PO Metronidazole

What should you assume w/ pain in early pregnancy?

ectopic -assume until proven otherwise

What is the MC site of ectopic pregnancy?

Fallopian tube- Ampulla

What is the classic triad of ectopic pregnancy?

abd pain, amenorrhea, vaginal bleeding

What dx should be considered in all women of childbearing age with abd/pelvic complaints OR with unexplained signs of hypovolemia?

ectopic pregnancy

What is the medical tx of ectopic pregnancy?

Methotrexate

*stops replication of actively proliferating cells (fetal cells)

What is the surgical tx of ectopic pregnancy?

laparoscopy: salpingostomy > salpingectomy (preserves tube for fertility)

What is a spontaneous abortion?

loss of pregnancy, <20 weeks or fetus weighing <500 grams

What is a threatened abortion?

*MC

pregnancy-related bloody discharge or bleeding (1st trimester pregnancy) without cervical dilatation

What is an inevitable abortion?

vaginal bleeding and cervical dilatation

What is an incomplete abortion?

passage of only parts of the products of conception

What is a complete abortion?

passage of all fetal tissue, including trophoblast and all products of conception, before 20 weeks of conception

What is a missed abortion?

fetal death at <20 weeks without passage of any fetal tissue for 4 weeks after

What is a septic abortion?

infection at any stage of abortion

What is the MCC of fetal wastage?

Chromosomal abnormalities

What is mandatory to define the type of abortion?

pelvic exam -need to see if cervix has dilated and if tissue has been passed

*may also get US to r/o ectopic or retained products

What is the tx for threatened abortion?

d/c with close follow-up, bedrest & dec activity (not effective)

*an inevitable miscarriage cannot be avoided

What is the tx for an incomplete abortion?

Dilation & Cutterage

What is the tx for a complete abortion (per US)?

discharged safely w/ follow up

What is the tx for a pt w/ a nonviable fetus?

admit or d/c w/ close f/u by her physician

*return if heavy bleeding, pain, fever

What is Gestational trophoblastic disease (GTD)?

neoplasm that arises in the trophoblastic cells of the placenta that produce b-hCG

What are symptoms of Gestational Trophoblastic Disease?

vaginal bleeding, hyperemesis, eclampsia, overly enlarged uterus

abnormally high b-hCG levels

(partial/complete) moles in GTD = deformed, nonviable fetus

partial

(partial/complete) moles in GTD = no actual fetus

complete

What is the tx for Gestational Trophoblastic Disease?

Dilation & Cutterage

*if b-hCG levels fail to decrease → chemotherapy

What is hyperemesis gravidarum?

severe nausea and vomiting of pregnancy

*seen w/ wt loss, volume depletion, hypokalemia, ketonemia

Is abdominal pain in NVP or hyperemesis gravidarum common?

NO -it's unusual and suggests another diagnosis

What is the 1st line tx for hyperemesis gravidarum?

IV fluids- LR or NS 0.9%

*consider doxylamine or pyroxidine (B6) too; 2nd line = antiemetic

What is the 2nd MCC of maternal death?

preeclampsia

What is preeclampsia?

HTN (>140/90 or 20 inc in SBP or 10 inc in DBP) in pregnancy

+ proteinuria (althought not usually present)

T/F: A normal-appearing BP may in fact be in the preeclampsia range for a given patient

True

What is the only definitive tx of preeclampsia?

delivery of fetus

What is the clinical presentation of preeclampsia?

HA, visual disturbances, edema, abd pain

What is eclampsia?

superimposition of seizures on preeclampsia or aggravated HTN

*usually occurs after 20 weeks; CAN occur up to 6+ weeks after delivery

What is HELLP syndrome?

Hemolysis, Elevated Liver enzymes, Low Platelets

*variant of preeclampsia, presents WITH abd pain, multigravid pt more likely

What is the tx for HELLP syndrome?

Methyldopa (for HTN) & Magnesium gtt

What is abruptio placentae?

premature separation of placenta from the uterine wall

*presents w/ late pregnancy bleeding & hyperactive contractions

What are RFs for abruptio placentae?

HTN (MC), maternal trauma, inc maternal age, smoking, previous abruptions

What is the tx for abruptio placentae?

Crystalloids, FFP, emergency OB consultation

What is placenta previa?

implantation of the placenta over the cervical Os

How does placenta previa present?

pregnant pt presents with painless bright-red bleeding

What should you AVOID whenever placenta previa is suspected?

digital & speculum exams

What imaging is done for placenta previa?

US

What is PROM?

rupture of membranes prior to onset of labor

How should the digital exam be done if PROM is suspected or confirmed?

deferred or done using sterile gloves

Risk of thromboembolisms is significantly inc from pregnancy. How would you tx a post-partum woman w/ a DVT?

anti-coag

PE considered with pregnant woman complaining of SOB, syncope, CP, or shock. What imaging study would you order?

CT

What is the MCC of postpartum hemorrhage?

*more common < 24 hrs

Uterine atony (uterine rupture)

What would you see upon speculum exam of Uterine atony?

uterine fundus is "doughy" ± blood visible from cervical os (retained products → remove)

If a mass is seen on a post-partum speculum exam, what is the likely dx?

uterine inversion

What is the tx for uterine atony?

administer Oxytocin diluted in NS

What is the MC serious complication puerperium?

postpartum infections

What is the suspected dx: persistent fever >38C (100.4F) in a postpartum pt?

Genital tract infection -until proven otherwise

What are ssx of a postpartum infection?

foul-smelling, profuse, bloody discharge, abd pain; shaking chills may indicate bacteremia

*watch out for necrotizing fasciitis

What is the tx for postpartum infection in 90% of patients?

Ampicillin & Gentamicin

What is an amniotic fluid embolus?

amniotic fluid enters bloodstream resulting in sudden CV collapse; seizures, death is rapid

*deliver infant immediately!!! (but mortality rate is still high)

What is peripartum cardiomyopathy?

development of heart failure during or shortly after labor with no apparent cause (usually dilated)

What indicates a poor prognosis w/ peripartum cardiomyopathy?

no underlying cause can be found

What is the typical delivery position?

Dorsal lithotomy

Are episiotomy’s recommend in normal spontaneous vaginal deliveries?

nope -discouraged

What should be done after the head of the baby is delivered, but before delivering the rest of the body?

clear airway → suction nose and mouth

When is the APGAR score calculated?

1 & 5 mins