Reproductive Health Emergency Medicine PDF

Emergency Medicine REPRODUCTIVE Objectives 1. Synthesize the etiology, epidemiology, symptoms and signs, laboratory findings, work-up, differential diagnosis, and treatment for the following reproductive disorders: ◦ Vaginal Bleeding ◦ Nonpregnant female ◦ Pregnant fema...

Emergency Medicine REPRODUCTIVE Objectives 1. Synthesize the etiology, epidemiology, symptoms and signs, laboratory findings, work-up, differential diagnosis, and treatment for the following reproductive disorders: ◦ Vaginal Bleeding ◦ Nonpregnant female ◦ Pregnant female ◦ Pelvic Pain ◦ Ectopic Pregnancy ◦ Abortion ◦ Nausea and Vomiting of pregnancy ◦ Postpartum Endometritis ◦ Mastitis ◦ Vulvovaginitis ◦ Pelvic Inflammatory Disease ◦ Ovarian torsion Objectives 2. Recognize when a pelvic ultrasound is indicated in the setting of pelvic pain and abnormal vaginal bleeding. 3. Identify the presenting signs and symptoms of ovarian torsion and ectopic pregnancy. 4. Differentiate between the various causes of abnormal uterine bleeding in the nonpregnant patient based on a clinical scenario. 5. Provide patient education regarding the prevention of vaginitis, cervicitis, and pelvic inflammatory disease. 6. Differentiate between the various classifications of spontaneous abortion based on a clinical scenario 7. Write a prescription for the treatment of PID and the various causes of vaginitis. Vaginal Bleeding in the Nonpregnant Patient Definitions Vaginal Bleeding in the Nonpregnant Patient 3 Categories: ◦ Prepubertal ◦ Trauma, abuse, vaginitis, tumors, FB ◦ Reproductive age/Perimenopausal ◦ Anovulation (MC), Exogenous hormones, Coagulopathy (20%), Uterine leiomyomas, polyps, infection, Thyroid dysfunction ◦ Postmenopausal ◦ Exogenous Estrogen, Atrophic vaginitis, Endometrial lesions Pregnancy status!!! PALM-COEIN Vaginal Bleeding in the Nonpregnant Patient Clinical Features ◦ Amount ◦ Duration ◦ Reproductive and sexual history ◦ STIs ◦ Trauma ◦ Meds ◦ Retained FB ◦ Bleeding disorder ◦ Up to 20% of adolescents with AUB may have a primary bleeding disorder i.e. von Willebrand disease ◦ Endocrine disorder ◦ TSH- typically in hypothyroid Vaginal Bleeding in the Nonpregnant Patient Physical Exam Significant blood loss ◦ Abdominal exam ◦ Dizziness ◦ Complete pelvic exam ◦ Weakness ◦ Speculum ◦ Abnormal VS ◦ Bimanual ◦ Get Orthostatic ◦ Skin ◦ Syncope ◦ Pallor ◦ Eyes ◦ Palpebral conjunctiva pallor http://epomedicine.com/wp-content/uploads/2013/11/Conjunctival-pallor_mini.jpg Vaginal Bleeding in the Nonpregnant Patient Work-Up Diagnosis ◦ Pregnancy test ◦ Abnormal uterine bleeding (AUB) ◦ Blood vs. Urine ◦ Unless otherwise confirmed ◦ UA ◦ CBC ◦ PT/INR, PTT ◦ +/- TSH ◦ +/- Pelvic US (Transvaginal) ◦ Size Any vaginal bleeding postmenopausal should be ◦ Endometrium urgently referred for malignancy workup ◦ Lesions ◦ Free fluid in the cul-de-sac ◦ Can be deferred to outpatient ◦ If stable and nonpregnant Vaginal Bleeding in the Nonpregnant Patient Vaginal Bleeding in the Nonpregnant Patient Treatment ◦ Stable ◦ Unstable ◦ NSAIDs ◦ ABCs ◦ Naproxen 500mg PO BID ◦ Gynecologic consultation ◦ Ibuprofen 400mg PO q6h ◦ Urgent D and C ◦ +/- Combined OCP ◦ +/- High dose Estrogen IV ◦ Ortho-Novum ◦ Admission ◦ 3 tabs PO daily x 7 days ◦ Or taper ◦ Medroxyprogesterone ◦ Recommended with any contraindications to estrogen ◦ 20mg PO TID x7 days or QD x 10 days ◦ Caution with hormone if postmenopausal ◦ Tranexamic acid ◦ Iron Supplementation ◦ DC Home ◦ Close F/U with Gynecologist Pelvic Pain in the Nonpregnant Patient Pelvic Pain in the Nonpregnant Patient History should be broad 2 Categories: GI sx? ◦ Acute ◦ Ovarian cyst Urologic sx? ◦ Ovarian torsion GYN? ◦ Obstructive or renal lithiasis Lumbosacral? ◦ Gradual Ask about recent pregnancies, ◦ Infectious process lactation, or ovulation inducing ◦ Mass treatments Pregnancy test!!! Sexual history Relationship to menses? ◦ Endometriosis Work-up Work up not always indicated unless history cannot rule out serious pathology Pelvic Pain in the Nonpregnant Patient Ovarian Cysts ◦ Acute unilateral pain ◦ +CMT ◦ +/- bleeding https://qph.fs.quoracdn.net/main-qimg-044a9af08cab30e9cf963ca2b74ffbd7-c Ovarian Cysts Follicular cysts corpus luteum cysts Diagnosis Can become “hemorrhagic cysts” Transvaginal ultrasound is useful for diagnosis and Rare to cause severe bleeding sizing These are normal cysts that occasionally cause pain Complicated cyst rupture Abnormal vital signs and acute abdomen Dermoid cyst Malignancy risk increases >45yo Any cyst >8cm, solid or multiloculated need urgent referral Also increase the risk for torsion All other cysts should be referred for monitoring Pelvic Pain in the Nonpregnant Patient Ovarian Torsion ◦ Acute severe adnexal pain (most commonly on the right) ◦ Up to 50% of patients may have intermittent or atypical symptoms ◦ Nausea and vomiting present in 70% of cases ◦ Risk factors ◦ Pregnancy ◦ Large cysts or tumors ◦ Chemical induction of ovulation ◦ Doppler US ◦ Not 100% sensitive or specific ◦ Surgical Emergency!!! ◦ Always get a gyn consultation http://3.bp.blogspot.com/-QBmtQm_OqQY/Vk3lX3HUGoI/AAAAAAAABmo/Co3b6wqKgSY/s1600/194.1.png Pelvic Pain in the Nonpregnant Patient Endometriosis ◦ Helpful if patient has a known diagnosis ◦ Otherwise, diagnosis in ER unlikely ◦ Correlation of symptoms with menses ◦ NSAIDs ◦ Gynecology referral https://www.vitalhealth.com/wp-content/uploads/2014/11/bladder-endometriosis-and-right-indirect-inguinal-hernia.jpg Pelvic Pain in the Nonpregnant Patient Leiomyomas ◦ Additional symptoms: ◦ AUB ◦ Dysmenorrhea ◦ Bloating ◦ Dyspareunia ◦ Backache ◦ Bimanual exam ◦ US ◦ NSAIDs ◦ Referral https://img2.tfd.com/mk/L/X2604-L-12.png Reproductive Nausea and Vomiting 90% of pregnancies Hyperemesis Gravidarum Severe N/V, weight loss, hypovolemia, hypokalemia, ketonemia Clinical findings and work-up NO Abdominal pain Suggests another diagnosis CBC BMP Electrolytes BUN/Cr UA Ketones? Nausea and Vomiting Treatment IV fluids (NS or LR) +/- 5% Dextrose Anti-emetics Metoclopramide 10mg IV + Benadryl 25-50mg IV Ondansetron 4-8mg IV Might be falling out of favor Outpatient Doxylamine with pyridoxine (B6) Ectopic Pregnancy Ectopic Pregnancy Leading cause of maternal death in the first trimester ◦ Diagnosis must be considered in EVERY woman ◦ Childbearing age + Abdominal pain + Vaginal bleeding Risk Factors: ◦ PID ◦ Surgical procedures ◦ Previous EP ◦ IUD ◦ Assisted reproductive techniques Most common location? Other locations? http://www.biyanicolleges.org/wp-content/uploads/2016/08/11.jpg Ectopic Pregnancy Classic triad ◦ Abdominal pain - 90% ◦ Vaginal bleeding – 50% - 80% ◦ Most common between 5- and 7-weeks gestation ◦ Amenorrhea – 70% ◦ > 4 weeks preceding clinical presentation Presentation differs ◦ Ruptured vs. Non-ruptured ◦ Location of EP ◦ Hemoperitoneum + Diaphragmatic irritation ◦ Upper abdomen or shoulder pain Ectopic Pregnancy Clinical Features Laboratory Work-up ◦ VS may be normal even if ruptured ◦ CBC ◦ Physical Exam – highly variable ◦ B-hCG ◦ Pelvic Exam ◦ Quantitative – Blood ◦ Normal ◦ Abnormal rise in beta HCG ◦ Cervical motion tenderness ◦ < 50% in 48 hours ◦ Adnexal tenderness ◦ Qualitative – Urine ◦ Possibly enlarged uterus ◦ PT/INR, PTT ◦ Type and Cross ◦ Rh negative women should receive 50 micro grams of anti-Rho (D) immunoglobulin!!! ◦ If 6000 TA or 1500 TV) + Empty Uterus ◦ Highly suggestive of EP ◦ Low B-hCG (< 1500 TV) ◦ Pregnancy may be too early to tell ◦ Repeat in 48 hours ◦ Normal – Increase by at least 53% ◦ An increase in Quant of >53% does not effectively rule out an Ectopic Pregnancy Ectopic Pregnancy Care and Disposition – Surgical Emergency!!! ◦ Combo of pelvic mass, free fluid in the cul-de-sac, and empty uterus is HIGHLY suggestive of ectopic ◦ Emergent OB/GYN consult ◦ Any amount of free fluid in the cul-de-sac should always peak your concern for ectopic ◦ Stable ◦ Beta greater than the discriminatory zone and no visible intra or extra-uterine pregnancy can still be referred outpatient ◦ Must give STRICT and clear return precautions and follow-up advice ◦ +/- consult ◦ Unstable ◦ ABCs ◦ Gynecologic consult ◦ Surgical emergency ◦ Methotrexate vs. Laparoscopic Salpingectomy Gestational Trophoblastic Disease Neoplasm that arises from trophoblastic cells Ultrasound of placenta Complete mole ◦ Non-invasive No embryo, fetus, or amniotic fluid ◦ Complete (MC) or partial hydatidiform mole Heterogenous mass ◦ Pre-malignant Ovarian cysts ◦ Invasive Partial mole ◦ Choriocarcinoma Fetus may be present +/- FHT ◦ Placental site trophoblastic tumor Growth restricted ◦ Epithelioid trophoblastic tumor Abnormal placental Symptoms Will have abnormally high BetaHcg >100,000 ◦ Vaginal Bleeding ◦ + urine preg ◦ Hyperemesis True diagnosis can only be made by uterine ◦ If persistent into second trimester evacuation and histological analysis ◦ Pre-eclampsia ◦ Hypertension Threatened Abortion & Abortion Spontaneous Abortion According to WHO between 20% and 40% of pregnancies will spontaneously abort ◦ Approximately 75% of these will occur before 8 weeks gestation. ◦ Most commonly due to chromosomal abnormalities Bleeding with or without abdominal pain is the most common presenting complaint First-trimester vaginal bleeding History Work-up Pads per hour? CBC LMP Beta Quant (serum) OB hx Type and Screen (or cross if heavy PE bleeding) Pelvic exam Rh factor Determines the type of abortion Cervix open or closed? UA Amount and site of bleeding Ultrasound Whether tissue has or is being passed Threatened Abortion & Abortion Threatened abortion Incomplete abortion ◦ First 20 weeks gestation ◦ Same as inevitable ◦ Closed cervical os ◦ Passage of tissue ◦ No passage of tissue ◦ Grayish white POC ◦ Normal exam Complete abortion ◦ Vaginal bleeding ◦ Same as above Inevitable abortion ◦ Passage of all fetal tissue ◦ Same as threatened ◦ Confirmed by US ◦ Dilated cervical os Threatened Abortion & Abortion Missed abortion Septic abortion ◦ First 20 weeks gestation ◦ Evidence of infection during any stage of abortion ◦ Fetal death ◦ Fever, abd pain, vag d/c ◦ No passage of tissue for 4 weeks ◦ Most common d/t retained POC ◦ Incomplete spontaneous ◦ Therapeutic abortion ◦ Bacteria introduced by instrumentation Threatened Abortion & Abortion Care and Disposition ◦ ABCs ◦ Rh negative women should receive 300 micro grams of anti-Rho (D) immunoglobulin!!! ◦ Emergent Gynecologic consult ◦ Incomplete, Missed, Septic ◦ Medical abortions vs. Dilation and curettage ◦ Septic ◦ Broad spectrum AB ◦ Outpatient Gynecologic F/U ◦ All other patients ◦ Inevitable ◦ Threatened Emergencies After 20 Weeks Gestation Emergencies After 20 Weeks Gestation Preeclampsia ◦ Hypertension ◦ Symptoms reflect end-organ damage ◦ > 140/90 mmHg ◦ HA ◦ 2 occasions more than 4 hours apart ◦ Visual disturbances ◦ Proteinuria ◦ ALOC ◦ > 300 mg in 24 hours ◦ Edema ◦ Proteinuria can be replaced with one of the ◦ Oliguria following: ◦ SOB ◦ Thrombocytopenia < 100,000 ◦ Abdominal pain ◦ Elevated LFTs 2x normal Can occur from: ◦ Renal Insufficiency ◦ 20 weeks gestation – 6 weeks postpartum ◦ Cr of 1.1 or doubling of Serum Cr ◦ Pulmonary edema ◦ New onset mental status disturbances or visual disturbances ◦ +/-Edema Preeclampsia / Eclampsia https://sbci464ypd-flywheel.netdna-ssl.com/wp-content/uploads/2018/03/Preeclampsia-Pathophysiology.jpg Emergencies After 20 Weeks Gestation HELLP Syndrome ◦ Hemolysis ◦ Schistocytes on peripheral blood smear ◦ Elevated LFTs ◦ Low Platelets Clinical variant of Preeclampsia More common in subsequent pregnancies RUQ or epigastric abdominal pain Any pregnant women at >20 weeks gestation up to 7 weeks post partum with abdominal pain should have HELLP eval Emergencies After 20 Weeks Gestation Preeclampsia, HELLP Syndrome, Eclampsia ◦ Care and Disposition ◦ Admission ◦ OB consult ◦ Labetalol IV or Hydralazine IV ◦ IV Magnesium ◦ prevents seizures ◦ Definitive treatment ◦ Delivery of fetus Eclampsia new onset seizure, coma or encephalopathy combined with preeclampsia Vaginal Bleeding During 2nd Half of Pregnancy A 35-year-old female G3P2 at 35 weeks gestation presents to the ER with painless vaginal bleeding. She reports two previous c-sections and has not had a recent ultrasound for this pregnancy. What is your top differential? How would you manage this patient? Vaginal Bleeding During 2nd Half of Pregnancy Placental Abruption ◦ Premature separation of placenta from uterine wall ◦ Spontaneous or any trauma ◦ Clinical Features ◦ Painful vaginal bleeding ◦ Abdominal pain ◦ Fetal distress ◦ Uterine tenderness ◦ Hypertonic contractions ◦ DIC http://www.elitereviews.net/wp-content/uploads/2016/07/Abruption.jpg Vaginal Bleeding During 2nd Half of Pregnancy Placenta Previa ◦ Implantation of placenta over cervical os ◦ Painless vaginal bleeding ◦ Usually admitted near the end of pregnancy for monitoring ◦ C-section https://upload.wikimedia.org/wikipedia/commons/2/23/2906_Placenta_Previa-02.jpg Vaginal Bleeding During 2nd Half of Pregnancy Work-up for Placenta Abruption and Previa ◦ Transabdominal US ◦ Prior to digital or speculum exam!!! ◦ ABCs ◦ Emergent OB consult! ◦ Possible emergent Cesarean delivery ◦ CBC ◦ CMP ◦ PT/INR, PTT ◦ Type and Cross ◦ Rh negative women should receive 300 micro grams of anti-Rho (D) immunoglobulin!!! Postpartum Emergencies Postpartum Emergencies Postpartum Endometritis ◦ Polymicrobial infection several days after delivery ◦ Presentation: ◦ Fever ◦ Lower abdominal pain ◦ Foul-smelling lochia ◦ Uterine or cervical motion tenderness ◦ Work-up ◦ CBC ◦ UA ◦ Cervical cultures What does this look like? http://www.stepwards.com/wp-content/uploads/2016/11/353_356_3.jpg Postpartum Emergencies Postpartum Endometritis ◦ Care and Disposition ◦ Stable patients ◦ (Amox or Doxy or Levofloxacin) + metronidazole ◦ Augmentin monotherapy ◦ Doxycycline contraindicated is women who are breast feeding ◦ F/U with OB/Gyn ◦ Admission ◦ Unstable or severe ◦ Caesarean section ◦ Surgical complication ◦ Underlying comorbidities ◦ IV Antibiotics ◦ Clindamycin + Gentamycin or Cefoxitin ◦ OB/Gyn consult Mastitis ◦ Cellulitis of peri glandular breast tissue ◦ Swelling ◦ Redness ◦ Tender engorgement of the involved portion of breast ◦ +/- Fever or chills ◦ US ◦ To differentiate between simple Mastitis and Abscess ◦ Why? ◦ Antibiotic therapy ◦ Staph aureus ◦ Dicloxacillin or Cephalexin ◦ Bactrim (contraindicated in women with infants 40yo may need biopsy to r/o vulvar ca Work-up GC/Ch testing Severe systemic illness may require labs Rare Treatment I&D with use of Word catheter or marsupialization ABX only indicated with signs of surrounding cellulitis Pelvic Inflammatory Disease Work-up should include: ◦ Pregnancy test ◦ Bi-manual/ pelvic exam  CMT ◦ Wet prep of vaginal secretions ◦ G&C testing UpToDate Regimen Pelvic Inflammatory Disease Outpatient Regimen – CDC Guidelines! ◦ Ceftriaxone 500 mg IM once ◦ AND Doxycycline 100 mg PO BID for 14 days ◦ AND Metronidazole 500 PO BID for 14 days References Blackbourne, L.H. (2012). Surgical Recall (6th ed.). Philadelphia, PA : Lippincot Williams & Wilkins. Papadakis, M. A., & McPhee, S. J. (2023). Current Medical Diagnosis and Treatment(62 ed.). McGraw-Hill Education / Medical. Tintinalli, J. (2020). Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (9th ed.). McGraw-Hill Education. UpToDate