Critical Concepts 2012-2013OBGYN CASES

Guidelines for TreatingAcute GYN Illnesses

Stacey L. Holman, MD, FACOG

Associate Residency Program Director

LSU Department of OBGYN

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?

TRIAGE VITAL SIGNS:Temperature 98.8Blood Pressure 110/70Pulse 95Respirations 12Weight 220 poundsHeight 5’5’’

Urine Pregnancy Test is Positive

Take a Complete HistoryHPI: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?

Take a Complete HistoryInitial 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

Take a Complete History

What else in your history taking will be important to know?

What questions do you want to ask the patient?

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

Take a Complete History

• OB History – G1: SVD at 34 weeksG2: miscarriage early in the pregnancy

(what are her G/P’s??)

• GYN History – past treatment for gonorrhea and chlamydianon-compliant with OCP’sno history of abnormal pap smears

First Trimester Bleeding

What’s your differential diagnosis?

Differential Diagnosis

1. Physiologic: normal intrauterine pregnancy,

implantation bleeding, ruptured corpus luteum cyst

2. Ectopic Pregnancy 3. Miscarriage4.Pathology – vagina, cervix, uterus

- vaginal laceration/foreign body- cervicitis/cervical mass- fibroids/polyps

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 lesionsmoderate blood in the vault with active bleeding at the cervical os- bimanual exam:8 week size uterus tender to palpationcervical os dilated 2 cm

What do you want next???

What do you want next???• LABS:

- quantitative βhCG- Type and Screen- CBC- +/- CMP

• pelvic ultrasound (remember to order with transvaginal images)

Results• LABS:

- quantitative βhCG = 5000- Type and Screen = O negative, antibody negative- CBC = 8

9 250 26

Results• Ultrasound report: uterus 8x4x3cm,

irregular shaped gestational sac, fetus measuring approximately 7 weeks with no fetal cardiac activity noted

Final diagnosis??

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

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

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

Abortion DefinitionsComplete: 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

Spontaneous AbortionIncidence: 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)

Questions??

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 lesionsminimal blood in the vault

- bimanual exam: palpable mass in the right lower quadrant with significant tenderness to palpation; 8 week size uterus

What do you want next???

What do you want next???• LABS:

- quantitative βhCG- Type and Screen- CBC- +/- CMP

• pelvic ultrasound (remember to order with transvaginal images)

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

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??

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

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

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?

Ectopic PregnancyRisk 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.

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

Questions??