Miscarriage

History

•  Vaginal bleeding ± passage of clots or tissue at <20 wk; abdominal pain/cramps

Physical Exam

•  Speculum and bimanual inspection to assess for passage of blood/POC and whether os is open or closed. (If copious bleeding, remove POC w/ gentle traction to allow uterus to clamp.)

Evaluation

•  Labs: UA, quant hCG, HCT, type and screen (crossmatch if HD unstable). If products expelled, send to pathology.

•  Imaging: Pelvic U/S to determine location of pregnancy

Classification of Miscarriage

•  Threatened: Os closed, no passage of POC, viable fetus w/ heart tones, mild cramping/bleeding (∼20% will eventually abort)

•  Inevitable: Os dilated and effaced; POC not passed; cramps, moderate bleeding

•  Complete: POC expelled, cervical os closed; little cramping or bleeding

•  Incomplete: Clots and tissue in cervical os w/ os open; severe cramps and bleeding

•  Missed: Uterus fails to expel fetus for >2 mo, os closed, no heart tones, pregnancy test negative

Treatment

•  ED:

•  Supportive management: IVFs, O₂, monitoring, position on L side

•  Blood products: Transfuse if HD unstable

•  Medication therapy:

•  Oxytocin: 20 U in 1 L NS for incomplete or inevitable abortion

•  Rh immunoglobulin: 300 mcg if Rh-negative

•  Consult: Gyn service if HD unstable or if need for D&C anticipated (inevitable, incomplete or missed abortion)

•  Home management:

•  Hormonal therapy: Methotrexate may be indicated under guidance of OB/Gyn

•  Abx: Consider prophylaxis w/ doxycycline or testing for STD if discharging home w/ open os

Disposition

•  Home: Stable pts w/ complete or threatened abortion; f/u w/ OB/Gyn w/i 72 h to monitor hCG levels

•  Admit: Uncontrolled bleeding or pts requiring immediate D&C

Pearl

•  Threatened and missed abortions can only be distinguished by pelvic U/S

Ectopic Pregnancy

History

•  Abdominal pain, vaginal bleeding. Most often presenting 6–10 wk after LMP.

•  RFs: H/o PID, IUD, fertility tx, recent abortion or prior ectopic

Physical Exam

•  Assess for HD stability. Signs of peritonitis if rupture has occurred. Speculum and bimanual exam may reveal pelvic tenderness and/or adnexal mass.

Evaluation

•  Labs: Quant hCG, HCT, Rh screen, PT/PTT and type and crossmatch 4 U (if HD unstable)

•  Imaging: Pelvic U/S; if HD unstable, FAST exam to assess for free fluid

Treatment

•  Supportive: 2 large-bore IVs, IVF resuscitation, monitor

•  Transfusion: If HD unstable

•  Medications: Rh immunoglobulin 300 mcg if Rh-negative

•  Consult: Urgent Gyn eval for consideration of medical (MTX) vs. surgical (laparoscopy/laparotomy) tx options

Placenta Previa and Abruptio Placentae

History

•  Placenta previa: Painless, bright red, vaginal bleeding usually after 28 wk (from placental implantation in adjacent to or over os). RFs: Multiple gestation, multiparity, advanced maternal age, previous placenta previa/C-section, maternal smoking or cocaine

•  Abruptio placentae: Painful, dark red bleeding (80%); may also present w/ signs/sxs of DIC. RFs: Eclampsia, DM, renal dz, HTN, abdominal trauma

Physical Exam

•  Check fundal height, contractions, and uterine tenderness:

•  Firm/tender uterus = placental abruption until proven o/w

•  AVOID SPECULUM AND VAGINAL EXAM

Evaluation

•  Labs: CBC, Chem 7, LFTs, PT/PTT, fibrinogen (r/o DIC), UA, type/crossmatch 2 U

•  Imaging: Doppler U/S (fetal heart tones); bedside abdominal U/S to assess placenta and signs of fetal movement, though may not always detect abruption

Treatment

•  Supportive: Place on L side, 2 large-bore IVs, IVF resuscitation, monitor pt and fetus

•  Transfusion: Blood products ± FFP (HD unstable or signs of DIC)

•  Medications: Rh immunoglobulin 300 mcg if Rh-negative, magnesium for fetal neuroprotection if emergent delivery under 32 wk

•  Consult: Urgent Gyn eval for possible STAT C-section

Disposition

•  Admit: All pts to the OB service even if HD stable for close monitoring

Retained Products of Conception and Postabortion Sepsis

History

•  Retained POC: Cramping, heavy bleeding

•  Postabortion sepsis: Cramping, bloody or purulent d/c, fever

Physical Exam

•  Fever, vaginal bleeding or purulent/bloody d/c, uterine tenderness

Evaluation

•  Labs: Quant hCG, type/crossmatch/preop labs

•  Imaging: Pelvic U/S

Treatment

•  Supportive: Stabilize (see Sepsis chapter), correct coagulopathy/anemia

•  Abx: If suspected infection, (Clindamycin 900 mg IV q8h PLUS gentamicin 2 mg/kg IV × 1 then 1.5 mg/kg q8h) OR (cefoxitin 2 g IV q8h PLUS doxycycline 100 mg IV q12h)

•  Consult: Gyn service for D&C

Disposition

•  Admit: All pts to OB/Gyn for D&C

Postcoital Bleeding

History

•  Trauma during intercourse? Vaginal d/c, assess domestic violence or abuse.

•  RFs: Cervical abnormalities, STDs, postmenopausal

Physical Exam

•  Ongoing bleeding; vaginal lacerations, abrasions

Evaluation

•  Labs: Urine hCG, GC/Chlamydia testing; HCT

Treatment

•  ED:

•  Abx: Treat STI appropriately (see STD section in Renal/GU)

•  Consult: Gyn service for laceration requiring extensive repair; social services if concern for domestic violence

PREECLAMPSIA AND ECLAMPSIA

Definition

•  Preeclampsia: BP >140/90 after 20 wk gestation, w/ associated edema and proteinuria, can be classified as mild to severe based on end-organ damage

•  Eclampsia: Preeclampsia w/ szs or coma; generally 3rd trimester or postpartum

•  Atypical preeclampsia/eclampsia can present postpartum or <20 wk

Approach to the Patient

History

•  HA, visual disturbances, mental status changes, abdominal pain, edema. ROS plural gestation? PMH (prior preeclampsia, nulliparity, extremes of age, HTN, obesity, antiphospholipid antibody syndrome, DM, chronic renal dz, connective tissue disorder)

Physical Exam

•  HTN, abdominal tenderness, hyperreflexia/clonus, peripheral edema, papilledema, altered sensorium

Evaluation

•  UA, CBC, Chem 7, LFTs, uric acid, coags, type and crossmatch, fetal/maternal monitoring

Treatment

•  BP: Hydralazine, labetalol, or nitroprusside (goal BP <140/90)

•  Sz prophylaxis: Magnesium 2–6 g IV load + 1–2 g/h

•  Szs: Magnesium (2–4 g IV q5–10min); refractory szs: Diazepam (5 mg IV q5min up to 20 mg) OR phenobarbital (200 mg IV)

•  Consult: Gyn for all pts; delivery = only definitive tx for eclampsia

Disposition

•  Home: Mild preeclampsia; schedule OB f/u in 24 h

•  Admit: Eclamptic and most severe preeclamptic pts need urgent delivery (pending BP and sz control) and ICU admission

HYPEREMESIS GRAVIDARUM

Approach to the Patient

History

•  Persistent vomiting? Poor urine output? Weight loss?

Physical Exam

•  Orthostatic hypotension, tachycardia, decreased skin turgor

Diagnostics

•  Chem 7, UA (for spec gravity and ketones)

Treatment

•  Supportive: IVF resuscitation w/ substrate (dextrose)

•  Antiemetics: Ondansetron (Class B, 1st line) or Compazine (Class C, 2nd line)

Disposition

•  Admit: Severe dehydration, unable to tolerate POs, acidosis or ketosis

EMERGENCY DELIVERY

Definition

•  True labor: Regular uterine contractions of increasing intensity at decreasing intervals

•  1st stage: Cervical dilatation and effacement (up to 12 h)

•  2nd stage: Complete cervical dilatation, culminating in delivery (up to 2 h)

Approach to the Patient

History

•  Frequency and intensity of contractions, rupture of membranes, fetal movement, has pt had prenatal care for eval of cx of pregnancy, screening tests, etc.

Physical Exam

•  External exam: Assess for crowning or active bleeding (if so, defer speculum/bimanual exam)

•  Sterile speculum exam: Confirm ROM by checking for ferning and/or Nitrazine test

•  Bimanual exam: Assess cervical effacement and dilatation (10 cm = complete), position, presentation (fetal part in canal), lie (relation of long axis to mother → longitudinal or transverse), and station (–3 to +3; 0 is at level of ischial spines); cord prolapse?

Diagnostics

•  Abdominal U/S if placenta previa of concern

Treatment

•  ED:

•  Cord prolapse: Manually place hand in vaginal vault, lift presenting part away from cord; place pt in knee–chest position or deep Trendelenburg. Administer tocolytics (magnesium 4–6 g IV, terbutaline 0.25 mg SQ).

•  Vaginal delivery: Place mother in lithotomy position; cleanse/drape perineum if possible; w/ contractions, ask mother to “bear down”

•  Head: One hand on occipital area and other on perineum, maintain fetal head in flexed position; if cord wrapped at neck loosen or cut cord

•  Shoulders: Rotate head and exert gentle pressure until anterior shoulder delivered; lift head upward to deliver posterior shoulders, attempt to guide posterior shoulder over perineum. If shoulders will not deliver, perform episiotomy by anesthetizing perineum; make sure to avoid anal sphincter.

•  Body: Support head and catch body w/ the other hand. Suction mouth and nose.

•  Cord: Clamp cord twice and cut, send cord blood for serology and Rh. Clamp cord 1–3 cm distal to navel and place child in heated isolette. Obtain Apgar scores at 1 and 5 min.

•  Placenta: Apply pressure above symphysis w/ minimal traction on cord (too much traction will cause uterine inversion); sudden gush of blood and lengthening cord will signify imminent placental delivery.

•  Aftercare: Massage uterus ± oxytocin 20 U IV (can be given as 10 U IM if no IV access for ongoing hemorrhage); inspect and repair lacerations of cervix, vagina

•  Perimortem delivery: >23 wk gestational age, should initiate w/i 4 min of maternal arrest, potential benefit up to 20 min post arrest

•  Vertical incision from 2–3 cm above pubic symphysis to 1 cm below the umbilicus and extend through subcutaneous fat to rectus sheath

•  Grasp rectus sheath w/ forceps and make incision w/ Mayo scissors to expose the uterus

•  Make midline vertical incision through uterus w/ scalpel/scissors and deliver fetus

FEMALE PELVIC PAIN

Approach to the Patient

History

•  Dyspareunia, vaginal bleeding or d/c? Urinary sxs, ROS PMH (STDs, recent procedure) MEDS (contraceptive devices, hormonal therapy), social (domestic violence)

Physical Exam

•  Abdominal exam; Gyn exam (d/c or bleeding, masses or tenderness)

Diagnostics

•  Labs: UA, GC/Chlamydia, Wet mount

•  Imaging: Pelvic U/S (assess flow, torsion, mass, fluid)

Ovarian Cyst

History

•  Dull, vague, unilateral sensation of pelvic pain or dyspareunia

•  Rupture: Sudden, unilateral, sharp pelvic pain; can also present as diffuse peritonitis

Physical Exam

•  Lower quadrant abdominal tenderness, adnexal tenderness/mass, vaginal bleeding

Evaluation

•  Labs: CBC, type and screen (crossmatch if HD unstable)

•  Imaging: Pelvic U/S to assess for size, complexity, torsion, presence of free fluid. Bedside FAST if HD unstable.

Treatment

•  Supportive: IVFs, transfuse if HD unstable

•  Analgesia: NSAIDs, Narcotics prn

•  Consult: Gyn Service for persistent pain, large-volume hemorrhage

Disposition

•  Home: Stable, pain well controlled; f/u w/ Gyn or PCP in 1–2 mo for repeat U/S to reassess size

•  Admit: HD unstable

Ovarian Torsion

History

•  Acutely worsening unilateral lower abdominal/pelvic pain, N/V

•  Can present as intermittent torsion w/ intermittent sxs

•  RFs: Ovarian cysts, dermoid and other tumors, pregnancy

Physical Exam

•  Nonspecific and variable; Gyn exam reveals unilateral, adnexal mass in majority of cases ± tenderness (though tenderness absent ∼30% of the time)

Evaluation

•  Labs: Urine hCG

•  Imaging: Pelvic U/S to assess for ovarian edema, cyst/mass, blood flow

Treatment

•  Analgesia/antiemetics

•  Consult: Gyn service for urgent laparoscopy

VAGINAL DISCHARGE (SEXUALLY TRANSMITTED INFECTION)

History

•  Purulent or malodorous d/c? Dyspareunia? Pruritus? Postcoital bleeding? Dysuria, urinary frequency or urgency

•  RFs: Multiple sexual partners and unprotected intercourse

Physical Exam

•  External: Inspect for lesions, ulcerations; adenopathy

•  Speculum: Vaginal wall inflammation/d/c; cervical inflammation/d/c

•  Bimanual: If cervical motion tenderness or adnexal tenderness, think PID (see below)

Evaluation

•  Labs: GC/Chlamydia testing; wet mount

Treatment

•  N. gonorrhoeae: Ceftriaxone 125 mg IM × 1

•  C. trachomatis: Azithromycin 1 g PO × 1 OR doxycycline 100 mg PO BID × 7 d OR levofloxacin 500 mg PO QD × 7 d

•  T. vaginalis: Metronidazole 2 g PO ×1 OR 500 mg PO BID × 7 d

•  Bacterial vaginosis metronidazole 500 mg PO BID × 7 d OR metronidazole 0.75% gel intravaginally × 5 d × 1 OR clindamycin 2% cream intravaginally × 7 d

•  Candidiasis: Topical azoles (over the counter) × 7 d OR fluconazole 150 mg PO × 1

Pearls

•  Educate all pts on safe sex practices

•  Advise pts to tell their partners to get tested/treated

PELVIC INFLAMMATORY DISEASE AND TUBO-OVARIAN ABSCESS

History

•  As above, plus abdominal/back pain, fever/systemic sxs

Physical Exam

•  Abdominal exam: Abdominal tenderness; RUQ tenderness (Fitz-Hugh–Curtis syndrome)

•  Speculum: Cervical inflammation/d/c

•  Bimanual: Cervical motion tenderness, adnexal mass/tenderness

Evaluation

•  Labs: GC/Chlamydia testing, CBC, blood cultures if suspected sepsis

•  Imaging: Pelvic U/S ± CT if concern for TOA

Treatment

•  Abx: Ceftriaxone 250 mg IM × 1 AND (doxycycline 100 mg PO BID OR azithromycin 1 g qwk × 14 d) OR cefoxitin 2 g IV q6h OR cefotetan 2 g IV q12h AND doxycycline 100 mg PO/IV q12h OR clindamycin 900 mg IV q8h AND gentamicin 2 mg/kg IV × 1 then 1.5 mg/kg q8h

•  Consult: Gyn service if concern for TOA

Disposition

•  Home: Reliable pts w/ simple PID

•  Admit: Tubo-ovarian abscess, pregnant, unable to tolerate POs

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