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EMERGENCIESOB-GYN
Nilesh Patel, DO, FACOEP, FAAEMPROGRAM DIRECTOR
ST. JOSEPH’S REGIONAL MEDICAL CENTER, PATERSON, NJ INTENSE REVIEW, JANUARY 16, 2016
DISCLOSURESCSL Behring
Paid speaker/consultantKcentra, 4 factor PCC
DIAGNOSISSoft ragged edge
CHANCROIDHaemophilus ducreyi
PainfulSoft ulcerUnilateral inguinal lymph node
DIAGNOSIS?Cauliflower like papules
VENEREAL WARTS-HPVCondyloma Acuminatum
Diagnosis?
SECONDARY SYPHILIS
Condyloma lataFlat wart like lesions
DIAGNOSIS?
UMBILICATED PAPULE
TERMSMOLLUSCUM CONTAGIOSUM
MOLLUSCUM CONTAGIOSUM
Umbilicated papuleSemisolid white materialAnywhere on skin
DIAGNOSIS?Erythematous base
GENITAL HERPESPainfulVesicles + ErythematousBase → Ulcerate
MC-HSV-2
TERMSMULTINUCLEATE
GIANT CELLS
TERMSMULTINUCLEATED GIANT CELL HERPES
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES
DIAGNOSIS?
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
• LYMPHOGRANULOMA VENEREUMChlamydia trachomatis
PELVIC INFLAMMATORY DISEASEOne of the following:CMTAdnexal tendernessUterine tenderness
Treat NG/CT
PELVIC INFLAMMATORY DISEASE Admit
IV ABX
Pregnant TOAPeritonealSeptic
No POUnknown DXIUD
PIDMild – moderate PID can be treated as an OUTPATIENT due to similar efficacy of IV vs PO antibiotics
Clinical pearl
ABX
INPATIENTOUTPATIENT
PIDEctopic pregnancy
Complications
AdhesionsTOAInfertility
FITZ HUGH CURTISQuick pearls
Shoulder/RUQ pain – Kehr’s signBacterial perihepatitis
VIOILIN STRING ADHESIONSTERMS
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS
DIAGNOSIS?Hard raised edge
SyphilisTreponema pallidum
Painless Indurated UlcerPainless LN
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
SECONDARY SYPHILIS
CONDYLOMA LATAMACULOPAPULAR RASH
TERMSTERTIARY SYPHILIS TABES DORSALIS, GUMMA
SYPHILISTx
PCN G ( 2.4 million units)
Doxycycline
DX SEROLOGY- VDRL/RPR
DIAGNOSIS?Strawberry cervix
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONAS
Trichomonas VaginalisStrawberry cervixGray/ yellow frothy discharge
ABX--METRONIDAZOLE
DIAGNOSIS?Clue cells
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS
BACTERIAL VAGINOSISGardnerella vaginosis
ABX--METRONIDAZOLE
CLUE CELLSKOH test-”FISHY ODOR”
DIAGNOSIS?
CANDIDACottage Cheese D/CKOH test - PSEUDOHYPHAE
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOUSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS
COTTAGE CHEESE D/C CANDIDA VAGINITIS
OVARIAN CYSTSComplications (HuRT)
HemorrhageRuptureTorsion
DX: US/LAP
DIAGNOSIS??OVARIAN TORSION
ABSENT DF
OVARIAN TORSION Risk Factors → Tumors & CystsMC: DERMOIDDX: LAP US
FAST FACTS OVARIAN CA
2 ND MC GYN CAHIGHEST MORTALITY
AGE > 60DX: US/CT/LAP
OVARIAN CACLINICAL PEARLNEW ONSET ASCITES IN FEMALEGYNECOLOGIC CA (TILL PROVEN OTHERWISE)
FAST FACTS Uterine CA
MC type?Most virulent?
Dx : Pap? (20%)
Age 60 -70
EndometrialSarcoma
DX: D&C/BX
UTERINE CAClinical PearlPost menopausal female withbleeding / abnml uterine enlargementUterine CA (Till proven otherwise)
FAST FACTS Pregnancy
Position - SymphysisPosition – Umbilicus
Blue, soft cervix
12 Weeks
Chadwick’s sign20 Weeks
TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOUSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS
COTTAGE CHEESE D/C CANDIDA VAGINITISCHOCOLATE CYST ENDOMETRIOMA
CHADWICK’S SIGN (Early) pregnancy
FAST FACTS Human Chorionic Gonadotropin
Earliest (+) hCG?Peak?
Doubles q 2-3 days
10-12 weeks8-9 days
1 st 7-8 weeks?
(+) Post delivery / abortion? 2-3 weeks post
B - hCGClinical PearlDON’T FOLLOW THE ABSOLUTE NUMBER TO DETERMINE VIABILITY, FOLLOW THE US(Especially > 10 WEEKS)
DSC Zone = HCG 1500Gestational SAC
Gestational Sac + Yolk Sac
Double decidual sign
Yolk sac & fetal pole
FAST FACTS Physiologic changes in pregnancy
23 yo G1 LMP 8 weeks ago presents with the following labs:(+) Hypokalemia(+) Ketonuria
IV hydration (D5NS)/ Antiemetics
HYPEREMESIS GRAVIDARUM
DIAGNOSIS?
SUBCHORIONIC HEMORRHAGE
FAST FACTS 1 ST TRIMESTER BLEEDING
50/50~20-25% affected 3 DDx ECTOPIC
ECTOPICECTOPICSCHABORTION
KEY FEATURES TREATMENTOS CLOSED RESTTHREATENED
TISSUE @OS D&CINCOMPLETEOS OPEN/TISSUE AT UTERUS ±D&CINEVITABLE
PASSED TISSUE RESTCOMPLETE
RETAINED POC IV ABX/D&CSEPTICRETAINED POC MISSED ±D&C
FAST FACTS 1 ST TRIMESTER BLEEDING
FAST FACTS RhoGHAM
Risk of fetal maternal hemorrhageWHO? WHEN?DOSE? 300 mcg 2/3 trimester
50 mcg 1st trimester
Risk of isommunization to <1%
DIAGNOSIS?
ECTOPIC PREGNANCY
FAST FACTS ECTOPIC PREGNANCY
ECTOPIC PREGNANCY & hCGNO SINGLE HCG IN ISOLATIONRULES OUT ECTOPIC
CLINICAL PEARL
IF NO GS WITHIN DISCRIMINATORYZONE = ECTOPIC TILL PROVEN OTHERWISE
1500 TV 6500 TA
Methotrexate candidates:
FAST FACTS ECTOPIC PREGNANCY
HCG < 5000Hemodynamically stableSize < 3-4 cmWBC > 2k; Platelets > 100k
“SNOWSTORM”Molar pregnancy
FAST FACTS MOLAR PREGNANCY
PAINLESS VAGINAL BLEEDINGUTERINE SIZE > GESTATIONAL AGEHIGHER THAN EXPECTED hCGHYPEREMESIS
VAGINAL BLEEDINGBLOODY SHOWABRUPTIO
MC CX?
(late pregnancy – 4%)
MC LIFE THREATNING CX?
WHAT’S LEFT? PLACENTA PREVIA VASA PREVIA UTERINE RUPTURE
DIAGNOSIS?PLACENTA PREVIA
PLACENTA PREVIA
DX: US
PLACENTA PREVIACLINICAL PEARLHemorrhage often stopsspontaneously and then recurs with labor
TX: SUPPORTIVE(ABCs, T & C, emergent consultation)
PLACENTA ABRUPTIOPAINFUL DARK/CLOTTED (3RD TRI) VBPAINFUL/FIRM/TENDER UTERUS
DX: CLINICAL, US, FETAL MONITOR
FAST FACTS PLACENTA ABRUPTIO
Spontaneous RFs? HTN, age, multiparous, stimulants, pre-eclampsia
Spontaneous MC v. Trauma
Complications? Fetal/Maternal Death, DIC
Dx? US (Nonspecific) Tocolytic monitoring
PLACENTA PREVIACLINICAL PEARLDegree of bleeding DOES NOT correlate with potential severity
TX: SUPPORTIVE ± DELIVERY(ABCS, T & C, Coags, Kleihauer-Betke test, Emergent consultation)
DIAGNOSIS?PLACENTA ABRUPTIO
AN 18 YO FEMALE PRESENTS TO YOUR ED WITH CC OF HA AND “DIFFICULTY SEEING”
VITALS 162/94; 104; 24; 99EXAM B/L EXTREMITY & FACIAL EDEMA
PREECLAMPSIA>20 WEEKS NEW ONSET HTN (140/90)
PROTEINURIA (300MG/24H)
<20 WEEK THINK MOLAR PREGNANCY
RFs PRIMIGRAVADAAge extremesDiabetesMolar pregnancyMultiple gestationRenal, Vascular, CTD
FAST FACTS PREECLAMPSIA (3-7%)
EXAM? EDEMA (HANDS/FEET/FACE)
VITALS? HYPERTENSIVE
URINE? PROTEINURIA
PROGRESSION TO ECLAMPSIA? 1 IN 200
FAST FACTS PREECLAMPSIA (3-7%)
ABCs, GLUCOSE, IV, FETAL MONITORING, LEFT LATERAL DECUBITUS
WORKUP? CBC, PLATELET, RENAL/LIVER FUNCTION, COAGS
WORKUP? HOSPITALIZE, ± ANTI-HTN, DELIVERY MAG (PREVENT/STOP SZ)
FAST FACTS MAGNESIUMDose: 4-6 gm IV over 20 min,2 gm/hrToxicity: Hypotension, Respdepression, AMSCa Gluconate 10%-10 ml over 3 minutes
FAST FACTS HELLPHemolysis, Elevated Liver enzymes, Low PlateletsPresentation: EpigastricpainTreatment: Same as preeclampsia
FAST FACTSECLAMPSIA
HYDRALAZINE 5-10 mg IV q20 min maximum 30 mg iv LABETALOL10-20 mg IV
DIAGNOSIS?
FAST FACTSTRAUMA IN PREGNANCYMaternal prognosis determines fetal prognosis
FAST FACTSTRAUMA IN PREGNANCY
Signs of fetal distress (DECELS) >8 Contractions/hour suggest abruption
KLEIHAUER BETKE
FAST FACTS TRAUMA – FMH
KEYS UNIVERSALRHOGHAM 300 MCG FOR RH (-) MOMS SUSTAINING BAT
FAST FACTS TRAUMATIC ARREST
KEYS TO FETAL SURVIVAL Cause of maternal deathGestational age Quality of CPRTIME FROM ARREST TO DELIVERYVertical abdominal and uterlne incision
Obstetric HemorrhagePreeclampsia/EclampsiaObstetric InfectionPulmonary EmbolismAmniotic Fluid EmbolismCardiomyopathyAnesthetic
33%
20%15%
13%
9%7% 3%
CAUSES OF PERIPARTUM MATERNAL DEATH
FAST FACTS POST PARTUM HEMORRHAGE
MC CX? UTERINE ATONY
TX UTERINE ATONY? FUNDAL MASSAGE, OXYTOCIN
OTHER CAUSES? UTERINE RUPTURERETAINED PLACENTAUTERINE INVERSIONLACERATIONCOAGULOPATHY
AN 32 YO FEMALE PRESENTS WITH CC OF “FOUL SMELLING” VAGINAL DISCHARGE AND ABDOMINAL PAIN. PATIENT REPORTS RECENT C/S 5D AGO
Vitals 110/60; 104;24;101.4
FAST FACTS ENDOMETRITIS
HIGH RATES IN C/S
PRESENTATION?
POLYMICROBIAL
FEVERABDOMINAL PAINFOUL SMELLING D/C Admit Broad spectrum ABX
DIAGNOSIS?MASTITIS
FAST FACTS MASTITIS
PRESENTATION? PAINFEVERERYTHEMASWELLING
CX? STAPHYLOCOCCALTX? CEPHALOSPORIN
SAFE TO BREASTFEED