APRIL 4 , 2013ELIZABETH SHOULDICE, MD CCFP(EM)
CCFP(EM) Academic Half Day
Obstetrical and Gynecological Emergencies:Women’s Health on the Fly
Agenda
Who am I?
Case Based
Gynecological Emergencies
Obstetrical Emergencies
Group Discussion
Who am I?
Conflict of Interest
None
Acknowledgments
Dr. Liisa HoneyDr. Sunita LalDr. Kimberley Creaser
Objectives
Vaginal bleeding/complications in the first 20 weeks of pregnancy
Vaginal bleeding/complications in the second 20 weeks of pregnancy
Obstetrical EmergenciesPreeclampsia and eclampsiaPostpartum emergencies Sexually transmitted infections
Case #1
Queensway Carleton Hospital26 y.o. female presents to triage after
“fainting” at workAccompanied by her partnerVitals: 37.5, 110, 85/50, 20, 100% ORAResuscitation room
Case #1
Brief history: On Alesse No medical problems Recent GI illness, vomiting/diarrhea No pregnancies LMP 2 weeks ago
Nurses: 2 large IVs, NS, Labs: CBC, lytes, BUN, Cr, Type cross match,
quantitative βHCG
Case #1
Abdomen soft, tender diffuselyBimanual exam, tender R adnexa, + blood on
gloveEDE: Free fluid RUQ, no IUPWhat do you do?
Case #2
Hay River, NWT18 year old femalePresents to ED with abdominal painVitals within normal limitsRecent treatment for ectopic pregnancy in
referral centre, discharged 5 days agoWhat would you do?
Case #2
Treated with single dose methotrexate in Yellowknife
Has not had serial βHCGVitals: 37.5, 85, 105/70, 20, 100% ORAAbdomen soft, non tenderBimanual exam no adnexal tenderness, no
bleeding EDE: No free fluid, no IUP, no formal U/S
available for a week, unless you ship her outHb stable, βHCG decreasingWhat now?
Ectopic Pregancy
~2% of all pregnancies Unless IUD in place, risk increases to 1/20
Risk factors: PID, surgical procedures, previous ectopic, DES
exposure, assisted reproductionTreatment with methotrexate becoming more
common Beware of ruptured tube, can happen days after mtx
ISRN Obstet Gynecol. 2012;2012:637094. Epub 2012 Feb 19. The evolution of methotrexate as a treatment for ectopic pregnancy and gestational trophoblastic neoplasia: a review.Skubisz MM, Tong S.Prescrire Int. 2009 Jun;18(101):125-30.Intrauterine devices: an effective alternative to oral hormonal contraception. Acta Obstet Gynecol Scand. 2009;88(12):1331-7.Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies: a randomized trial.Krag Moeller LB, Moeller C, Thomsen SG, Andersen LF, Lundvall L, Lidegaard Ø, Kjer JJ, Ingemanssen JL, Zobbe V, Floridon C, Petersen J, Ottesen B.
Case #3
Queensway Carleton Hospital29 y.o. femaleCC: PV bleeding x 10 days, G2P2
HPI: Delivery of healthy male child October 26 Light PV bleeding in December At time of assessment PV bleeding x 10 days
Case #3
HPI (cont’d): LLQ pain 3/7 before ED visit
Positive home pregnancy test on day of ED visit
Case #3
O/E Triage Vitals: 36.6 86 128/76 97%ORA
Looks well, no distress
Normal abdo and PV exam
EDE: deferred
Case # 3
Labs:
βHCG 284223
Case # 3
Patient returned next day: Formal U/S:
Mildly thickened endometrium R/O molar pregnancy
EDE Equivocal
Case # 3
Called obs/gyne: ?trophoblastic tissue elsewhere Repeat βHCG, add liver enzymes, coags and CXR Resident will be down to see patient
Case # 3
CXR
Case # 3
Resident assessment Ordered CT head/chest/abdomen/pelvis in a.m. Revealed 5cm splenic metastasis
Discussed with gyne onc at OGH Will see urgently
Arranged urgent D&C for next dayDiagnosis metastatic choriocarcinoma
Case #3
Admitted to gyne onc at OGH Feb 9 for expedited treatment
Stage IV High risk, requiring combination chemotherapy Goal of cure 5-7 % chance of infertility
First & Second Trimester Bleeding
Gestational Trophoblastic Diseases (GTD) Disorders of fertilization
Hydatiform mole• Noninvasive, localized• 90% of cases• Starts with empty egg, fertilized by two sperm
Placental site trophoblastic tumor Choriocarcinoma Gestational trophoblastic neoplasia
Learning Points (cont.)….
Arise from trophoblastic epithelium of placenta
All are characterized by high βHCG Maternal tumor arises from gestational
tissue, not maternal tissueCan develop from molar pregnancy or from
TA/SA, ectopic, term or preterm pregnanciesVery rare, hydatidiform mole 23-1299/100
000 pregnancies, other types even more rare
Learning Points (cont.)….
Risk factors Extremes of maternal age (>35 and <20) History of previous GTD Smoking History of infertility Nulliparity OCP use
Learning Points (cont.)….
Presentation PV bleeding Enlarged uterus Pelvic pain Theca lutein cysts Anemia Hyperemesis gravidarum Hyperthyroidism (βHCG has thyroid stimulating
activity) Preeclampsia before 20 wks gestation
Learning Points (cont.)….
Monitoring of βHCG after molar pregnancy is often how GTN is diagnosed Must be monitored for at least 6 months
Ultrasound can have characteristic appearance, but often misdiagnosed as incomplete or complete abortion
Learning Points (cont.)….
Management Initial management is always D&C, useful for
pathology Very common to have increased hemorrhage, need to
have blood on hand Thorough work up for distant metastases Chemo, at times prophylactically for high risk disease Contraception
Learning Points (cont.)….
http://radiographics.rsna.org/content/21/6/1409/F11.expansion.html
Learning Points (cont.)….
Consider quantitative βHCG Even if you’re somewhere where this is difficult!
Even if U/S shows nothing, with very high βHCG consider GTD
Look for trophoblastic tissue elsewhere (CXR, liver enzymes, CT)
High propensity for bleeding Consider transfer for D&C to centre with blood and
ICU
Quick Points – First Trimester Bleeding
Notes from our gynecology consultants:
Spontaneous miscarriage – patients with severe pain or vasovagal response, examine for products of conception in the cervical os
Retained products of conception <8 weeks gestation can often be managed by two doses of misoprostol 800ug q24 hours
Don’t forget to give miscarrying patients pain control for home, narcotics are often required
Second & Third Trimester Complications & Bleeding
Vaginal bleeding in the second 20 weeks of pregnancy Placental abruption Placenta previa Uterine rupture Vasa previa Preterm labour
Second & Third Trimester Complications & Bleeding (cont.)….
Key Points:Evaluation of Preterm Labor
Pelvic pressure, vaginal discharge, vaginal bleeding, or low-back pain
Many hospitals require patients with pregnancies less than 20 weeks gestation to be evaluated in the emergency department
A detailed history of symptoms can help differentiate between spontaneous and evoked preterm labor
A complete obstetric history, including gestational age, is important to determine the risk for possible recurrent preterm birth
Maternal vital assessment, especially temperature and blood pressure
Prim Care. 2012 Mar;39(1):95-113. Third-trimester pregnancy complications. Newfield E
Second & Third Trimester Complications & Bleeding (cont.)….
Fetal vital assessment Documentation of normal fetal heart tones is sufficient for fetuses < 23
wks Continuous external fetal heart rate monitoring for all > 24 wks Continuous tocometry is recommended Informal (bedside) US should be performed
Physical exam of should be performed, including ultrasound before sterile PV exam
Fetal fibronectin Invalid if the cervix has been manipulated in the prior 24 hours A glycoprotein present at the maternal-fetal interface, absent
between 24 and 34 weeks’ gestation. The negative predictive value of the test approximates to 99%;
symptomatic patients with a negative result of fetal fibronectin test are very unlikely to deliver in the following 7 days
Second & Third Trimester Complications & Bleeding (cont.)….
Causes of preterm labour…. Neisseria gonorrhoeae and Chlamydia trachomatis,
bacterial vaginosis, trichomoniasis, or Candida infection
Urine analysis and culture is recommended Cocaine and amphetamines are associated with
preterm labor, often secondary to placental abruption
Other considerations…. Group B Streptococcus (GBS) testing should be
performed
Case #4
Perth and Smiths Falls District Hospital, Perth Site
February 19, 20130330 Nurse Calls the On Call Room:
32 year old, G6P4SA1, 41W1D 3 hours of contractions 1 minute apart, lasting 30 seconds In the department, midwife told her she wouldn’t
make it to Almonte Nearest obstetrical unit 20-30 minutes away You’re the only MD in the hospital
What do you do?
Case #4
Obstetrical Emergencies
Emergency Delivery Equipment Personnel Rest of the department OB unit on the phone! Neonatal consideration
Case #5
Dominican Republic, 2011
Case #5
18 year old womanPresents to “clinic”Reports being 8 months gestation and
concerned re: decreased fetal movement and wanting refill of medication
One previous pregnancy, complicated by preterm birth for seizure, baby did not survive
Limited family support, as family have all moved to US
Shows box of labetolol given in neighbouring town
Case #5
Vitals: 37.5, 70, 160/110, 20, 100% ORAFurther history:
Denies headache or blurred vision, but reports increased ankle edema (does the ankle edema matter??)
On examination: Gravid uterus No abdominal pain FHT >120, with bell of stethoscope
What now?
Preeclampsia & Eclampsia
Hypertensive disorders account for 15% of maternal deaths Four categories:
chronic hypertension preeclampsia/eclampsia gestational hypertension preeclampsia superimposed on chronic hypertension
Preeclampsia: Affects 3 to 5% of pregnant women Can result in maternal and perinatal morbidity and mortality Higher rates in developing countries No single screening test used for preeclampsia prediction has
gained widespread acceptance into clinical practice
Rev Bras Ginecol Obstet. 2011 Nov;33(11):367-75. Early screening for preeclampsia.Costa Fda S, Murthi P, Keogh R, Woodrow N.
Preeclampsia & Eclampsia (cont.)….
Severe preeclampsia 1 of the or signs in the presence of preeclampsia: SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2
occasions at least 6 hours apart Proteinuria of more than 5 g in a 24-hour collection or more than
3+ on 2 random urine samples collected at least 4 hours apart Pulmonary edema or cyanosis Oliguria (< 400 mL in 24 h) Persistent headaches Epigastric pain and/or impaired liver function Thrombocytopenia Oligohydramnios, decreased fetal growth, or placental abruption
Preeclampsia & Eclampsia
The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) can be considered a variant of severe preeclampsia
May present independently of hypertension and proteinuria
Risk for severe maternal and fetal complications; perinatal mortality has ranged from 7% to 60% and maternal mortality is high
Case #6
The Ottawa Hospital, Civic Campus 37 year old woman, 5 weeks post partum First pregnancy No complications Baby at home with father Presents as blood pressure “high” at postpartum visit
with family physician
Case #6
Vitals: 37.5, 70, 160/110, 20, 100% ORAO/E…..
Patient has generalized tonic clonic seizure
Treatment?? IV MgSO4 4g IV Bolus, then 2g IV/hour
Further management? Benzos prn Close monitoring
Case #7
Queensway Carleton Hospital33 y.o. female presents to triage with R lower
quadrant abdominal pain, 17 weeks pregnantVitals: 37.2, 88, 97/61, 20, 100% ORACubicles
Case #7
G3P2No PV bleedingPain worse with movementNo fever, chills, urinary symptomsEDE - + FHT, fetal movementDiscussed with gyne ?round ligament pain, ?MSKFormal U/S – + FHT, small amount of free fluid,
appendix not visualized, normal flow to R ovary, but + tender during exam
General surgery consulted, clinically not appendicitis, return for R/A prn
Case #7
Next day, patient returns, pain worseNow vomitingU/S repeated – SLIUP, appendix normal,
simple cyst R ovary, larger than previous, no definite flow, ovarian torsion on DDx
Patient taken to OR by general surgery and gyne
Right ovarian torsion, tube and ovary remained necrotic after being untorted
Right salpingo-oophorectomy
Case #7
What are the key points? Can mimic appendicitis Can have nausea, vomiting and fever (caused by
necrosis) ~20% of ovarian torsion occurs in pregnancy Torsion most commonly occurs in women under 30
Was this a missed torsion? What do you think?
Sexually Transmitted Infections
http://www.phac-aspc.gc.ca/std-mts/sti-its/
QUESTIONS? COMMENTS? CONCERNS?
Thanks!