Critical Concepts 2013-2014
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Transcript of Critical Concepts 2013-2014
Critical Concepts 2013-2014
Guidelines for TreatingAcute GYN Illnesses
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??