Presentation on theme: "Guidelines for Treating Acute GYN Illnesses"— Presentation transcript:
1Guidelines for Treating Acute GYN Illnesses Critical ConceptsGuidelines for TreatingAcute GYN IllnessesLSU Department of OBGYN
2A 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?
3TRIAGE VITAL SIGNS:Temperature 98.8Blood Pressure 110/70Pulse 95Respirations 12Weight 220 poundsHeight 5’5’’Urine Pregnancy Test is Positive
4Take a Complete History HPI: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?
5Take a Complete History Initial Presentation - - -Patient’s LMP was about 7 weeks ago but she can’t remember the date; has not received any prenatal care yetPresent Illness – bleeding started 3 days ago but the amount of bleeding got worse today so she decided to come to the ERAssociated Symptoms – feeling tired and having some cramping in her belly over the past several hours
6Take a Complete History What else in your history taking will be important to know?What questions do you want to ask the patient?
7Take a Complete History Medical History – no medical problemsSurgical History - noneMedicines – IbuprofenAllergies – no known drug allergies; allergic to latexSocial History – tobacco use, social alcohol, no drugs
8Take 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
9First Trimester Bleeding What’s your differential diagnosis?
11Physical Examination – Patient #1 vital signs: BP 95/60 HR 100abdominal exam –midline tenderness to palpation, no rebound no guardingpelvic 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
13What do you want next??? LABS: - quantitative βhCG - Type and Screen - CBC- +/- CMPpelvic ultrasound (remember to order with transvaginal images)
14Results LABS: - quantitative βhCG = 5000 - Type and Screen = O negative, antibody negative- CBC =9 25026
15ResultsUltrasound report: uterus 8x4x3cm, irregular shaped gestational sac, fetus measuring approximately 7 weeks with no fetal cardiac activity notedFinal diagnosis??
16Spontaneous/Incomplete Abortion Gestational Sac – structure can be seen but may be irregular in shapeYolk Sac – may or may not be presentFetal cardiac activity will help to define type of miscarriage
17Intrauterine Pregnancy Gestational Sac – ring structure seen by 5 weeks embedded into the deciduaYolk Sac – appears at 5-6 weeks and disappears by 10 weeksFetal cardiac activity usually seen by 6 weeks
18Incomplete Abortion Options for management: Conservative management with/without prostaglandins to complete abortionSurgical therapy with suction D&COther considerations:Blood type – does this patient need RhoGam?Antibiotics if uterus was instrumented during examination
19Abortion DefinitionsComplete: all POC are expelled from uterine cavity, cervix closedIncomplete: partial expulsion of POC from uterine cavity with dilated cervical osThreatened: all POC in uterine cavity, with heartbeat, cervix closed, bleeding presentMissed: all POC in uterine cavity, no heartbeat, cervix closed
20Spontaneous AbortionIncidence: about 10-15% of clinically recognized pregnancies; nearly 80% before 12 weeks gestationRisk Factors:Advanced maternal agePrevious spontaneous abortion (20% after 1, 40% after 3 consecutive)SmokingExcess alcohol and caffeine intakeMaternal weight: BMI <18 or >25- Etiology: chromosome abnormalities account for about 50% of 1st trimester losses (nearly 90% of those 8 weeks or less)
22Physical Examination – Patient #2 vital signs: BP 95/60 HR 100abdominal exam – significant for right lower quadrant tenderness to palpation, no rebound, voluntary guardingpelvic 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
24What do you want next??? LABS: - quantitative βhCG - Type and Screen - CBC- +/- CMPpelvic ultrasound (remember to order with transvaginal images)
25Results LABS: - quantitative βhCG = 5000 - Type and Screen = O negative, antibody negative- CBC =9 25026- CMP shows that electrolytes and liver functions are within normal limits
26Results Final diagnosis?? 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 pelvisFinal diagnosis??
27Ectopic PregnancyDiagnosis of ectopic pregnancy is made by physical exam and ultrasound findingsClassic signs are: amenorrhea, abdominal pain, and vaginal bleedingDefinitive Diagnosis:(in adnexal region)cardiac activityfetal pole/fetusyolk sac
28Ectopic 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-upRelative contraindications:- beta >10, size >3.5cm- cardiac activity - free fluid in the pelvis
29Ectopic PregnancyIf MTX is contraindicated – proceed with surgical removal of ectopic by salpingostomy or salpingectomyOther 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?
30Ectopic Pregnancy Risk Factors: Pelvic inflammatory disease Previous ectopic pregnancyPrevious tubal or pelvic surgerySmokingCurrent use of an intrauterine deviceIncreasing ageMust have transvaginal ultrasound and quant beta hCG levels to accurately diagnose.
31What if her beta was only 1400?? Beta hCG level: rises in the first trimester and plateaus after about 10 weeks gestationdoubling of level occurs about every daysmajority of pregnancies will increase 66% every 48 hoursabnormal rise or plateau is correlated with abnormal pregnancyDiscriminatory zone: correlates the level of hCG with the ability to see a gestational sacwith transvaginal imagesREPEAT IN 48 HOURS