Gynecology and Obstetrics Tintinall’s 647-676 Jay Cleveland 10/5/06

Vaginal Bleeding in the Nonpregnant Patient Differential Dx of abnormal vag bleeding in nonpregnant reproductive aged females Ovulatory abnl bleeding Anovulatory abnl bleeding Non uterine bleeding

Ovulatory Bleeding May be associated with regular menstrual periods due to low estrogen levels Intermenstrual bleeding causes Cervical polyps Cervicitis Cervical CA Endometrial CA Fibroids

Ovulatory bleeding Heavy menstrual bleeding due to: Endometriosis PID Ovarian neoplasms

Anovulatory Bleeding Adolescence Secondary to immature hypothalamic-piuitary - ovarian axis Investigate when Bleeding >9 days Intervals< 21 days Anemia

Anovulatory Bleeding Reproductive Age Secondary to ovarian follicular degeneration - decreased estrogen Present classically as prolonged amenorrhea with periodic menorrhagia

Anovulatory Bleeding Most common cause of midcycle bleeding is ? OCP’s Other causes: Eating disorders Stress/exercise Meds that inc the p450 system of liver - leads to metabolism of glucocorticods causing withdrawal bleeding

Nonuterine bleeding Coagulation disorders accounts for 20% or acute monorrhagia in adolecents (VWD most common) Vaginal lacs - aka Steve Hodes Special Consider, urinary tract lesions (urethral carbuncles, urethral diverticula) Cervical CA, polyps, infection

Adolescent bleeding Anovulation Pregnancy Exogenous hormone use Coagulopathy

Reproductive Pregnancy Anovulation Exogenous hormone use Uterine leimyomas Cervical and endometrial polyps Thyroid dysfunction

Perimenopausal Anovulation Uterine leiomyomas Cervical and endometrial polyps Thyroid dysfunction

Postmenopausal Endometrial lesions (30%) Exogenous hormone use (30%) Atrophic vaginits (30%) Other tumor - vulvar, vaginal, cervical (10%)

Management of Uterine Bleeding If hemodynamically stable Premarin10mg/d x 7-10 days or 25mg IV q 4 hrs x 24 hrs Provera (should be added to premarin when bleeding subsides or can use alone for 10 days) Note that stopping will cause a synchronized withdrawal bleed OCP full dose x 7 days or taper x 9 days

Abdominal and Pelvic Pain in Nonpregnant Patients Long list of differential dx

Ovarian Cysts Rupture, hemorrhage, torsion, infections Hx - sudden onset unilateral pelvic pain PE - Peritoneal signs if ruptured Tests - UPT, HCT, UA, Pelvic US

Ovarian Cysts

Adnexal torsion Hx of adnexal cyst/tumor Sudden onset unilateral pelvic pain PE- peritoneal signs if rupture Tests - UPT, HCT, UA, US w/ doppler

Torsion

PID Hx - Lower abd/pelvic pain - often bilateral, vag bleeding or discharge, UTI sx’s, fever PE - Fever, CMT (chandelier sign), mucopurulent cervical discharge (every intern’s favorite) Dx - UPT, Cx’s for Gonorrhea, Chlamydia, U/S if TOA suspected

Endometriosis Hx - Dysmenorrhea, chronic pelvic pai, usually 30’s-40’s PE - variable Dx - UPT, Hct, UA, U/S

Adenomyosis Occurrs when endometrial glands and stroma exten into uterine musculature Hx - Dysmenorrhea, menorrhagia - usually 30’-40’s PE - Symmetrically enlarged uterus or mass Dx - UPT, hct, U/S

Leiomyomas (Fibroids) Most common pelvic tumor and most common indication for major surgery inwomen Hx - Pelvic pain or mass 30’s to 40’s PE - Pelvic or abd mass Dx - UPT, U/S

TOA Hx - Fever, unilateral lower abd or pelvic pain, vag bleeding or discharge PE - Fever, lower ad or adnexal TTP, +/- CMT Dx - UPT, Cx’s, U/S

Other causes to consider Appendicitis Diverticulitis Incarcerated Hernias

Ectopic Pregnancy Conceptus implanted outside the uterine cavity Classic triad Abd pain Vag bleeding Amenorrhea

Ectopic Pregnancy

Risk factors for Ectopic Pregnancy PID Hx of tubal surgery IUD Assisted reproduction Previous Ectopic Preg

Ectopic Pregnancy Bottomline is that EP must be considered in all women of childbearing age who present with abdominal or pelvic complaints or with unexplained signs/sx’s of hypovolemia

Lab Tests and EP Serum BhCG, UPT Nothing is 100%, for instance a dilute urine specimen can be falsely negative for pregnancy Clinical acumen is essential for diagnosing an EP US should be preformed even in pt’s with BhCG’s <500 as EP’s can occur at this level

The Battle With Ultrasound Begins Discriminatory zone - level of BhCG at which findings of an IUP are expected on sonography. IF BhCG is higher than the discriminatory zone and uterus is empty - suggests EP TV 1,500 TA 6,000 However, US should be preformed even in pt’s with BhCG’s <500 as EP’s can occur at this level - so call the tech in!

Treatment for EP Rhogam if Rh neg (regardless if bleeding noted as alloimmunization occurs with 0.1ml of fetal blood exposed to mother’s blood Laparoscopy vs MTX Pain after MTX -diff to know if sec to abortion or ruptured EP Bottomline - ID the EP and get an OB

Normal Pregnancy in the ED Regardless of chief complaint the possibility of pregnancy must be considered in every woman of reproductive age who presents to the ED 7% of women who stated there was no chance of pregnancy and had a nl previous menstrual period were in fact pregnant

Cardiovascular System 40-45% increae in circulating blood volume 43% increase in Cardiac Output 17% increase in Resting Heart Rate SVR decreases by 20% BP is lowest during 2nd Trimester Left Lateral Decubitus (uterus off IVC)

Cardiovascular System Elevation of diaphragm displaces heart superiorly and left - large cardiac silhouette and LAD on EKG Benign pericardial effusion is frequently present - enlarge heart on CXR

Respiratory System Dyspnea during pregnancy RR unchanged 40% inc in TV FRC decreased sec to diaphragm elevation

Gastointestinal System Gastric Reflux - delayed gastric emptying, decreased intestinal motility and decreased LES tone Placental Alk Phos may increase maternal serum Alk Phos Gallbladder emptying is delayed and less efficient - increases risk of cholesterol stones

Urinary System Inc kidney size, renal blood flow and GFR GFR may inc by >50% Dilation of ureteral and renal calyces sec to uretueral compression (less evident on left b/c sigmoid colon acts as a cushion)

Heme System Circulating blood volume expands 40-45% sec to inc plasma volume and number of erythrocytes Relative dec in Hgb (usually not <11) Mild leukocytosis 12,000 is normal Second trimester - dec leukocyte fcn leads to inc infection susceptibility

Endocrine System Hyperinsulinemia Fasting hypoglycemia Postprandial hyperglycemia - ensures glc supply to fetus

Pelvic Ultrasound What is the earliest definitve sonographic finding in pregnancy? Gestational sac When is it detected? 4-5 wks by TV 5.5-6 wks by TA

Specific issues in Pregnancy

Abdominal Discomfort Round Ligament Pain -- from tension causes lower abd pain (sharp, bilat or unilat and worse w/ movement, often noted EARLY in pregnancy. Braxton-Hicks Contractions --Irregular palpable contractions occurring during LATE pregnancy

Abdominal Discomfort Don’t forget about appendicitis, cholecystitis, and other acute surgical emergencies Where is the pain associated with appendicitis in late pregnancy? Up and to the Right

Syncope Differential Dx is Broad Anemia, electrolyte imbalance, dehydration, PE, arrythmia (PAC, PVC)

Medications PCN and cephalosporins are safe in any trimester Acetaminphen is agent of choice for pain or fever during pregnancy Phenergan, reglan are safe Lidocaine for anaesthetic Td immuniztion is safe

Comorbid Diseases

Diabetes 2-3% of all pregnancies 90% is gestational No oral hypoglycemics (poor control, congenital anomalies) Ketoacidosis occurs more rapidly and at lower glc levels (same Tx + fetal monitoring)

Hyperthyroidism Increased risk of preeclampsia, low birth wt and congintal malformations Txd w/ PTU - if purpuric skin rash stop PTU and start methimazole watch for agraulocytosis - do NOT start methimazole

Thyroid Storm Mortality Rate up to 25% IVF, O2, PTU, propranolol, actaminophen/cooling blanket (hyperthermia) DO NOT use radioactive iodine therapy - fetus will concentrate and cause congenital hypothyroidism

Chronic Hypertension - 4-5% or all pregnancies - 140/90 prior to 12th wk gestation - Rx when sys >160 or diastolic >100 - labetalol, nifedipine DO NOT use diuretics - dec placental blood flow or ACE-I - teratogenic Acute tx - labetalol, hydralzine

Thromboembolism DVT in 0.5% of preg Dx w/ Duplex PE - VQ scan, Pulm angio, +/-CT PE Do NOT tx with warfarin - crosses placenta

Asthma Exacerbation B2 agonist, iv or oral steroids (watch for hyperglycemia), SC epi (1:1000) Peak flow 380-550L/min Hypoxia worsened in supine position - leftward tilt

Cystitis/Pyelonephritis Inc urinary stasis (Right hydro) E.coli 75% Klebsiella or Proteus 10-15% Simple cystitis 3 day course of nitrfurantoin, amp or a cephalosporin Pyelo 10-15% become bacteremic --Hospitalize, IVF, Cephalosporin (2nd or 3rd gen)

Seizures Avoid valproic acid early in pregnancy - inc neural tube defes Single grand mal sz - fetal brady x 20 min. Leftward tilt, supplemental 02 Status - 50% fetus mortality, 33% maternal mortality --Aggressively tx. Low threshold for intubation - ventilation

Radiation Exposure What rad procedure has the lowest rad exposure to the fetus? CXR W/ SHIELDING (0.00005) KUB, L spine, Upper GI, Head CT, are all less than 0.3 Chest CT <1 What rad procedure has the highest rad exposure to the fetus? Barium enema potentially w/ 3.9, Abdominal or L-Spine CT are up there w/ 3.5