1. Gynecology and Obstetrics
Tintinall’s
Jay Cleveland
10/5/06

2. 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

3. 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

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

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

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

7. 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

8. 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

9. Adolescent bleeding Anovulation Pregnancy Exogenous hormone use
Coagulopathy

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

11. Perimenopausal Anovulation Uterine leiomyomas
Cervical and endometrial polyps
Thyroid dysfunction

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

13. 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

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

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

16. Ovarian Cysts

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

18. Torsion

19. 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

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

21. 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

22. 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

23. 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

24. Other causes to consider
Appendicitis
Diverticulitis
Incarcerated Hernias

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

26. Ectopic Pregnancy

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

28. 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

29. 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

30. 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!

31. 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

32. 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

33. 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)

34. 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

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

36. 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

37. 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)

38. 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

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

40. 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

41. Specific issues in Pregnancy

42. 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

43. 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

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

45. 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

46. Comorbid Diseases

47. 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)

48. 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

49. 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

50. 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

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

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

53. 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)

54. 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

55. Radiation Exposure
What rad procedure has the lowest rad exposure to the fetus?
CXR W/ SHIELDING ( )
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