ob-gyn emergenciesacoep.org/files/patel-obgyn-ir-2016.pdf · fetal/maternal death, dic. dx? us...

EMERGENCIESOB-GYN

Nilesh Patel, DO, FACOEP, FAAEMPROGRAM DIRECTOR

ST. JOSEPH’S REGIONAL MEDICAL CENTER, PATERSON, NJ INTENSE REVIEW, JANUARY 16, 2016

DISCLOSURESCSL Behring

Paid speaker/consultantKcentra, 4 factor PCC

DIAGNOSISSoft ragged edge

CHANCROIDHaemophilus ducreyi

PainfulSoft ulcerUnilateral inguinal lymph node

DIAGNOSIS?Cauliflower like papules

VENEREAL WARTS-HPVCondyloma Acuminatum

Diagnosis?

SECONDARY SYPHILIS

Condyloma lataFlat wart like lesions

DIAGNOSIS?

UMBILICATED PAPULE

TERMSMOLLUSCUM CONTAGIOSUM

MOLLUSCUM CONTAGIOSUM

Umbilicated papuleSemisolid white materialAnywhere on skin

DIAGNOSIS?Erythematous base

GENITAL HERPESPainfulVesicles + ErythematousBase → Ulcerate

MC-HSV-2

TERMSMULTINUCLEATE

GIANT CELLS

TERMSMULTINUCLEATED GIANT CELL HERPES

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM

MULTINUCLEATED GIANT CELL HERPES

DIAGNOSIS?

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

• LYMPHOGRANULOMA VENEREUMChlamydia trachomatis

PELVIC INFLAMMATORY DISEASEOne of the following:CMTAdnexal tendernessUterine tenderness

Treat NG/CT

PELVIC INFLAMMATORY DISEASE Admit

IV ABX

Pregnant TOAPeritonealSeptic

No POUnknown DXIUD

PIDMild – moderate PID can be treated as an OUTPATIENT due to similar efficacy of IV vs PO antibiotics

Clinical pearl

ABX

INPATIENTOUTPATIENT

PIDEctopic pregnancy

Complications

AdhesionsTOAInfertility

FITZ HUGH CURTISQuick pearls

Shoulder/RUQ pain – Kehr’s signBacterial perihepatitis

VIOILIN STRING ADHESIONSTERMS

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

VIOLIN STRING ADHESIONS FITZ HUGH CURTIS

DIAGNOSIS?Hard raised edge

SyphilisTreponema pallidum

Painless Indurated UlcerPainless LN

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS

SECONDARY SYPHILIS

CONDYLOMA LATAMACULOPAPULAR RASH

TERMSTERTIARY SYPHILIS TABES DORSALIS, GUMMA

SYPHILISTx

PCN G ( 2.4 million units)

Doxycycline

DX SEROLOGY- VDRL/RPR

DIAGNOSIS?Strawberry cervix

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS

STRAWBERRY CERVIX TRICHOMONAS

Trichomonas VaginalisStrawberry cervixGray/ yellow frothy discharge

ABX--METRONIDAZOLE

DIAGNOSIS?Clue cells

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS

STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS

BACTERIAL VAGINOSISGardnerella vaginosis

ABX--METRONIDAZOLE

CLUE CELLSKOH test-”FISHY ODOR”

DIAGNOSIS?

CANDIDACottage Cheese D/CKOH test - PSEUDOHYPHAE

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOUSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS

STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS

COTTAGE CHEESE D/C CANDIDA VAGINITIS

OVARIAN CYSTSComplications (HuRT)

HemorrhageRuptureTorsion

DX: US/LAP

DIAGNOSIS??OVARIAN TORSION

ABSENT DF

OVARIAN TORSION Risk Factors → Tumors & CystsMC: DERMOIDDX: LAP US

FAST FACTS OVARIAN CA

2 ND MC GYN CAHIGHEST MORTALITY

AGE > 60DX: US/CT/LAP

OVARIAN CACLINICAL PEARLNEW ONSET ASCITES IN FEMALEGYNECOLOGIC CA (TILL PROVEN OTHERWISE)

FAST FACTS Uterine CA

MC type?Most virulent?

Dx : Pap? (20%)

Age 60 -70

EndometrialSarcoma

DX: D&C/BX

UTERINE CAClinical PearlPost menopausal female withbleeding / abnml uterine enlargementUterine CA (Till proven otherwise)

FAST FACTS Pregnancy

Position - SymphysisPosition – Umbilicus

Blue, soft cervix

12 Weeks

Chadwick’s sign20 Weeks

TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOUSUM

MULTINUCLEATED GIANT CELL HERPES BUBOES LGV

VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS

STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS

COTTAGE CHEESE D/C CANDIDA VAGINITISCHOCOLATE CYST ENDOMETRIOMA

CHADWICK’S SIGN (Early) pregnancy

FAST FACTS Human Chorionic Gonadotropin

Earliest (+) hCG?Peak?

Doubles q 2-3 days

10-12 weeks8-9 days

1 st 7-8 weeks?

(+) Post delivery / abortion? 2-3 weeks post

B - hCGClinical PearlDON’T FOLLOW THE ABSOLUTE NUMBER TO DETERMINE VIABILITY, FOLLOW THE US(Especially > 10 WEEKS)

DSC Zone = HCG 1500Gestational SAC

Gestational Sac + Yolk Sac

Double decidual sign

Yolk sac & fetal pole

FAST FACTS Physiologic changes in pregnancy

23 yo G1 LMP 8 weeks ago presents with the following labs:(+) Hypokalemia(+) Ketonuria

IV hydration (D5NS)/ Antiemetics

HYPEREMESIS GRAVIDARUM

DIAGNOSIS?

SUBCHORIONIC HEMORRHAGE

FAST FACTS 1 ST TRIMESTER BLEEDING

50/50~20-25% affected 3 DDx ECTOPIC

ECTOPICECTOPICSCHABORTION

KEY FEATURES TREATMENTOS CLOSED RESTTHREATENED

TISSUE @OS D&CINCOMPLETEOS OPEN/TISSUE AT UTERUS ±D&CINEVITABLE

PASSED TISSUE RESTCOMPLETE

RETAINED POC IV ABX/D&CSEPTICRETAINED POC MISSED ±D&C

FAST FACTS 1 ST TRIMESTER BLEEDING

FAST FACTS RhoGHAM

Risk of fetal maternal hemorrhageWHO? WHEN?DOSE? 300 mcg 2/3 trimester

50 mcg 1st trimester

Risk of isommunization to <1%

DIAGNOSIS?

ECTOPIC PREGNANCY

FAST FACTS ECTOPIC PREGNANCY

ECTOPIC PREGNANCY & hCGNO SINGLE HCG IN ISOLATIONRULES OUT ECTOPIC

CLINICAL PEARL

IF NO GS WITHIN DISCRIMINATORYZONE = ECTOPIC TILL PROVEN OTHERWISE

1500 TV 6500 TA

Methotrexate candidates:

FAST FACTS ECTOPIC PREGNANCY

HCG < 5000Hemodynamically stableSize < 3-4 cmWBC > 2k; Platelets > 100k

“SNOWSTORM”Molar pregnancy

FAST FACTS MOLAR PREGNANCY

PAINLESS VAGINAL BLEEDINGUTERINE SIZE > GESTATIONAL AGEHIGHER THAN EXPECTED hCGHYPEREMESIS

VAGINAL BLEEDINGBLOODY SHOWABRUPTIO

MC CX?

(late pregnancy – 4%)

MC LIFE THREATNING CX?

WHAT’S LEFT? PLACENTA PREVIA VASA PREVIA UTERINE RUPTURE

DIAGNOSIS?PLACENTA PREVIA

PLACENTA PREVIA

DX: US

PLACENTA PREVIACLINICAL PEARLHemorrhage often stopsspontaneously and then recurs with labor

TX: SUPPORTIVE(ABCs, T & C, emergent consultation)

PLACENTA ABRUPTIOPAINFUL DARK/CLOTTED (3RD TRI) VBPAINFUL/FIRM/TENDER UTERUS

DX: CLINICAL, US, FETAL MONITOR

FAST FACTS PLACENTA ABRUPTIO

Spontaneous RFs? HTN, age, multiparous, stimulants, pre-eclampsia

Spontaneous MC v. Trauma

Complications? Fetal/Maternal Death, DIC

Dx? US (Nonspecific) Tocolytic monitoring

PLACENTA PREVIACLINICAL PEARLDegree of bleeding DOES NOT correlate with potential severity

TX: SUPPORTIVE ± DELIVERY(ABCS, T & C, Coags, Kleihauer-Betke test, Emergent consultation)

DIAGNOSIS?PLACENTA ABRUPTIO

AN 18 YO FEMALE PRESENTS TO YOUR ED WITH CC OF HA AND “DIFFICULTY SEEING”

VITALS 162/94; 104; 24; 99EXAM B/L EXTREMITY & FACIAL EDEMA

PREECLAMPSIA>20 WEEKS NEW ONSET HTN (140/90)

PROTEINURIA (300MG/24H)

<20 WEEK THINK MOLAR PREGNANCY

RFs PRIMIGRAVADAAge extremesDiabetesMolar pregnancyMultiple gestationRenal, Vascular, CTD

FAST FACTS PREECLAMPSIA (3-7%)

EXAM? EDEMA (HANDS/FEET/FACE)

VITALS? HYPERTENSIVE

URINE? PROTEINURIA

PROGRESSION TO ECLAMPSIA? 1 IN 200

FAST FACTS PREECLAMPSIA (3-7%)

ABCs, GLUCOSE, IV, FETAL MONITORING, LEFT LATERAL DECUBITUS

WORKUP? CBC, PLATELET, RENAL/LIVER FUNCTION, COAGS

WORKUP? HOSPITALIZE, ± ANTI-HTN, DELIVERY MAG (PREVENT/STOP SZ)

FAST FACTS MAGNESIUMDose: 4-6 gm IV over 20 min,2 gm/hrToxicity: Hypotension, Respdepression, AMSCa Gluconate 10%-10 ml over 3 minutes

FAST FACTS HELLPHemolysis, Elevated Liver enzymes, Low PlateletsPresentation: EpigastricpainTreatment: Same as preeclampsia

FAST FACTSECLAMPSIA

HYDRALAZINE 5-10 mg IV q20 min maximum 30 mg iv LABETALOL10-20 mg IV

DIAGNOSIS?

FAST FACTSTRAUMA IN PREGNANCYMaternal prognosis determines fetal prognosis

FAST FACTSTRAUMA IN PREGNANCY

Signs of fetal distress (DECELS) >8 Contractions/hour suggest abruption

KLEIHAUER BETKE

FAST FACTS TRAUMA – FMH

KEYS UNIVERSALRHOGHAM 300 MCG FOR RH (-) MOMS SUSTAINING BAT

FAST FACTS TRAUMATIC ARREST

KEYS TO FETAL SURVIVAL Cause of maternal deathGestational age Quality of CPRTIME FROM ARREST TO DELIVERYVertical abdominal and uterlne incision

Obstetric HemorrhagePreeclampsia/EclampsiaObstetric InfectionPulmonary EmbolismAmniotic Fluid EmbolismCardiomyopathyAnesthetic

33%

20%15%

13%

9%7% 3%

CAUSES OF PERIPARTUM MATERNAL DEATH

FAST FACTS POST PARTUM HEMORRHAGE

MC CX? UTERINE ATONY

TX UTERINE ATONY? FUNDAL MASSAGE, OXYTOCIN

OTHER CAUSES? UTERINE RUPTURERETAINED PLACENTAUTERINE INVERSIONLACERATIONCOAGULOPATHY

AN 32 YO FEMALE PRESENTS WITH CC OF “FOUL SMELLING” VAGINAL DISCHARGE AND ABDOMINAL PAIN. PATIENT REPORTS RECENT C/S 5D AGO

Vitals 110/60; 104;24;101.4

FAST FACTS ENDOMETRITIS

HIGH RATES IN C/S

PRESENTATION?

POLYMICROBIAL

FEVERABDOMINAL PAINFOUL SMELLING D/C Admit Broad spectrum ABX

DIAGNOSIS?MASTITIS

FAST FACTS MASTITIS

PRESENTATION? PAINFEVERERYTHEMASWELLING

CX? STAPHYLOCOCCALTX? CEPHALOSPORIN

SAFE TO BREASTFEED

Thank you!

nnpatel1291@hotmail.com

Twitter: @nnpatel1291