gynecology and obstetrics tintinalls 647-676 jay cleveland 10/5/06
TRANSCRIPT
Gynecology and ObstetricsTintinall’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
1) Ovulatory abnl bleeding
2) Anovulatory abnl bleeding
3) Non uterine bleeding
Ovulatory Bleeding May be associated with regular menstrual
periods due to low estrogen levels Intermenstrual bleeding causes1) Cervical polyps2) Cervicitis3) Cervical CA4) Endometrial CA5) Fibroids
Ovulatory bleeding Heavy menstrual bleeding due to:
1) Endometriosis
2) PID
3) Ovarian neoplasms
Anovulatory Bleeding Adolescence Secondary to immature hypothalamic-
piuitary - ovarian axis Investigate when
1) Bleeding >9 days
2) Intervals< 21 days
3) 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:1) Eating disorders2) Stress/exercise3) 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
1) Anovulation
2) Pregnancy
3) Exogenous hormone use
4) Coagulopathy
Reproductive
1) Pregnancy
2) Anovulation
3) Exogenous hormone use
4) Uterine leimyomas
5) Cervical and endometrial polyps
6) Thyroid dysfunction
Perimenopausal
1) Anovulation
2) Uterine leiomyomas
3) Cervical and endometrial polyps
4) 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 stable1) Premarin10mg/d x 7-10 days or 25mg IV q
4 hrs x 24 hrs2) 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
1) 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
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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 19.7/1000 preg (2%) Classic triad
1) Abd pain
2) Vag bleeding
3) Amenorrhea
Ectopic Pregnancy
QuickTime™ and aTIFF (Uncompressed) decompressor
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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