Transcript Gynecology and Obstetrics

Gynecology and Obstetrics
Tintinall’s 647-676
Jay Cleveland
10/5/06
Vaginal Bleeding in the
Nonpregnant Patient
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Differential Dx of abnormal vag
bleeding in nonpregnant reproductive
aged females
1)
Ovulatory abnl bleeding
Anovulatory abnl bleeding
Non uterine bleeding
2)
3)
Ovulatory Bleeding
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1)
2)
3)
4)
5)
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
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1)
2)
3)
Heavy menstrual bleeding due to:
Endometriosis
PID
Ovarian neoplasms
Anovulatory Bleeding
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1)
2)
3)
Adolescence
Secondary to immature hypothalamicpiuitary - ovarian axis
Investigate when
Bleeding >9 days
Intervals< 21 days
Anemia
Anovulatory Bleeding
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Reproductive Age
Secondary to ovarian follicular
degeneration - decreased estrogen
Present classically as prolonged
amenorrhea with periodic menorrhagia
Anovulatory Bleeding
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1)
2)
3)
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
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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)
2)
3)
4)
Anovulation
Pregnancy
Exogenous hormone use
Coagulopathy
Reproductive
1)
2)
3)
4)
5)
6)
Pregnancy
Anovulation
Exogenous hormone use
Uterine leimyomas
Cervical and endometrial polyps
Thyroid dysfunction
Perimenopausal
1)
2)
3)
4)
Anovulation
Uterine leiomyomas
Cervical and endometrial polyps
Thyroid dysfunction
Postmenopausal
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Endometrial lesions (30%)
Exogenous hormone use (30%)
Atrophic vaginits (30%)
Other tumor - vulvar, vaginal, cervical
(10%)
Management of Uterine
Bleeding
If hemodynamically stable
1)
Premarin10mg/d x 7-10 days or 25mg IV q
4 hrs x 24 hrs
2)
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
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Abdominal and Pelvic Pain in
Nonpregnant Patients
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Long list of differential dx
Ovarian Cysts
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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 a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Adnexal torsion
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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 a
TIFF (Uncompressed) decompressor
are needed to see this picture.
PID
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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
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Hx - Dysmenorrhea, chronic pelvic pai,
usually 30’s-40’s
PE - variable
Dx - UPT, Hct, UA, U/S
Adenomyosis
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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)
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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
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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
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Appendicitis
Diverticulitis
Incarcerated Hernias
Ectopic Pregnancy
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2)
3)
Conceptus implanted outside the
uterine cavity
19.7/1000 preg (2%)
Classic triad
Abd pain
Vag bleeding
Amenorrhea
Ectopic Pregnancy
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Risk factors for Ectopic
Pregnancy
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PID
Hx of tubal surgery
IUD
Assisted reproduction
Previous Ectopic Preg
Ectopic Pregnancy
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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
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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
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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
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Regardless of chief complaint the possibility
of pregnancy must be considered in every
woman of reproductive age who presents to
the ED
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7% of women who stated there was no
chance of pregnancy and had a nl previous
menstrual period were in fact pregnant
Cardiovascular System
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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
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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
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Dyspnea during pregnancy
RR unchanged
40% inc in TV
FRC decreased sec to diaphragm
elevation
Gastointestinal System
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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
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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
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Circulating blood volume expands 4045% 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
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Hyperinsulinemia
Fasting hypoglycemia
Postprandial hyperglycemia - ensures
glc supply to fetus
Pelvic Ultrasound
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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
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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
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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
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Differential Dx is Broad
Anemia, electrolyte imbalance,
dehydration, PE, arrythmia (PAC, PVC)
Medications
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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
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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
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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
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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
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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
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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
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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
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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
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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