OB/GYN

Rapid Review

• Background
  • Vaginitis due to a complex alteration of vaginal flora in which lactobacilli decrease and anaerobic pathogens overgrow.
• Signs/Symptoms
  • Symptoms: Fishy odor. Not typically pruritic or irritable.
  • Signs: (+)Thin, gray/white discharge
• Diagnosis
  • Amsel Criteria (Need 3/4)
    • Clue cells, pH > 4.5, positive whiff test, thin/gray homogeneous discharge
• Treatment
  • If asymptomatic, no need to treat unless pregnant
  • If symptomatic, oral/topical metronidazole. Clindamycin as an alternative.
• Disposition
  • Majority of cases can be discharged safely with PCP or GYN follow up.

Pearls

• Topical treatment regimens (eg. metronidazole 0.75% gel) is preferred for pregnant patients to reduce systemic effects.
• Always advise against alcohol intake during treatment with metronidazole, as this can cause a disulfiram-like effect.

Deep Dive

• Bacterial Vaginosis (Merck)

Rapid Review

• Background
  • Yeast infection of the vulva and vagina, most commonly caused by Candida albicans.
  • Most commonly seen in females in high estrogen states (pregnancy, contraceptive use, diabetes)
• Signs/Symptoms
  • Symptoms: Pruritus (most common and specific), burning sensation, dyspareunia, dysuria
  • Signs: (+) white, cottage cheese-like discharge, though not always present. Not typically malodorous
• Diagnosis
  • Wet mount (shows yeast buds, pseudohyphae)
  • Vaginal pH < 4.5
• Treatment
  • If asymptomatic, no treatment is needed
  • If symptomatic, oral fluconazole (1st line). May do topical azole if pregnant
• Disposition
  • Majority of cases can be discharged safely with PCP or GYN follow-up.

Pearls

• Frequent recurrences (> 4 infections in one year) warrant collecting cultures to rule out infection by non-Candida albicans species.
• Vaginal candidiasis frequents presents after menses or after recent antibiotic usage.

Deep Dive

• Candidal Vaginitis (Merck Manual)

Rapid Review

• Background
  • Implantation of a fertilized ovum outside the uterus. The fallopian tube is the most common.
  • Occurs in about 2% of all pregnancies and accounts for 6% of all maternal deaths.
• Signs/Symptoms
  • Vaginal bleeding, abdominal/pelvic pain, adnexal mass, amenorrhea
  • Rupture of ectopic pregnancy can cause hypotension, syncope, and peritonitis 
• Diagnosis
  • Beta HCG > 1500, but no signs of intrauterine pregnancy on transvaginal ultrasound.
  • If beta-hCG levels rise, but do not double over the course of 48 hours, then it is likely an ectopic pregnancy.
• Treatment
  • Resuscitate, give RhoGAM to Rh ( -) women, consult OB/GYN
  • Methotrexate (unless contraindicated). Surgery may be needed.
• Disposition
  • If stable with reliable follow-up (within 4-7 days), patients may be discharged after consulting OB/GYN.
  • Admission is required for any hemodynamically unstable patients or those with unreliable follow-up.

Pearls

• Ectopic pregnancy should be considered in every patient of child-bearing age wih vaginal bleeding.
• Conception is rare in patients with IUD, but if they do conceive, approximately 25-50% of them will have ectopic pregnancy.

Deep Dive

• Ectopic Pregnancy (SAEM)

Rapid Review

• Background
  • Endometriosis is the presence of endometrial tissue implanted outside the uterus (pelvic cavity, uterine ligament, bowel, lungs, ovaries, etc.)
  • Most common site is the ovaries
• Signs/Symptoms
  • “Three D’s” (dyspareunia, dyschezia, dysmenorrhea)
  • Often presents asymptomatically or with pelvic pain before/during menses
• Diagnosis
  • Laparoscopy and biopsy required for definitive diagnosis 
• Treatment
  • Analgesics (NSAIDS)
  • Hormone therapy (danazol, oral contraceptives, progestins, GnRH agonists, aromatase inhibitors)
• Disposition
  • Most patients can be discharged with an OB/GYN referral
  • Admit if the patient has significant bleeding, peritoneal signs, or intractable pain.

Pearls

• Endometriosis is an estrogen-dependent disorder. Consider initiating oral contraceptives with consultation of OB/GYN or PCP. 
• Patients not responding to conservative management may undergo uterine ablasion or hysterectomy with their OB/GYN.

Deep Dive

• Endometriosis (Merck Manual)

Rapid Review

• Background
  • Complication of pelvic inflammatory disease (PID) characterized by capsular inflammation of the liver. 
  • Most commonly caused by chlamydia or gonococcal infection
• Signs/Symptoms
  • Symptoms: Sudden onset RUQ pain, worse with inspiration. May radiate to the shoulder.
  • Signs: (+) RUQ tenderness
• Diagnosis
  • Clinical diagnosis. 
  • Labs may show normal or mildly elevated ALT/AST. 
  • CT may show inflammatory changes in pelvic/perihepatic region
• Treatment
  • Usual treatment for pelvic inflammatory disease (ceftriaxone + doxycycline +/- metronidazole)
• Disposition
  • Admission often required as a complication of pelvic inflammatory disease.

Pearls

• Fitz-Hugh Curtis syndrome often mimics cholecystitis. Be detailed in your history and physical exam.
• In rare cases, this syndrome can affect males as well.

Deep Dive

• Fitz-Hugh-Curtis Syndrome (PubMed)

Rapid Review

• Background
  • HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome is a clinical variant of severe preeclampsia
  • Occurs in 10-20% of women with severe preeclampsia
• Signs/Symptoms
  • Symptoms: abdominal pain, headache, flu-like symptoms
  • Signs: (+) RUQ/epigastric tenderness, (+) edema
• Diagnosis
  • Microangiopathic hemolytic anemia (high LDH, low haptoglobin, schistocytes) + Transaminitis (AST/ALT twice the upper limit) + thrombocytopenia (< 1000,000/mm3)
• Treatment
  • Delivery is the definitive treatment
  • Manage hypertension (labetalol, hydralazine, nifedipine)
  • Correct thrombocytopenia and anemia with transfusions, as needed.
• Disposition
  • Admission is required for all patients with suspected HELLP syndrome.

Pearls

• HELLP syndrome can also occur in the postpartum period (usually between 2-7 days post-delivery)
• Despite being a complication of preeclampsia, some patients with HELLP syndrome may have normal blood pressure.

Deep Dive

• Preeclampsia & HELLP (EMCrit)

Rapid Review

• Background
  • Severe form of nausea/vomiting during pregnancy, often resulting in weight loss, dehydration, and ketosis. Usually occurs between 4th-10th weeks of pregnancy
  • Affects 0.3-2% of pregnancies
• Signs/Symptoms
  • Symptoms: severe nausea/vomiting, weight loss, fatigue, dizziness
  • Signs: (+) signs of dehydration 
• Diagnosis
  • Clinical diagnosis
  • Urinalysis may show evidence of dehydration (increased specific gravity, ketonuria). CBC may show electrolyte abnormalities or elevated creatinine
• Treatment
  • Manage dehydration (NS or LR)
  • Manage nausea/vomiting (First line is Vitamin B6 initially)
    • May add doxylamine, promethazine, dimenhydrinate, or metoclopramide
• Disposition
  • Most can be discharged if they do not have significant electrolyte derangements and are able to successfully complete a PO challenge.

Pearls

• Be careful diagnosing pregnant patients with hyperemesis gravidarum, especially if there are greater than 9 weeks gestation. Maintain a broad differential.
• These patients can develop thiamine (vitamin B1) deficiencies if vomiting persists beyond 3 weeks. Be vigilant in replenishing their thiamine to prevent Wernicke’s encephalopathy.

Deep Dive

• Hyperemesis Gravidarum (emDocs)

Rapid Review

• Background
  • Fluid-filled sac within the ovary. Generally benign, but can lead to torsion, rupture, hemorrhage, or infection.
  • Follicular cysts are the most common; other types include corpus luteum cysts (can cause rapid bleeding) and Theca lutein cysts (seen in pregnancy) 
• Signs/Symptoms
  • Most are asymptomatic; common symptoms include lower abdominal pain, bloating, and dyspareunia.
  • If ruptured, can cause significant pain, hypotension, tachycardia
• Diagnosis
  • Transvaginal ultrasound
  • Masses > 5 cm concerning for ovarian torsion
• Treatment
  • Most cysts < 5cm resolve on their own. Provide NSAIDs for analgesia
  • Surgery required for complicated cysts
• Disposition
  • Benign cysts (no torsion or significant hemorrhage from rupture) can be discharged with OB/GYN follow-up.

Pearls

• Patients with ovarian cysts should be advised to look out for signs/symptoms of ovarian torsion and be advised to return to the ED if they suspect this.
• Ovarian cysts tend to be more common on the right side, with rupture typically occurring just prior to menses (due to increased vascularity). 

Deep Dive

• Benign Ovarian Masses (Merck Manual)

Rapid Review

• Background
  • Rotation of the ovary, and sometimes fallopian tube, causing interrupted blood flow and ischemia/necrosis. Usually occurs on the right side. 
  • Risk factors include ovarian cysts/tumors > 4 cm, pregnancy, or induction of ovulation
• Signs/Symptoms
  • Symptoms: Sudden, severe abdominal pain (50%), nausea/vomiting (70%), 
  • Signs: (+) abdominal tenderness, (+) adnexal mass
• Diagnosis
  • Transvaginal US + Color doppler initially
  • Can only be definitively confirmed by laparoscopy
• Treatment
  • Surgery (attempt to untwist initially, but must remove if non-viable)
• Disposition
  • Admission with early GYN consult

Pearls

• Ovarian torsion cannot be definitively ruled out by normal doppler flow on ultrasound. It is often a dynamic process with frequent episodes of torsion/detorsion. Maintain a low threshold to consult GYN if your clinical suspicion for this is high. 
• Up to 20% of cases are seen in pregnant women, particularly those in the first trimester or those receiving fertility treatments.

Deep Dive

• Ovarian Torsion (CDEM)

Rapid Review

• Background
  • Acute, bacterial infection that ascends from cervix/vagina to the upper genital tract (uterus, fallopian tubes, ovaries, and adjacent structures)
  • Most commonly caused by Chlamydia trachomatis
• Signs/Symptoms
  • Lower abdominal pain, fever, vaginal discharge/bleeding
  • (+) “Chandelier sign” (cervical motion tenderness), (+) mucopurulent cervicitis
• Diagnosis
  • Clinical diagnosis
  • Must have tenderness (abdominal, uterine, adnexal, or cervical) + one more criteria (fever, discharge, elevated ESR/CRP, documented GC/Chlamydia infection)
• Treatment
  • Antibiotics (ex. ceftriaxone + doxycycline +/- metronidazole)
  • Treat infected partners
• Disposition
  • Most patients can be discharged with PCP or OB/GYN follow-up within 48-72 hours.
  • Admission is required if they are pregnant, hemodynamically unstable, have failed outpatient therapy,  or have uncontrollable symptoms.

Pearls

• Patients with suspected PID should be offered testing for other STIs as well, such as HIV, hepatitis, and syphilis, etc.
• Although quinolones have been used previously for PID, many causative pathogens such as gonorrhea are becoming increasingly resistant to this antibiotic class.

Deep Dive

• Pelvic Inflammatory Disease (WikEM)

Rapid Review

• Background
  • Hemorrhage caused by premature separation (partial or full) of implanted placenta from the uterine wall after 20 weeks gestation.
  • Often associated with trauma; most common cause of third trimester bleeding
• Signs/Symptoms
  • Painful vaginal bleeding is the most common sign, but may not always be present. 
  • May have a tender uterus and signs of shock
• Diagnosis
  • Clinical diagnosis
  • Ultrasound may help identify retroplacental bleeding
• Treatment
  • Stabilize (ABC’s, blood products, RhoGAM). Consult OB/GYN emergently
  • Definitive treatment is the delivery of the fetus/placenta. 
• Disposition
  • All patients with known or suspected placental abruption must be admitted. ICU is required if significant hemorrhage, DIC, or amniotic fluid embolism.
  • Transfer these patients to the closest labor/delivery unit when stable.

Pearls

• Hypotension tends to be a late finding in the overall course of hypovolemic shock in pregnancy. 
• The amount of vaginal bleeding that the patient presents with does not necessarily correlate with the extent of placental abruption. The bleeding may be “concealed” between the placenta and uterine wall with no obvious external bleeding. 

Deep Dive

• Placental Abruption (emDOCs)

Rapid Review

• Background
  • Implantation of the placenta over, or near, the internal cervical os.
  • Commonly causes vaginal bleeding in pregnant women in the third trimester due to tearing of placental vessels from uterine enlargement/cervical dilation.
• Signs/Symptoms
  • Symptoms: painless vaginal bleeding, may be minor or massive
  • Signs: May be hypotensive or tachycardic if bleeding is severe. Do not perform a digital or speculum vaginal exam if suspicious for previa (may exacerbate injury)
• Diagnosis
  • Transvaginal ultrasound
• Treatment
  • Resuscitate, if needed (blood transfusion). Give RhoGam (if mother Rh -)
  • Consult OB. May need emergent C-section
• Disposition
  • Most patients will need admission for monitoring/treatment
  • If bleeding has resolved, may consider discharge after consultation with OB
• Disposition
  • Most patients will require admission to labor and delivery. Some patients may be managed outpatient, but only after OB consultation.

Pearls

• Do not perform a digital or speculum exam in patients with suspected placenta previa (may exacerbate symptoms).
• In general, placenta previa is painless. If it is painful, consider placental abruption.

Deep Dive

• Placenta Previa (emDocs)

Rapid Review

• Background
  • Preeclampsia is defined as gestational hypertension + proteinuria (or other end-organ damage)
  • Eclampsia is when unexplained generalized seizures occur in patients with established preeclampsia. 
• Signs/Symptoms
  • Symptoms: May be asymptomatic, or cause headache, visual disturbances, nausea/vomiting, abdominal pain
  • Signs: (+) swelling in hands/face, (+) RUQ pain 
• Diagnosis
  • Preeclampsia criteria requires Hypertension (BP > 140/90) + Proteinuria (> 300 mg/24 hours)
    • Proteinuria can be substituted for thrombocytopenia, renal insufficiency, pulmonary edema, or impaired liver function
• Treatment
  • Delivery is the definitive treatment
  • Treat hypertension (labetalol, hydralazine, nifedipine). 
  • Treat/prevent seizure (magnesium)
• Disposition
  • Most patients with preeclampsia/eclampsia will require admission
  • Asymptomatic patients with no end-organ dysfunction (proteinuria, transaminitis, AKI, thrombocytopenia) may be discharged if close obstetric follow is guaranteed.

Pearls

• Preeclampsia/eclampsia can before, during, and up to 6 weeks after labor.
• Antihypertensives and magnesium are crucial for the management of these patients, but delivery is the definitive treatment.

Deep Dive

• Preeclampsia and Eclampsia (CORE EM)

Rapid Review

• Background
  • Defined as blood loss > 1000 mL or signs/symptoms of hypovolemia within 24 hours of birth
  • Occurs in 4% of vaginal deliveries and 6% of C-sections. Most common cause is uterine atony.
• Signs/Symptoms
  • Ongoing blood loss, typically painless
  • May show evidence of hypovolemia (tachycardia, AMS, tachypnea, clammy skin)
• Diagnosis
  • Clinical diagnosis based on exam
  • Ultrasound may show retained products of conception or intra abdominal free fluid.
• Treatment
  • Resuscitate with fluids/blood products and early TXA. Reverse coagulopathies
  • Manage uterine atony (bimanual massage, oxytocin/methergine, uterine packing/tamponade)
  • Manage trauma (laceration repair of genital tract)
• Disposition
  • All patients with active hemorrhage will require admission with early OB consult
  • Mild, delayed postpartum hemorrhage can be considered with outpatient treatment and close OB follow up.

Pearls

• Most deaths from post-partum hemorrhage are due to delayed diagnosis and inadequate resuscitation. Identify early and be aggressive with your treatments!
• Uterine atony is the most common cause of primary postpartum hemorrhage (70%-80%). Initiate fundal massages early.

Deep Dive

• Management of Postpartum Hemorrhage (First10EM)