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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.