1. Guidelines for Treating Acute GYN Illnesses
Critical Concepts
Guidelines for Treating
Acute GYN Illnesses
LSU Department of OBGYN

2. A 24 year old female presents to the emergency department complaining of vaginal bleeding. In triage, her vital signs are stable and the nurse calls to tell you that she is in the exam room.
What initial information do you want about this patient?

3. TRIAGE VITAL SIGNS:
Temperature 98.8
Blood Pressure 110/70
Pulse 95
Respirations 12
Weight 220 pounds
Height 5’5’’
Urine Pregnancy Test is Positive

4. Take a Complete History
HPI:
What do you want to know about her presenting complaint of vaginal bleeding??
Other symptoms to ask about??
What else in your history taking will be important to know?

5. Take a Complete History
Initial Presentation - - -
Patient’s LMP was about 7 weeks ago but she can’t remember the date; has not received any prenatal care yet
Present Illness – bleeding started 3 days ago but the amount of bleeding got worse today so she decided to come to the ER
Associated Symptoms – feeling tired and having some cramping in her belly over the past several hours

6. Take a Complete History
What else in your history taking will be important to know?
What questions do you want to ask the patient?

7. Take a Complete History
Medical History – no medical problems
Surgical History - none
Medicines – Ibuprofen
Allergies – no known drug allergies; allergic to latex
Social History – tobacco use, social alcohol, no drugs

8. Take a Complete History
OB History –
G1: SVD at 34 weeks
G2: miscarriage early in the pregnancy
(what are her G/P’s??)
GYN History –
past treatment for gonorrhea and chlamydia
non-compliant with OCP’s
no history of abnormal pap smears

9. First Trimester Bleeding
What’s your differential diagnosis?

10. Differential Diagnosis
1. Physiologic: normal intrauterine pregnancy,
implantation bleeding, ruptured corpus
luteum cyst
2. Ectopic Pregnancy
3. Miscarriage
Pathology – vagina, cervix, uterus
- vaginal laceration/foreign body
- cervicitis/cervical mass
- fibroids/polyps

11. Physical Examination – Patient #1
vital signs: BP 95/60 HR 100
abdominal exam –midline tenderness to palpation, no rebound no guarding
pelvic exam
- use the speculum to visualize the cervix:
no gross lesions
moderate blood in the vault with active bleeding at the cervical os
- bimanual exam:
8 week size uterus tender to palpation
cervical os dilated 2 cm

12. What do you want next???

13. What do you want next??? LABS: - quantitative βhCG - Type and Screen
- CBC
- +/- CMP
pelvic ultrasound (remember to order with transvaginal images)

14. Results LABS: - quantitative βhCG = 5000
- Type and Screen = O negative, antibody negative
- CBC =
9 250 26

15. Results
Ultrasound report: uterus 8x4x3cm, irregular shaped gestational sac, fetus measuring approximately 7 weeks with no fetal cardiac activity noted
Final diagnosis??

16. Spontaneous/Incomplete Abortion
Gestational Sac – structure can be seen but may be irregular in shape
Yolk Sac – may or may not be present
Fetal cardiac activity will help to define type of miscarriage

17. Intrauterine Pregnancy
Gestational Sac – ring structure seen by 5 weeks embedded into the decidua
Yolk Sac – appears at 5-6 weeks and disappears by 10 weeks
Fetal cardiac activity usually seen by 6 weeks

18. Incomplete Abortion Options for management:
Conservative management with/without prostaglandins to complete abortion
Surgical therapy with suction D&C
Other considerations:
Blood type – does this patient need RhoGam?
Antibiotics if uterus was instrumented during examination

19. Abortion Definitions
Complete: all POC are expelled from uterine cavity, cervix closed
Incomplete: partial expulsion of POC from uterine cavity with dilated cervical os
Threatened: all POC in uterine cavity, with heartbeat, cervix closed, bleeding present
Missed: all POC in uterine cavity, no heartbeat, cervix closed

20. Spontaneous Abortion
Incidence: about 10-15% of clinically recognized pregnancies; nearly 80% before 12 weeks gestation
Risk Factors:
Advanced maternal age
Previous spontaneous abortion (20% after 1, 40% after 3 consecutive)
Smoking
Excess alcohol and caffeine intake
Maternal weight: BMI <18 or >25
- Etiology: chromosome abnormalities account for about 50% of 1st trimester losses (nearly 90% of those 8 weeks or less)

21. Questions??

22. Physical Examination – Patient #2
vital signs: BP 95/60 HR 100
abdominal exam – significant for right lower quadrant tenderness to palpation, no rebound, voluntary guarding
pelvic exam
- use the speculum to visualize the cervix:
no gross lesions
minimal blood in the vault
- bimanual exam: palpable mass in the right lower quadrant with significant tenderness to palpation; 8 week size uterus

23. What do you want next???

24. What do you want next??? LABS: - quantitative βhCG - Type and Screen
- CBC
- +/- CMP
pelvic ultrasound (remember to order with transvaginal images)

25. Results LABS: - quantitative βhCG = 5000
- Type and Screen = O negative, antibody negative
- CBC =
9 250 26
- CMP shows that electrolytes and liver functions are within normal limits

26. Results Final diagnosis??
Ultrasound report: uterus 8x4x3cm, no intrauterine pregnancy seen, ring-like structure seen near the right adnexa, measuring 3x3 cm with yolk sac present - no cardiac activity, moderate free fluid in pelvis
Final diagnosis??

27. Ectopic Pregnancy
Diagnosis of ectopic pregnancy is made by physical exam and ultrasound findings
Classic signs are: amenorrhea, abdominal pain, and vaginal bleeding
Definitive Diagnosis:
(in adnexal region)
cardiac activity
fetal pole/fetus
yolk sac

28. Ectopic Pregnancy - Management
Contraindications to Methotrexate:
- hemodynamic instability/risk of rupture
- abnormal renal or liver functions
- active peptic ulcer disease or pulmonary disease
- allergy to MTX
- breastfeeding
- inability to follow-up
Relative contraindications:
- beta >10, size >3.5cm
- cardiac activity - free fluid in the pelvis

29. Ectopic Pregnancy
If MTX is contraindicated – proceed with surgical removal of ectopic by salpingostomy or salpingectomy
Other considerations:
If hemodynamic instability/potential rupture: does the patient need 2nd IV site, PRBC’s, exlap for emergent therapy?
Blood type – does this patient need RhoGam?

30. Ectopic Pregnancy Risk Factors: Pelvic inflammatory disease
Previous ectopic pregnancy
Previous tubal or pelvic surgery
Smoking
Current use of an intrauterine device
Increasing age
Must have transvaginal ultrasound and quant beta hCG levels to accurately diagnose.

31. What if her beta was only 1400??
Beta hCG level: rises in the first trimester and plateaus after about 10 weeks gestation
doubling of level occurs about every days
majority of pregnancies will increase 66% every 48 hours
abnormal rise or plateau is correlated with abnormal pregnancy
Discriminatory zone: correlates the level of hCG with the ability to see a gestational sac
with transvaginal images
REPEAT IN 48 HOURS

32. Questions??