april 4, 2013 elizabeth shouldice, md ccfp(em) ccfp(em) academic half day obstetrical and...

APRIL 4 , 2013ELIZABETH SHOULDICE, MD CCFP(EM)

CCFP(EM) Academic Half Day

Obstetrical and Gynecological Emergencies:Women’s Health on the Fly

Agenda

Who am I?

Case Based

Gynecological Emergencies

Obstetrical Emergencies

Group Discussion

Who am I?

Conflict of Interest

None

Acknowledgments

Dr. Liisa HoneyDr. Sunita LalDr. Kimberley Creaser

Objectives

Vaginal bleeding/complications in the first 20 weeks of pregnancy

Vaginal bleeding/complications in the second 20 weeks of pregnancy

Obstetrical EmergenciesPreeclampsia and eclampsiaPostpartum emergencies Sexually transmitted infections

Case #1

Queensway Carleton Hospital26 y.o. female presents to triage after

“fainting” at workAccompanied by her partnerVitals: 37.5, 110, 85/50, 20, 100% ORAResuscitation room

Case #1

Brief history: On Alesse No medical problems Recent GI illness, vomiting/diarrhea No pregnancies LMP 2 weeks ago

Nurses: 2 large IVs, NS, Labs: CBC, lytes, BUN, Cr, Type cross match,

quantitative βHCG

Case #1

Abdomen soft, tender diffuselyBimanual exam, tender R adnexa, + blood on

gloveEDE: Free fluid RUQ, no IUPWhat do you do?

Case #2

Hay River, NWT18 year old femalePresents to ED with abdominal painVitals within normal limitsRecent treatment for ectopic pregnancy in

referral centre, discharged 5 days agoWhat would you do?

Case #2

Treated with single dose methotrexate in Yellowknife

Has not had serial βHCGVitals: 37.5, 85, 105/70, 20, 100% ORAAbdomen soft, non tenderBimanual exam no adnexal tenderness, no

bleeding EDE: No free fluid, no IUP, no formal U/S

available for a week, unless you ship her outHb stable, βHCG decreasingWhat now?

Ectopic Pregancy

~2% of all pregnancies Unless IUD in place, risk increases to 1/20

Risk factors: PID, surgical procedures, previous ectopic, DES

exposure, assisted reproductionTreatment with methotrexate becoming more

common Beware of ruptured tube, can happen days after mtx

ISRN Obstet Gynecol. 2012;2012:637094. Epub 2012 Feb 19. The evolution of methotrexate as a treatment for ectopic pregnancy and gestational trophoblastic neoplasia: a review.Skubisz MM, Tong S.Prescrire Int. 2009 Jun;18(101):125-30.Intrauterine devices: an effective alternative to oral hormonal contraception. Acta Obstet Gynecol Scand. 2009;88(12):1331-7.Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies: a randomized trial.Krag Moeller LB, Moeller C, Thomsen SG, Andersen LF, Lundvall L, Lidegaard Ø, Kjer JJ, Ingemanssen JL, Zobbe V, Floridon C, Petersen J, Ottesen B.

Case #3

Queensway Carleton Hospital29 y.o. femaleCC: PV bleeding x 10 days, G2P2

HPI: Delivery of healthy male child October 26 Light PV bleeding in December At time of assessment PV bleeding x 10 days

Case #3

HPI (cont’d): LLQ pain 3/7 before ED visit

Positive home pregnancy test on day of ED visit

Case #3

O/E Triage Vitals: 36.6 86 128/76 97%ORA

Looks well, no distress

Normal abdo and PV exam

EDE: deferred

Case # 3

Labs:

βHCG 284223

Case # 3

Patient returned next day: Formal U/S:

Mildly thickened endometrium R/O molar pregnancy

EDE Equivocal

Case # 3

Called obs/gyne: ?trophoblastic tissue elsewhere Repeat βHCG, add liver enzymes, coags and CXR Resident will be down to see patient

Case # 3

CXR

Case # 3

Resident assessment Ordered CT head/chest/abdomen/pelvis in a.m. Revealed 5cm splenic metastasis

Discussed with gyne onc at OGH Will see urgently

Arranged urgent D&C for next dayDiagnosis metastatic choriocarcinoma

Case #3

Admitted to gyne onc at OGH Feb 9 for expedited treatment

Stage IV High risk, requiring combination chemotherapy Goal of cure 5-7 % chance of infertility

First & Second Trimester Bleeding

Gestational Trophoblastic Diseases (GTD) Disorders of fertilization

Hydatiform mole• Noninvasive, localized• 90% of cases• Starts with empty egg, fertilized by two sperm

Placental site trophoblastic tumor Choriocarcinoma Gestational trophoblastic neoplasia

Learning Points (cont.)….

Arise from trophoblastic epithelium of placenta

All are characterized by high βHCG Maternal tumor arises from gestational

tissue, not maternal tissueCan develop from molar pregnancy or from

TA/SA, ectopic, term or preterm pregnanciesVery rare, hydatidiform mole 23-1299/100

000 pregnancies, other types even more rare

Learning Points (cont.)….

Risk factors Extremes of maternal age (>35 and <20) History of previous GTD Smoking History of infertility Nulliparity OCP use

Learning Points (cont.)….

Presentation PV bleeding Enlarged uterus Pelvic pain Theca lutein cysts Anemia Hyperemesis gravidarum Hyperthyroidism (βHCG has thyroid stimulating

activity) Preeclampsia before 20 wks gestation

Learning Points (cont.)….

Monitoring of βHCG after molar pregnancy is often how GTN is diagnosed Must be monitored for at least 6 months

Ultrasound can have characteristic appearance, but often misdiagnosed as incomplete or complete abortion

Learning Points (cont.)….

Management Initial management is always D&C, useful for

pathology Very common to have increased hemorrhage, need to

have blood on hand Thorough work up for distant metastases Chemo, at times prophylactically for high risk disease Contraception

Learning Points (cont.)….

http://radiographics.rsna.org/content/21/6/1409/F11.expansion.html

Learning Points (cont.)….

Consider quantitative βHCG Even if you’re somewhere where this is difficult!

Even if U/S shows nothing, with very high βHCG consider GTD

Look for trophoblastic tissue elsewhere (CXR, liver enzymes, CT)

High propensity for bleeding Consider transfer for D&C to centre with blood and

ICU

Quick Points – First Trimester Bleeding

Notes from our gynecology consultants:

Spontaneous miscarriage – patients with severe pain or vasovagal response, examine for products of conception in the cervical os

Retained products of conception <8 weeks gestation can often be managed by two doses of misoprostol 800ug q24 hours

Don’t forget to give miscarrying patients pain control for home, narcotics are often required

Second & Third Trimester Complications & Bleeding

Vaginal bleeding in the second 20 weeks of pregnancy Placental abruption Placenta previa Uterine rupture Vasa previa Preterm labour

Second & Third Trimester Complications & Bleeding (cont.)….

Key Points:Evaluation of Preterm Labor

Pelvic pressure, vaginal discharge, vaginal bleeding, or low-back pain

Many hospitals require patients with pregnancies less than 20 weeks gestation to be evaluated in the emergency department

A detailed history of symptoms can help differentiate between spontaneous and evoked preterm labor

A complete obstetric history, including gestational age, is important to determine the risk for possible recurrent preterm birth

Maternal vital assessment, especially temperature and blood pressure

Prim Care. 2012 Mar;39(1):95-113. Third-trimester pregnancy complications. Newfield E

Second & Third Trimester Complications & Bleeding (cont.)….

Fetal vital assessment Documentation of normal fetal heart tones is sufficient for fetuses < 23

wks Continuous external fetal heart rate monitoring for all > 24 wks Continuous tocometry is recommended Informal (bedside) US should be performed

Physical exam of should be performed, including ultrasound before sterile PV exam

Fetal fibronectin Invalid if the cervix has been manipulated in the prior 24 hours A glycoprotein present at the maternal-fetal interface, absent

between 24 and 34 weeks’ gestation. The negative predictive value of the test approximates to 99%;

symptomatic patients with a negative result of fetal fibronectin test are very unlikely to deliver in the following 7 days

Second & Third Trimester Complications & Bleeding (cont.)….

Causes of preterm labour…. Neisseria gonorrhoeae and Chlamydia trachomatis,

bacterial vaginosis, trichomoniasis, or Candida infection

Urine analysis and culture is recommended Cocaine and amphetamines are associated with

preterm labor, often secondary to placental abruption

Other considerations….  Group B Streptococcus (GBS) testing should be

performed

Case #4

Perth and Smiths Falls District Hospital, Perth Site

February 19, 20130330 Nurse Calls the On Call Room:

32 year old, G6P4SA1, 41W1D 3 hours of contractions 1 minute apart, lasting 30 seconds In the department, midwife told her she wouldn’t

make it to Almonte Nearest obstetrical unit 20-30 minutes away You’re the only MD in the hospital

What do you do?

Case #4

Obstetrical Emergencies

Emergency Delivery Equipment Personnel Rest of the department OB unit on the phone! Neonatal consideration

Case #5

Dominican Republic, 2011

Case #5

18 year old womanPresents to “clinic”Reports being 8 months gestation and

concerned re: decreased fetal movement and wanting refill of medication

One previous pregnancy, complicated by preterm birth for seizure, baby did not survive

Limited family support, as family have all moved to US

Shows box of labetolol given in neighbouring town

Case #5

Vitals: 37.5, 70, 160/110, 20, 100% ORAFurther history:

Denies headache or blurred vision, but reports increased ankle edema (does the ankle edema matter??)

On examination: Gravid uterus No abdominal pain FHT >120, with bell of stethoscope

What now?

Preeclampsia & Eclampsia

Hypertensive disorders account for 15% of maternal deaths Four categories:

chronic hypertension preeclampsia/eclampsia gestational hypertension preeclampsia superimposed on chronic hypertension

Preeclampsia: Affects 3 to 5% of pregnant women Can result in maternal and perinatal morbidity and mortality Higher rates in developing countries No single screening test used for preeclampsia prediction has

gained widespread acceptance into clinical practice

Rev Bras Ginecol Obstet. 2011 Nov;33(11):367-75. Early screening for preeclampsia.Costa Fda S, Murthi P, Keogh R, Woodrow N.

Preeclampsia & Eclampsia (cont.)….

Severe preeclampsia 1 of the or signs in the presence of preeclampsia: SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2

occasions at least 6 hours apart Proteinuria of more than 5 g in a 24-hour collection or more than

3+ on 2 random urine samples collected at least 4 hours apart Pulmonary edema or cyanosis Oliguria (< 400 mL in 24 h) Persistent headaches Epigastric pain and/or impaired liver function Thrombocytopenia Oligohydramnios, decreased fetal growth, or placental abruption

Preeclampsia & Eclampsia

The HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) can be considered a variant of severe preeclampsia

May present independently of hypertension and proteinuria

Risk for severe maternal and fetal complications; perinatal mortality has ranged from 7% to 60% and maternal mortality is high

Case #6

The Ottawa Hospital, Civic Campus 37 year old woman, 5 weeks post partum First pregnancy No complications Baby at home with father Presents as blood pressure “high” at postpartum visit

with family physician

Case #6

Vitals: 37.5, 70, 160/110, 20, 100% ORAO/E…..

Patient has generalized tonic clonic seizure

Treatment?? IV MgSO4 4g IV Bolus, then 2g IV/hour

Further management? Benzos prn Close monitoring

Case #7

Queensway Carleton Hospital33 y.o. female presents to triage with R lower

quadrant abdominal pain, 17 weeks pregnantVitals: 37.2, 88, 97/61, 20, 100% ORACubicles

Case #7

G3P2No PV bleedingPain worse with movementNo fever, chills, urinary symptomsEDE - + FHT, fetal movementDiscussed with gyne ?round ligament pain, ?MSKFormal U/S – + FHT, small amount of free fluid,

appendix not visualized, normal flow to R ovary, but + tender during exam

General surgery consulted, clinically not appendicitis, return for R/A prn

Case #7

Next day, patient returns, pain worseNow vomitingU/S repeated – SLIUP, appendix normal,

simple cyst R ovary, larger than previous, no definite flow, ovarian torsion on DDx

Patient taken to OR by general surgery and gyne

Right ovarian torsion, tube and ovary remained necrotic after being untorted

Right salpingo-oophorectomy

Case #7

What are the key points? Can mimic appendicitis Can have nausea, vomiting and fever (caused by

necrosis) ~20% of ovarian torsion occurs in pregnancy Torsion most commonly occurs in women under 30

Was this a missed torsion? What do you think?

Sexually Transmitted Infections

http://www.phac-aspc.gc.ca/std-mts/sti-its/

QUESTIONS? COMMENTS? CONCERNS?

Thanks!