Gynecologic EmergenciesGynecologic Emergencies

Pelvic Inflammatory DiseasePelvic Inflammatory Disease

Breakdown of normal host barriers Breakdown of normal host barriers (cervical mucous, lysozymes, local IgA, (cervical mucous, lysozymes, local IgA, cervix) allows ascension of pathogens.cervix) allows ascension of pathogens.

Breakdown is most commonly Breakdown is most commonly secondary to menstruation.secondary to menstruation.

80% of cases are secondary to 80% of cases are secondary to N. gonorrhea and chlamydiaN. gonorrhea and chlamydiaRisk factors?Risk factors?

P.I.D.P.I.D.

Classic picture is a sexually active Classic picture is a sexually active woman with bilateral abdominal pain, woman with bilateral abdominal pain, vaginal discharge, fever and vaginal discharge, fever and constitutional symptoms. constitutional symptoms.

Exam reveals CMT, discharge and Exam reveals CMT, discharge and bilateral adnexal tenderness.bilateral adnexal tenderness.

What is the differential for the What is the differential for the same presentation with UNI-same presentation with UNI-lateral adnexal tenderness? lateral adnexal tenderness?

EctopicEctopicTubo-ovarian abscessTubo-ovarian abscessAdnexal torsionAdnexal torsionAppendicitisAppendicitisOvarian CystOvarian Cyst

Diagnostic Studies: Diagnostic Studies:

CBCCBC Endocervical specimensEndocervical specimens B-HcgB-Hcg UltrasoundUltrasound LaparoscopyLaparoscopy

Diagnosing PIDDiagnosing PIDDefinitively diagnosed by:Definitively diagnosed by:a.a. confirmation of fluid filled tubes or confirmation of fluid filled tubes or

TOATOAb.b. histopathologic confirmation of histopathologic confirmation of

endometritisendometritisc.c. PID findings on laparoscopyPID findings on laparoscopyClinically diagnosed by: Clinically diagnosed by: a. lower abd. tenderness, CMT, adnexal a. lower abd. tenderness, CMT, adnexal

tenderness with temp, vaginal d/c, tenderness with temp, vaginal d/c, leukocytosis, + GC or chlamydia swableukocytosis, + GC or chlamydia swab

Treatment: All regimens cover Treatment: All regimens cover GC, chlamydia, anaerobes, G – GC, chlamydia, anaerobes, G –

rods, streprods, strep

Who warrants inpatient treatment?Who warrants inpatient treatment?

Outpt: Ceftriaxone +doxy X 14d or Outpt: Ceftriaxone +doxy X 14d or azithroazithro

Inpt: Cefoxitin/Cefotetan + doxy or Inpt: Cefoxitin/Cefotetan + doxy or

Clinda + gentClinda + gent

Why do we care about PID?Why do we care about PID?

It is a risk factor for future ectopic, It is a risk factor for future ectopic, infertility and chronic pelvic paininfertility and chronic pelvic pain

Its complications include TOA, Fitz-Its complications include TOA, Fitz-Hugh-Curtis syndrome and obstetric Hugh-Curtis syndrome and obstetric complicationscomplications

CervicitisCervicitis

May be GC, Chlamydia or trichMay be GC, Chlamydia or trich Clinical diagnosis (pelvic exam and Clinical diagnosis (pelvic exam and

wet prep)wet prep) Think of this as on a spectrum with Think of this as on a spectrum with

PIDPID Tx: Flagyl if trichomonads on wet prep Tx: Flagyl if trichomonads on wet prep

or with Ceftriaxone + Azithro or Doxyor with Ceftriaxone + Azithro or Doxy

Vaginal Discharge and Vaginal Discharge and VulvovaginosisVulvovaginosis

Differentiating between Differentiating between trichomoniasis, bacterial vaginosis, trichomoniasis, bacterial vaginosis, candidiasis and PID...candidiasis and PID...

Trichomonas VaginitisTrichomonas Vaginitis Foul smelling d/c with vaginal itching, lower Foul smelling d/c with vaginal itching, lower

abdominal pain and dysuriaabdominal pain and dysuria 4-28d incubation period4-28d incubation period Exam shows foamy, yellow-green d/c with Exam shows foamy, yellow-green d/c with

vaginal erythema and strawberry cervixvaginal erythema and strawberry cervix Wet mount shows flagellated, motile, tear-Wet mount shows flagellated, motile, tear-

drop-shaped protozoa with vaginal pH >5.5drop-shaped protozoa with vaginal pH >5.5 Tx with FlagylTx with Flagyl Ass’d with PROM, preterm delivery and Ass’d with PROM, preterm delivery and

postpartum endometritispostpartum endometritis

““Strawberry Cervix”Strawberry Cervix”

Wet prep showing Wet prep showing trichomonadstrichomonads

Vulvovaginal CandidiasisVulvovaginal Candidiasis

Overgrowth of normal vaginal floraOvergrowth of normal vaginal flora Pt with vaginal itching and thin, watery to Pt with vaginal itching and thin, watery to

thick, white d/cthick, white d/c Exam reveals thick, cottage cheese d/c, Exam reveals thick, cottage cheese d/c,

vulvovaginal erythema, possible satellite vulvovaginal erythema, possible satellite lesionslesions

Vaginal pH <4.5Vaginal pH <4.5 tx with intravaginal azoles or po tx with intravaginal azoles or po

fluconazolefluconazole

Fungus on wet prep without Fungus on wet prep without stainstain

Bacterial VaginosisBacterial Vaginosis The most common cause The most common cause Believed to be polymicrobialBelieved to be polymicrobial Pt. complains of itching and fishy dischargePt. complains of itching and fishy discharge Dx: must have ¾: homogenous d/c coating Dx: must have ¾: homogenous d/c coating

walls of vagina (doesn’t pool), + whiff test, walls of vagina (doesn’t pool), + whiff test, pH>4.5, clue cells on wet mountpH>4.5, clue cells on wet mount

Tx with metronidazole or TV clindaTx with metronidazole or TV clinda Importance: increased PROM, preterm Importance: increased PROM, preterm

labor, preterm birth and post-cesarean labor, preterm birth and post-cesarean endometritisendometritis

Clue cell on wet prepClue cell on wet prep

Adnexal TorsionAdnexal Torsion

An ovary twists on its vascular pedicle causing An ovary twists on its vascular pedicle causing compromised blood supply and necrosis.compromised blood supply and necrosis.

Usually secondary to an enlarged or overstimulated Usually secondary to an enlarged or overstimulated ovaryovary

May occur at any age and at any point in the menstrual May occur at any age and at any point in the menstrual cyclescycles

Hx of sudden onset, usually unilateral adnexal painHx of sudden onset, usually unilateral adnexal pain

Evaluation and Evaluation and Management: Management:

CMT may be present, may be bilateral CMT may be present, may be bilateral though typically unilateralthough typically unilateral

May palpate an adnexal massMay palpate an adnexal mass Afebrile or tachycardic out of proportion Afebrile or tachycardic out of proportion

to feverto fever Routine labs are unrevealing. Routine labs are unrevealing. UltrasoundUltrasound Tx is surgicalTx is surgical Consequences include shock, peritonitis, Consequences include shock, peritonitis,

tubal scarringtubal scarring

Abnormal Vaginal Bleeding Abnormal Vaginal Bleeding (Non-pregnancy related)(Non-pregnancy related)

There are multiple etiologies: There are multiple etiologies: a.a. Endocrine alterations (menopause)Endocrine alterations (menopause)b.b. Drugs (ABX, anticonvulsants, anticoagulants)Drugs (ABX, anticonvulsants, anticoagulants)c.c. Infections (Vulvovaginitis, Endometritis)Infections (Vulvovaginitis, Endometritis)d.d. Neoplasms (Cervical, Polyps)Neoplasms (Cervical, Polyps)e.e. Post-operative Post-operative f.f. Trauma (Foreign bodies and straddle injuries)Trauma (Foreign bodies and straddle injuries)g.g. IUDs (IUDs (h.h. Medical problems (Coagulopathies, Medical problems (Coagulopathies,

Thrombocytopenia)Thrombocytopenia)i.i. DUB (a diagnosis of exclusion)DUB (a diagnosis of exclusion)

Our responsibilities are the Our responsibilities are the same... same...

Assuring hemodynamic stabilityAssuring hemodynamic stability Stabilizing the life-threatening bleedsStabilizing the life-threatening bleeds Identifying correctable causesIdentifying correctable causes

References: References:

1. Preparing for the Written Board Exam in Emergency Medicine. 51. Preparing for the Written Board Exam in Emergency Medicine. 5thth ed. Vol 1. Rivers, Carol. pp 534-549ed. Vol 1. Rivers, Carol. pp 534-549

2. www.fertilite.org/images/ic/cervitisit_tri.gif2. www.fertilite.org/images/ic/cervitisit_tri.gif3. 3.

http://www.microbelibrary.org/microbelibrary/files/ccImages/Articlehttp://www.microbelibrary.org/microbelibrary/files/ccImages/Articleimages/Buxton/03%20Vaginal/Trichomonas%20vaginalisimages/Buxton/03%20Vaginal/Trichomonas%20vaginalis%20fig5.jpg%20fig5.jpg

4. 4. http://www.microbelibrary.org/microbelibrary/files/ccImages/Articlehttp://www.microbelibrary.org/microbelibrary/files/ccImages/Articleimages/Buxton/03%20Vaginal/Candida%20albicans%20fig6.jpgimages/Buxton/03%20Vaginal/Candida%20albicans%20fig6.jpg

5. http://www.fpnotebook.com/_media/GynVaginitisClueCell.jpg5. http://www.fpnotebook.com/_media/GynVaginitisClueCell.jpg6. 6.

http://download.imaging.consult.com/ic/images/S19330332087011http://download.imaging.consult.com/ic/images/S1933033208701125/gr13a-midi.jpg25/gr13a-midi.jpg