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Toronto Notes 2019 Gynecologic/Urologic Emergencies
Physical Exam
• ABC(especiallynotingposturalBP/HRandmucousmembranes)
• abdominalexamination(signsofperitonealpathology,tenderness,distension,mass)
• speculumexamination(NOTIF2nd/3rdtrimesterbleeding;performonlyifplacentapreviahasbeen
ruled out with U/S)
■ look for active bleeding, trauma/anomaly, and cervical dilatation
• bimanualexamination(cervicalmotiontenderness,sizeofuterus,cervicallength/dilatation)
• sterileglovesandspeculumifpregnant
• POCUS:ruleinintra-uterineorectopicpregnancy,checkforfreefluidinpelvis/RUQ/LUQ,consider
assessment of fluid responsiveness (intra-hepatic IVC collapsibility, carotid flow measurement)
Investigations
• β-hCGtestforallpatientswithchildbearingpotential
• CBC,bloodandRhtype,quantitativeβ-hCG,PTT,INR
• type&crossifsignificantbloodloss
• transvaginalU/S(ruleoutectopicpregnancyandspontaneousabortion)
• abdominalU/S(ruleoutplacentaprevia,fetaldemise,orretainedproductspost-partum)
Management
• ABCs
• pulseoximeterandcardiacmonitorsifunstable
• Rhimmuneglobulin(Rhogam®)forvaginalbleedinginpregnancyandRh-negativemother • 1st/2ndtrimesterpregnancy
■ ectopic pregnancy: definitive treatment with surgery or methotrexate
■ intrauterinepregnancy,noconcernsofcoexistentectopic:dischargepatientwithobstetricsfollow-up ■ U/S indeterminate or β-hCG >1,000-2,000 IU: further workup and/or gynecology consult
■ abortions: if complete, discharge if stable; for all others, consult gynecology
• 2nd/3rdtrimesterpregnancy
■ placenta previa or placental abruption: obstetrics consult for possible admission
• postpartum
■ manage ABCs: start 2 large bore IV rapid infusion, type & cross 4 units of blood, consult OB/GYN
immediately • non-pregnant
■ if unstable admit to gynecology for IV hormonal therapy, possible D&C
■ non-structural abnormalities
◆ tranexamic acid (Cyklokapron®) to stabilize clots
◆ medroxyprogesterone acetate 10 mg PO OD x 10d, warn patient of a withdrawal bleed
■ stable structural abnormalities (fibroids, polyps, endometrial thickening, adenomyosis), outpatient
gynecology referral once stable
Disposition
• decisiontoadmitordischargeshouldbebasedonthestabilityofthepatient,aswellasthenatureofthe underlying cause; consult OB/GYN for patients requiring admission
• ifpatientcanbesafelydischarged,ensurefollow-upwithfamilyphysicianorgynecologist
• instructpatienttoreturntoEDforincreasedbleeding,presyncope
Pregnant Patient in the ED
Emergency Medicine ER41
Vaginal bleeding can be life-threatening Always start with ABCs and ensure your patient is stable
Need β-hCG ≥1,200 to see intrauterine changes on transvaginal U/S
An ectopic pregnancy can be ruled out by confirming an intrauterine pregnancy by bedside U/S unless the patient is using IVF due to the high risk of heterotopic pregnancy
Vaginal bleeding (and its underlying causes) can be a very distressing event for patients; ensure appropriate support is provided
Table 25. Complications of Pregnancy
Trimester
First 1-12 wk
Second 13-27 wk
Third 28-41 wk
Fetal
Pregnancy failure
Spontaneous abortion
Fetal demise
Gestational trophoblastic disease
Disorders of fetal growth IUGR
Oligo/polyhydramnios Vasa previa
Maternal
Ectopic pregnancy Anemia
Hyperemesis gravidarum UTI/pyelonephritis
Gestational DM Rh incompatibility UTI/pyelonephritis
Preterm labour/PPROM
Preeclampsia (hypertension in pregnancy)/eclampsia Placenta previa
Placental abruption
Uterine rupture
DVT/PE