BASICS
Pregnancy located outside the uterus
• Fallopian tube ectopic (outer one-third most common)
• Cervical and extrauterine ectopic (rare)
ETIOLOGY
Conditions that block the fallopian tube
• History of sexually transmitted disease
• Past ectopic
• Past abdominal surgeries
• Endometriosis
• Intrauterine device or tubal ligation reversal
Increased risk with age >35, smoking, and fertility treatments
SIGNS AND SYMPTOMS
Pelvic pain (sudden, sharp, diffuse, or local)
Vaginal bleeding, spotting
Low back pain, shoulder pain
Weakness, dizziness, syncope
Tachycardic, hypotensive if ruptured
DIAGNOSTICS
Pelvic ultrasound, consider ultrasound bedside fast exam if concern for rupture
Lab tests: β-hCG (human chorionic gonadotropin), complete blood count (CBC), type and screen, comprehensive metabolic panel
TREATMENT
ABCs (airway, breathing, circulation), supportive, IVFs, transfuse when necessary
Immediate obstetric/gynecologic (OB/GYN) consultation for consideration of:
• Removal of the abnormal pregnancy
• Salpingectomy
• Methotrexate
BASICS
Inflammation of the endometrium
Can be acute or chronic
ETIOLOGY
Caused by anaerobes and aerobes from genital tract
Chlamydia trachomatis and Neisseria gonorrhoeae are uncommon causes
Instrumentation, cesarean delivery, prolonged labor, multiple cervical exams, abortion
SIGNS AND SYMPTOMS
Postpartum fever, tachycardia, midline lower abdominal pain, uterine tenderness, malaise, purulent discharge
DIAGNOSTICS
History and clinical exam findings
TREATMENT
Supportive, IVFs, pain control, antibiotics for anaerobic coverage
BASICS
Inflammation of breast tissue that may or not be associated with infection
Primarily women of childbearing age
Most common in first-time nursing mothers
ETIOLOGY
Can be classified into three major categories:
• Infectious
Lactational mastitis is most common
Associated with abscesses; cellulitis is rare
Common pathogens are Staphylococcus aureus (MRSA is most common), less frequently Streptococcus pyogenes, E. coli, or Bacteroides
• Noninfectious
Postirradiation mastitis, periductal mastitis, superficial thrombophlebitis of the breast, duct ectasia
• Malignancy associated
Large tumors can cause secondary infection as tissue becomes necrotic
SIGNS AND SYMPTOMS
Severe soreness, hardness, redness, heat, swelling of breast, generalized chills and fever
DIAGNOSTICS
History and clinical exam findings
Consider ultrasound for abscess
TREATMENT
Antibiotics can be used for infectious and noninfectious causes:
• Outpatient: dicloxacillin or cephalexin or clindamycin
• If at risk for MRSA: Bactrim or clindamycin
• Severe infection requiring admission: vancomycin
Pain control, increased fluid intake, ice
Continue nursing or pumping on infected breast and make sure to empty breast completely
If symptoms persist with antibiotics, consider abscess or malignancy
BASICS
A pregnancy that has failed prior to 20 weeks gestation
Complete abortion: passage of all products of conception (POC)
Incomplete abortion: partial passage of POC
Inevitable abortion: POC have not passed, but cervical os is open with vaginal bleeding
Threatened abortion: vaginal bleeding without POC passage and closed cervical os
Missed abortion: death of embryo or fetus without passage of POC
ETIOLOGY
Chromosomal abnormalities, advanced maternal age, congenital abnormalities, trauma, hypothyroidism, medications, or substance abuse
SIGNS AND SYMPTOMS
Vaginal bleeding, abdominal cramping
DIAGNOSTICS
Lab testing including: CBC, β-hCG, Rh
Pelvic ultrasound which can be performed outpatient if known intrauterine pregnancy
TREATMENT
Hemodynamic monitoring for blood loss
Rhogam for Rh-negative patients
Consider OB/GYN consultation for possible D+C if patient is hemodynamically unstable
OVARIAN MASS, OVARIAN CYST, AND OVARIAN TORSION
BASICS
Common, ranging from small physiologic cysts to large masses causing ovarian torsion and necrosis, to malignancy
ETIOLOGY
Typically benign, but are defined as pathologic if >2.5 cm
Women of all ages are at risk
Most common in reproductive years
SIGNS AND SYMPTOMS
Often asymptomatic, mild to moderate pelvic and abdominal pain, dyspareunia
Abdominal and/or pelvic tenderness, adnexal tenderness
DIAGNOSTICS
Ultrasound
Labs including hCG to rule out ectopic, CBC if concern for hemorrhagic cyst (Table 11.1)
TREATMENT
Control pain, outpatient follow-up for repeat ultrasound
| Ultrasound Characteristics of Ovarian Masses |
Benign Cysts | Malignant |
|
|
Most will resolve within 1 to 3 months
If malignancy suspected, refer to gynecology oncologist for laboratory testing and possible surgical exploration
Ruptured/Hemorrhagic Ovarian Cyst
BASICS
A rupture of a follicular cyst can be asymptomatic, mild transient pain, or significant pain
In severe cases, intraperitoneal hemorrhage can occur
ETIOLOGY
Occurs to women of reproductive years
Exact etiology is unknown though can occur in trauma
SIGNS AND SYMPTOMS
Severe, unilateral pelvic pain mid-menstrual cycle immediately following sexual intercourse, or with pelvic exam (can occur at other times of cycle or without sexual intercourse)
Abdominal and/or pelvic tenderness, adnexal tenderness; can have tachycardia and hypotension if significant blood loss
DIAGNOSTICS
Ultrasound
Serum β-hCG, hemoglobin/hematocrit (platelet count, prothrombin time (PT), partial thromboplastin time (PTT) if on antiplatelet or warfarin therapy or history of coagulopathy)
TREATMENT
Hemodynamically stable:
• Control pain with po or IV pain medications
• Consider serial hematocrit and observation if ongoing pain or anemia
Hemodynamically unstable:
• NPO, two large-bore IV, type and screen, pain control
• Surgery indicated only for brisk blood flow to ovary and continued bleeding
BASICS
Twisting or rotation of the ovary, which can lead to occlusion of the ovary’s blood supply
Three percent of all GYN emergencies
Prompt diagnosis is imperative to preserve function of ovary
ETIOLOGY
Most often occurs when a mass or functional cyst is present on ovary
Twisting of both ovary and fallopian tube on vascular pedicle → venous/lymphatic destruction → congestion and edema → ischemia and necrosis → infarction
Risk increases with size of mass until mass is so large that it becomes fixed in the pelvis
SIGNS AND SYMPTOMS
Sudden onset of unilateral, severe, sharp pelvic pain, often with vomiting, generally occurs midcycle
Low-grade fever; abdominal, pelvic, and adnexal tenderness
DIAGNOSTICS
Detailed history and clinical exam findings with an ovarian cyst
Labs including: serum β-hCG to rule out ectopic pregnancy; CBC, basic metabolic panel (BMP), type and screen
Urgent pelvic ultrasound with doppler, can be misleading due to dual blood supply of ovary
TREATMENT
ABCs, supportive, IV fluids, pain control
Consult GYN for emergent laparoscopy
• Even if blood flow is normal on ultrasound
• Laparoscopy is gold standard to confirm torsion and assess viability of ovary
BASICS
Inflammation of pelvic organs, which can lead to infertility in women
ETIOLOGY
Bacteria, usually gonorrhea and Chlamydia, from the vagina or cervix travels into the uterus, fallopian tubes, ovaries, pelvis or the upper reproductive tract
Risk factors include:
• Sexual partner with gonorrhea or Chlamydia
• Multiple sexual partners
• Past history of any sexually transmitted infection/pelvic inflammatory disease (PID)
• Recent insertion of an intrauterine device
• Sexual activity during adolescence/young age
• Age <25 years
• Unprotected sex
SIGNS AND SYMPTOMS
Pelvic and lower abdominal pain
Vaginal discharge
Fevers and chills
Postcoital bleeding
Painful sexual intercourse
Tubo-ovarian abscess (TOA): unilateral adnexal tenderness, systemic symptoms
DIAGNOSTICS
PID: pelvic exam with findings of vaginal discharge, cervical motion tenderness (chandelier sign)
TOA: pelvic ultrasound
Cultures may show N. gonorrhoeae or C. trachomatis
TREATMENT
Centers for Disease Control and Prevention recommended regimen for outpatient treatment
• Ceftriaxone 250 mg intramuscular in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days
Consider inpatient therapies if patient pregnant, unable to tolerate orals, or TOA
• Cefotetan or cefoxitin plus doxycycline
• Clindamycin plus gentamicin
PLACENTAL ABRUPTION AND PLACENTAL PREVIA
BASICS
Premature separation of placenta from uterine wall
Significant cause of maternal and perinatal morbidity
ETIOLOGY
Chronic placental disease, abnormalities in early implantation, blunt abdominal trauma or rapid uterine decompression, uterine abnormalities, cocaine use, smoking
Risk factors: hypertension (HTN), preeclampsia, advanced maternal age, thrombophilia, prior spontaneous abortion, prior abruption, smoking, cocaine use, trauma, chorioamnionitis
SIGNS AND SYMPTOMS
Painful, vaginal bleeding (dark and scant to large-volume bright red blood)
Uterine tenderness, increased uterine tone, fetal distress; if severe, can lead to disseminated intravascular coagulation
DIAGNOSTICS
CBC, BMP, liver function test (LFT), PT, PTT, and type and screen, disseminated intravascular coagulation panel as indicated
Ultrasound: often not useful as high rate of false negative results
Any woman with small bleeding from placental separation is at risk of severe abruption
TREATMENT
ABCs, supportive, place on left side, IV fluids, consider transfusion, Rhogam
Urgent GYN consultation for further management and delivery
BASICS
Implantation of placenta over cervical os
ETIOLOGY
Risk factors: previous placenta previa, previous C-section or intrauterine surgical procedure, multiple gestation, multiparity, advanced maternal age, infertility treatment, previous abortion, smoking, cocaine use, male fetus
SIGNS AND SYMPTOMS
Painless, bright red vaginal bleeding after 20 weeks gestation
Defer full speculum exam to OB/GYN
DIAGNOSTICS
Prompt pelvic ultrasound to evaluate placental location
Labs including: CBC, BMP, LFT, PT, PTT, fibrinogen level, type and screen, Rh
TREATMENT
Most women require conservative care after first episode if no severe bleeding
ABCs, supportive, place on left side, IV fluids, consider transfusion, Rhogam
Urgent GYN consultation for further management and delivery
Emergent delivery for fetal distress, maternal hemorrhage refractory to treatment, significant bleeding after 34 weeks
• Cesarean section is method of choice
PREECLAMPSIA, ECLAMPSIA, AND HELLP
BASICS
A syndrome of HTN (>140/90), proteinuria, and edema after 20 weeks gestation
Eclampsia includes above plus seizure
• Generally seen in third trimester or up to 10 days postpartum
ETIOLOGY
Exact cause is unknown
Risk factors include:
• Young or advanced maternal age
• History of HTN
• Diabetes, kidney disease
• Multiple gestation
• Hydatidiform mole
SIGNS AND SYMPTOMS
Hypertension, peripheral edema, headache, visual changes, papilledema
Eclampsia includes seizures
DIAGNOSTICS
Physical exam including attention to blood pressure, lower extremities
Labs including urine to evaluate for proteinuria
TREATMENT
Treatment is blood pressure control with hydralazine
Consult GYN for further management and fetal and maternal monitoring
Eclampsia:
• Left lateral decubitus position to increase blood flow to uterus
• Seizure treatment:
Magnesium sulfate
If refractory, use Phenytoin or diazepam
• Definitive treatment is delivery of fetus
BASICS
Severe, clinical variant of preeclampsia
• Hemolysis
• Elevated liver enzymes
• Low platelets
ETIOLOGY
Exact cause is unknown
Risk factors include:
• Maternal age >35
• Multiparity
• White race
• History of poor pregnancy outcomes
SIGNS AND SYMPTOMS
Abdominal pain (usually epigastric or right upper quadrant), nausea, vomiting, malaise
DIAGNOSTICS
Labs including: urinalysis, CBC with smear, BMP, LFT, PT, PTT, 24-hour urine
Hemolytic anemia with schistocytes
Platelet count <150,000
Aspirate aminotransferase >70 IU per L
Total bilirubin >1.2 mg per dL
TREATMENT
Definitive treatment is urgent delivery, but can be timed based on safety and severity of maternal illness
Treat HTN and seizure prophylaxis
BASICS
Not sexually transmitted infection
Associated with multiple sex partners, vaginal lactobacilli, douching
ETIOLOGY
Overgrowth of anaerobic microorganisms primarily: Gardnerella vaginalis
SIGNS AND SYMPTOMS
Vaginal irritation, pain, pruritus, white, thick malodorous discharge
DIAGNOSTICS
Wet mount
pH 5.0 to 5.5, clue cells, fishy odor with KOH (whiff test)
TREATMENT
Metronidazole 500 mg po bid ×7 days (or)
MetroGel PV (or)
Clindamycin cream PV
Treat pregnant women only if symptomatic
BASICS
Sexually transmitted infection
Men/women commonly asymptomatic
ETIOLOGY
Protozoa: Trichomonas vaginalis
SIGNS AND SYMPTOMS
Malodorous frothy yellow-green vaginal discharge dyspareunia, abdominal pain
DIAGNOSTICS
Wet mount
pH >4.5 and trichomonads
TREATMENT
Metronidazole 2 g po single dose
Metronidazole 500 mg bid ×7 days
Treat all sexual partners
BASICS
Pregnancy, diabetes, antibiotics
ETIOLOGY
Yeast/fungi: Candida albicans
SIGNS AND SYMPTOMS
Vulvar pruritus, white, curd-like vaginal discharge, erythema, dyspareunia, dysuria
DIAGNOSTICS
Wet mount
pH <4.5, pseudohyphae, culture (+) for Candida
TREATMENT
Fluconazole 150 mg po single dose (nonpregnant women only) (or)
Topical antifungal PV
