Obstetrics and Gynecology in the Emergency Department

Introduction

Women frequently present to the emergency department (ED) with obstetric (pregnancy-related) or gynecologic (non–pregnancy-related) symptoms that originate from issues of the female genital tract. As genital tract organs are colocated within the abdominal cavity with organs of the gastrointestinal and urologic systems, the evaluation of symptomatic patients often requires a careful evaluation to pinpoint which of these three systems is involved.

Anatomy

The female genital tract consists of:

1.

The external genitalia
- a.
  
  Labia majora
- b.
  
  Labia minora
2.

The vagina
3.

The uterus
4.

Two fallopian tubes
5.

Two ovaries ( Fig. 29.1 )

Fig. 29.1

Structures of the female reproductive system.

(From Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Female genitalia. In: Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW, eds. Seidel’s Guide to Physical Examination . 10th ed. Elsevier; 2023:448–498.)

Physiology

The menstrual cycle is governed by relationships between the pituitary gland and the organs of the female genital tract. The cycle is designed to give the woman a chance to become pregnant approximately once every month. The ovaries are active “endocrine-type” organs providing a source of ova (eggs) that become available for fertilization, as well as source of estrogen and progesterone, the major female hormones. Estrogen and progesterone target multiple genital tract tissues, but they primarily regulate a cycle at the beginning of which their levels rise, leading to uterine wall thickening to prepare for a potential pregnancy. If a pregnancy does not occur, the levels of estrogen and progesterone fall, leading to sloughing of the uterine wall each month, which causes vaginal (menstrual) bleeding.

A patient becomes pregnant when an egg cell is extruded from the ovaries and comes into contact with sperm cells in the fallopian tube. One sperm cell fertilizes the ovum (i.e., adds its genetic material to the cell), and cell division follows. The fertilized egg or zygote now exits the fallopian tubes and implants in the lining of the uterus (endometrium) where cell division and tissue differentiation continue. The developing fetus produces a hormone (human chorionic gonadotropin [HCG]) that stimulates the ovary to continue secreting high levels of estrogen and progesterone to maintain the developing pregnancy. A portion of this hormone (the β subunit) is virtually unique to a developing pregnancy, although several types of cancers can produce HCG. HCG’s β subunit is the substance that is measured by all types of pregnancy tests. The unit of measurement of HCG is international units per liter.

General Approach to the Patient With Abdominal Pain or Vaginal Bleeding, Unknown Pregnancy Status

In addition to the vital signs, determining whether the patient is pregnant is the key step in evaluating all women of childbearing age with abdominal or vagina complaints. The ED technician (EDT) can play a key role in speeding up the evaluation of these patients, almost all of whom require a pregnancy test by collecting urine for this test even before it is formally ordered.

There are two types of pregnancy tests. A qualitative test (generally done in the ED) determines whether a woman is pregnant, but it does not provide the exact level of HCG in the bloodstream. In order to determine a quantitative HCG level, blood must be sent to the lab and the results may take an hour. For some clinical situations, the ED qualitative test suffices, but in other situations, both the qualitative test (for speed of diagnosis) and the quantitative test (which contextualizes the findings on exam and sonogram) are both required.

There are generally three ways to perform a point-of care (POC) pregnancy test in the ED:

1.

Urine card test: This is the simplest test and is also the basis for all home pregnancy tests. Most card tests use a technique called enzyme-linked immunosorbent assay. The test’s sensitivity using a randomly collected urine sample corresponds to a serum level of about 20 international units per liter. This means that the test can be positive even before the missed period. The test performs quite well if done on a urine sample collected anytime during the day, and it is not necessary to get a first morning sample.
2.

Whole blood on a urine card: If a woman is unable to produce urine, the EDT can perform a finger stick, place three drops of whole blood on a urine pregnancy test card, and read the result in about 10 minutes. For more accurate testing, tape a red-top tube of the patient’s blood to a wall and allow to clot for about 10 minutes, leaving clear serum at the top of the tube. Carefully draw the serum from the tube using a needle and syringe, then place the same number of drops on the card as instructed by the testing kit.
3.

Commercial POC cartridge machine: A variety of commercial cartridge-based POC systems are available that can do bedside qualitative and quantitative HCG testing on heparinized whole blood. These systems are available in most EDs for a variety of tests. They take about 10 minutes to run the assay and are considered very accurate.

Once a patient’s pregnancy status has been established, it is important to determine what other information is needed. Dating the pregnancy and determining the patient’s obstetric history can help provide clinical context. Other information that may be helpful to gather during the initial patient triage includes any history of ectopic pregnancy, sexually transmitted diseases, or preeclampsia. A thorough understanding of patients’ history of gynecologic or obstetric complications provides the care team with an idea of their risk factors for the disease processes that will be described below.

Pelvic Exam Setup

When a patient presents with vaginal bleeding, abnormal discharge, or other complaints of potential OBGYN pathology, the provider may need to perform a pelvic exam in the ED. The EDT (particularly if female) may be asked to assist with the exam. Having all the materials prepared for a pelvic exam is very important, as sometimes the provider is not sure of what they will need before they begin the examination. Most EDs have a “pelvic cart” with multiple drawers containing a variety of devices and diagnostic tests that could be needed for the exam.

The exam should be performed in the most private and quietest space available, and the EDT should thoroughly explain the procedure and facilitate the provider’s answering any more complex questions.

Materials needed for a pelvic exam are a disposable speculum (see Fig. 29.2 ), a light source to illuminate the vagina (may either be built into the speculum or be an external light source), wall suction with appropriately sized catheters, sterile lubricant, sterile gloves, and disposable pads ( Table 29.1 ). Ensuring correct speculum size and understanding that there are options for different speculum sizes is important for patient comfort.

TABLE 29.1

Material That May Be Needed for a Pelvic Exam

Equipment	Test
Red-top tube, saline flush, sterile swabs	Vaginal “wet prep” for bacterial vaginosis and Trichomonas
Cervical swabs	Gonorrhea and chlamydia
Potassium hydroxide solution	Vaginal yeast infection

In patients with significant bleeding or copious vaginal discharge, gauze and large-tip cotton swabs to clear the clinician’s visual field should be available at bedside. Positioning is also essential for proper exam and visualization of the cervix. As an EDT, helping a patient to the foot of the bed, with rolls of blankets or a bedpan underneath the patient’s lower back and sacrum to allow for adequate pelvic positioning, can be very helpful to complete the exam quickly and with minimal discomfort if stirrups are not available on the types of ED stretchers used (See , Assisting with a Pelvic Exam).

General Approach to the Known Pregnant Patient

The duration of a pregnancy is measured in weeks beginning on the date that the last menstrual period (LMP) began. A pregnancy is divided into three 12-week “trimesters.” Table 29.2 outlines key developmental milestones in each trimester.

TABLE 29.2

Milestone Development in Different Semesters

Trimester	Weeks
First	0–12	Heartbeat 6–8 wks
Second	13–25	Can determine sex on sonography	Growth of hair	Baby moves for first time
Third	26–39	Baby moves frequently	Definitive viable baby

In addition to measuring and classifying pregnancy by trimester, the number of weeks a fetus spends in development designates the “term” classification for the pregnancy’s duration as outlined in Table 29.3 .

TABLE 29.3

Term Classification in Pregnancy