OBGYN-GU.pptx - sinaiem.org - Mount Sinai EM Residents - Home

the inservice exam
Feb 25, 2009
Short term  $$$ (moonlighting, Mets)
Long term  $$$$$$ (licensure, career in EM)
But also: intro to EM practice
Similar questions to ABEM
Last year: 207 questions counted
Physician’s Evaluation and Educational Review VII
Las Vegas Board Review Course MP3s (2003?)
EMEDS Review sinaiem.org/files/articles/BR-emeds/ … jar files

This lecture series
Board review: Five months, 20 lectures…
Different than Dr. Cherkas sessions
This year:
More engagement than 2005-6
More questions, buzzwords than last year
More repetition
More candy

OB+GYN+GU
About 19 questions in PEER VII (out of 410)
Some overlap in ID, S+S, Procedures + Skills
Last year’s inservice: it was 8+7 out of 207
CV, GI, Pulm, Trauma each ~20
Likely emphasis: details that make or break ED diagnosis or management

OB+GYN+GU
Today: Pregnancy, UTI, PID
Select Male Concerns: scrotal and penile
No renal / stones / HD / PD complications
You already got some STDs from Jim Hinchey

Warning: Graphic Photos
of our Holiday Parties

Question 1
A 32 year old man presents with a painful erection that has lasted for more than 10 hours. Which of the following medications is the most likely cause of this condition?
Olanzapine
Not the psych drug (Zyprexa) you should be thinking of…
Pseudoephedrine
No – this is a therapy (only if given early)
Terbutaline
No – this is a therapy (0.25 mg subQ q30 min … in the deltoid)
Trazodone
Most causes of priapism are iatrogenic, from anti-HTN or psych meds
Venlafaxine
Also linked to priapism but much less common than trazodone

Priapism
Low flow (90%, ischemia), venous obstruction
Meds (psychotropics, antihistamines, anti-HTN, viagra, cocaine)
Hematologic (sickle cell, leukemia, thalassemia)
Intra-cavernosalinjections (pre-1998)
Spinal cord injuries
Painful
12+ hours  to thrombosis and ischemia  impotence
High flow (10%), arterial source
Secondary to groin or straddle injury
Arterial cavernosal shunt
Less pain, no fibrosis
Treat with embolization

Priapism Rx
General Treatment:
Focus on pain control, urinary obstruction, hydration, O2 (sicklers)
Alpha-adrenergic antagonists: terbutalineIM, intracorporalphenylephrine
Corporal aspiration
Shunt surgery
Sickle cell: PRBCs, hyperbaric oxygen
Iatrogenic (due to penile injections for impotence)
Leukemia: terbutaline, chemo
Non-reversible causes: idiopathic, high spinal cord injury, meds

Question 2
A 47 year old uncircumcised, obese man presents with painful “tip of the penis.” Exam shows a swollen and tender glans and foreskin. On retraction, the foreskin appears excoriated and has a foul-smelling, purulent discharge. No other findings are present. What is the diagnosis?
Balanoposthitis
Balanitis (glans) + foreskin! Usually skin flora. Treat with sitz, cleaning, keflex. If it’s cheesy, it’s candida. May be the presenting sign for diabetes – check a FSBS!
Fournier’s gangrene
Patient not immunocompromised, no systemic signs or spreading beyond tip.
Herpes simplex
Vesicles… not discharge.
Paraphimosis
Can’t extend. Vicious cycle; true emergency. Give ice, sugar, puncture… slit?
Phimosis
Can’t retract. Can lead to pain, UTI. Dilate, plus 4-6 weeks of steroid cream.

Balanoposthitis
Balanitis = inflammation of the glans penis
Posthitis = inflammation of the foreskin
Cause:
Usually Staph/Strep, can be fungal
Poor hygiene, undiagnosed DM, seborrheic dermatitis
Rx:
Local measures: soap, drying
Antifungal cream, possible broad spectrum antibiotics (cephalosporin)

Phimosis / Paraphimosis
Phimosis = inability to retract foreskin
Uncommon cause of urinary retention
Congenitial or bc of chronic balanoposthitis
Paraphimosis = retracted skin that cannot be reduced
A true urologic emergency
Can lead to gangrene of glansbc of
arterial compromise
Leave foley in place if present
Rx: If unable to reduce manually
Use Local anesthetic at constricting band, make superficial vertical incision to decompress

Question 3
A 13 year old boy is brought in for sudden onset of groin pain. On exam, the patient’s right testis is swollen, tender, and slightly elevated in the scrotum. Which of the following statements regarding this condition is correct?
CT is the imaging study of choice
CT gives great anatomy… but who wants IV, radiation on a kid’s nads?
Duplex ultrasonography provides little data about testicular anatomy
US is 100% specific for torsion, good anatomy. Manual detorsion shouldn’t wait.
Positive cremasteric reflex confirms the diagnosis
Reflex should be absent in torsion
Relief of pain with elevation reliably differentiates this condition from epididymitis
Relief of pain with elevation (Prehn’s sign) suggests epididymitis… not reliable…
The “bell-clapper” deformity predisposes patients to this condition
Tunica vaginalis (a fold of peritoneum) should just cover superior pole of testis and attach to posterior scrotum. If it covers entire testicle and attaches to spermatic cord, testis can rotate more freely.

Testicular Torsion
Cause: twisting of the spermatic cord
Maldeveloped testes (at baseline tend to lie more horizontal than vertical = bell clapper deformity)
Findings: Young male with abdominal pain
Peak incidence in puberty but can occur at any age
Sudden onset of pain, not changed by scrotal elevation
Absence of cremasteric reflex (normal: stroking proximal medial thigh causes testicle to elevate)
Tests: Ultrasound Doppler, Nuclear Scan
Rx: Emergent urology consult for surgical repair
May try Manual Derotation while waiting
(rotate testicle in lateral direction, “open book.”
Relief of pain indicates success.)

Testicular AppendageTorsion
Cause: twisting of pedunculated structures on the epididymis or testis
More common than testicular torsion in prepubertal boys
Findings:
“Blue Dot Sign:” pathognomonic, represents hemorrhage of appendage visualized through thin scrotal skin.
Tests: Doppler ultrasound
Rx: Possible surgery. May not be necessary if doppler of testicle is normal.

Epididymitis
Cause: Inflammatory process (gradual)
Can be infectious or due to reflux of sterile urine
Young boys: think of congenital abnormalities
Gram neg. Secondary to structural, neurologic,
functional abnormalities of lower tract
Sexually active: usually STD-related
If Gram neg, give erythromcin
Elderly: think of obstruction (prostate, stricture)
Usually E.coli and Klebsiella
5-25% of testicular cancers are initially misdiagnosed as epididymitis
S/Sxs: gradual onset of pain
Prehn’s sign = relief of pain with elevation of scrotum
Rx: Abx as indicated by age, NSAIDs, bed rest, scrotal support, intermittent ice packs

Acute Prostatitis
Cause:
Sexually Active: consider STD (GC)
Elderly: consider E.coli
S/Sxs:
Perineal pain, dysuria, frequency, fever/chills, urinary retention
“Boggy” enlarged, tender prostate
Prostate massage is contraindicated
May lead to bacteremia

Question 4
A 56 year old man with DM II presents with 3-4 days of fever and groin pain. There is no hx of recent illness, but glucose levels have been difficult to control for over a week. His exam is in the next figure. What is the most appropriate initial treatment?
Can we do this, Cherkas-style?
High-dose intravenous penicillin
Hyperbaric oxygen therapy
Intravenous piperacillin/tazobactam
Suprapubic catheterization
Surgical debridement

Question 4, continued
A 56 year old man with DM II presents with 3-4 days of fever and groin pain. There is no hx of recent illness, but glucose levels have been difficult to control for over a week. His exam is in the next figure. What is the most appropriate initial treatment?
High-dose intravenous penicillin
Not enough coverage (most common Cx is E. coli, Bacteroides, and staph…)
Hyperbaric oxygen therapy
An adjunct, and a controversial one. Certainly not initial therapy.
Intravenous piperacillin / tazobactam
Could go for pen (for G+ and C. perfringes) plus aminoglycoside or 3g cephalo for gram negs, plus anaerobe coverage with metronidazole or clinda.
Suprapubic catheterization
May become necessary, depending on extent. But not initial therapy for this pt.
Surgical debridement
Almost certainly necessary, but not the initial treatment.

Scrotal Abscess
Must differentiate between abscess of the skin (hair follicle carbuncle/furuncle) vs. Abscess of scrotal contents
Skin abscess Rx: I&D, no abx
Intra-scrotal abscess can be a complication of epididymitis
Ultrasound can help to distinguish
Must differentiate from Fournier’s
Low threshhold for Urologic Consultation

Fournier’s Gangrene
Surgical Emergency
Extensive tissue loss and increased
mortality with delayed diagnosis
Cause:
Polymicrobialinfxn of subcutaneous
tissue that originates either in the skin, urethra, rectum
Immunocompromised at risk (DM,EtOH, IVDA, chronic steroids)
Findings:
Can start as a benign infection or abscess
Quickly becomes “virulent” with crepitus
Always consider this in any pt with scrotal, rectal or genital pain or tachycardia out of proportion to clinical findings

Question 5
In the treatment of a 3 year-old boy with UTI, which of the following additional signs is the strongest indication for hospital admission?
Localized myalgias
whatever
Maculopapular rash
not really associated with UTI at any age
Marked fever
no – this is often the presenting symptom
Mucoid diarrhea
may help distinguish UTI from AGE at this age, shouldn’t affect dispo
Persistent vomiting
Vomicking unable to take ABx, mandates IV therapy and admission

Question 6
A 24 year old woman complains of dysuria, urgency, and frequency. She denies f/c, no n/v, no back pain. She has no known drug allergies and a urine pregnancy test is negative. Bedside urine dip shows 3+ blood, 1+ nitrites, and 1+ leukocyte esterase. What is the most appropriate course?
Order a urine culture and treat with an appropriate ABx for 3 days
Rosen’s and Tintinalli say no culture is necessary, only 10-20% will fail empiric tx
Order a urine culture and treat with an appropriate ABx for 7 days
Not pregnant, not a male, not elderly, not diabetic, no hx of prior UTI’s…
Treat with an appropriate ABx for 3 days
Empiric therapy without UCx is appropriate if no risk factors for complications
Treat with an appropriate ABx for 7 days
3d is enough. Use local abiogram to guide ABx choice.
Wait for microscopic analysis of the urine before deciding whether to order a urine culture.
Wait for FEW ORG SEEN ??? A UTI patient should be your fastest dispo of the day.

Urinary Tract Infection
Cause:
E.coli (90%), Klebsiella, Proteus, Enterobacter (5-20% combined)
Males usually secondary to urologic disease
Dx:
Sxs + 100 CFUs of single pathogen
Relapse = same organism & serotype,
< 1 month since initial infection
Reinfection = recurrence of sxs 1-6 months after initial infection, usually different organism

UTIs: Deeper Thoughts
Complicated UTIs
Underlying urologic pathology, pregnancy,
immunocompromised, usually not E.coli
Asymptomatic bacteriuria:
Can progress to symptomatic infection,
especially in pregnancy
Acute Urethral Syndrome
+Dysuria, but with low (or no) bacterial count in urine cultures. UA often positive.
Generally indicates infection & should be treated
DysuriaDdx: chlamydia, herpes, GC, vaginitis

UTIs: Lab Tests
Nitrite: specific (90%) but not sensitive (50%)
Based on bacteria-induced change of nitrate to nitrite (varies by bug, urine incubation)
Leukocyte Esterase: similar (80% sp, 48% sn)
Based on presence of WBCs in urine
Pyuria = 2-5 WBC in females,
1-2 WBC in males
Bacteriuria = any bacteria in an uncentrifuged gram stain smear, or > 15/HPF in centrifuged specimen
Chlamydia infection can be associated with low WBC and low bacterial counts

UTIs: When to Culture?
Pyelonephritis, recent hxpyelonephritis
Underlying urologic pathology
Children, Males
Diabetics, Immunocompromised
Recent Instrumentation, Indwelling catheter
Prolonged Sxs prior to Rx
3 or more UTIs in the past year
DO NOT need to culture young, healthy women with uncomplicated UTIs
DO need to r/o other sources of pyuria/dysuria: STDs, prostatitis, pyelonephritis, epididymitis

Adult UTI Treatment
Female, lower tract, nonrecurrent, simple
TMP/SMZ BID x 3d
Quinolone x 3d
Female, lower tract, complicated / or Male, upper tract
TMP/SMZ x 10d
Macrobid x 10d
Cefadroxil x 10d
Amox/Augmentin x 10d
Quinolone x 10d
Female, lower tract, suspected STD
Doxycycline x 10d
TMP/SMZ x 10d
Erythromycin x 10d (E.coli not covered)
culture for chlamydia, GC
Think Pseudomonas in high-risk patients
Cover with broad spectrum Abx

High-Risk Pyelonephritis
Pregnancy:
Incidence of pyelonephritis increases in the 3rd trimester and may precipitate preeclampsia, sepsis & miscarriage
DM, Sickle Cell Anemia
Renal Calculi / obstruction
Elderly / Debilitated
Carcinoma, Chemotherapy
Recent hospitalization
Recent instrumentation of UT
Pyelonephritis = leading cause of perinephric abscess

Question 7
A 17 year old woman complains of dysuria x3 days. She denies f/c, no n/v/d, no abd pain. Pelvic exam reveals a homogenous white discharge that coats the vaginal walls. Pregnancy test is negative. Wet mount shows clue cells. The best treatment is:
azithromycin
this is not chlamydialurethritis or PID! (chlamydiais #1 reported STI)
ceftriaxone
this is not gonococcalurethritis or PID!
fluconazole
if it were fungal, they would have said cottage cheese..
levofloxacin
this is not a UTI! and levaquin has poor anaerobe coverage…
metronidazole
therapy of choice in both pregnant and nonpregnant patients. A seven-day course of clinda cream or pills is also acceptable. Metronidazole also works on trichomonas, which can present similarly to vaginosis (but is described with dyspareunia, dysuria, and a wet mount that shows flagellates).

Gardnerella (BV)
New term: AnerobicVaginosis
Gram negative rod, faculatative anaerobe
“fishy” order, rather than maldorous
Clue cells: anaerobes sticking to squamous epithelial cells. Looks like a fried egg with salt and pepper under microscope.
Rx: Flagyl.
Truly, flagylin first trimester is controversial.

Trichomonas
Women: Frothy, grey, malodorous
Men: asymptomatic, urethritis
Drop it on slide: see swimming things
Word STRAWBERRY: GOES WITH TRICH
Other strawberries: tongue
A protozoan. Rx: Flagyl (not intuitive)
Think Flagyl if you have no idea what to use! (giardia, anaerboes, ameobas, other parasites)
What else should you be doing after you treat the patient: treat partner
Single dose therapy
In Pictures: look like fat sperm

Candida
Yeast
Risk factors:
diabetes (common presentation of new onset DM)
contraception
antibiotics
Cottage cheese, no smell
Drop on slide: KOH dissolves other elements, leaves behind hyphae (spaghetti) and spores (meatballs)
RX: single treatment of fluconazole, or lotrimin suppository

Question 8
A 23 year old woman presents complaining of lower abdominal pain. Pelvic exam reveals yellow vaginal discharge, as well as moderate CMT. Adnexa are tender, but no masses are present. Outpatient management may be considered if the patient has:
A physician who can provide followup care
It’s hard to discharge PID: Poor followup, adolescence, HIV, N/V, ambiguity…
Pelvic abscess
Um, no. This would be a reason for IV ABx, admission
Positive urine pregnancy test
No. Pregnancy should actually protect against PID – this presentation is ominous.
Already taken antibiotics for similar complaints
So they’ve failed outpatient therapy and need IV ABx and admission
Temperature greater than 38.8C
Fever is not uncommon but I guess the PEER folks found this concerning

PID/Salpyngitis
Causes: Neisseriagonorrhoeae, chlamydiatrachomatis (#1), Gardnerellavaginalis, anerobes
Ascending disease: starts in cervix, goes through tubes
Risk Factors: anything that mucks up the tubes. Previous PID, IUD, adolescent w/multiple partners

PID, continued
Can’t be ruled on physical exam. FORGET CMT
CMT, adnexal tenderness, elevated temperature, discharge
DON’T NEED TO ADMIT ALL PATIENTS Consider for:
Pregnancy—this is very uncommon
Immunosuppressed
IUD
Clinically ill
Outpatient compliance issues
Fertility issues
TOA
peritonitis

More on PID
Cervical culture not correlates with actually causative organism. Treatment always empiric
Complicatons:
Chronic pain/dyspareunia
TOA
infertility (most common cause of infertility)
Fitz-Hugh-Curtis: RUQ pain w/o biliary disease
Watch out in RUQ pain questions on boards. What is the next thing you do? answer is pelvic exam
F-H-C catch phrase: violin strings (adhesions between capsule of liver and abdominal wall)

PID
Rx: treat Gonorrhea and chlamydia.
Gonococci: ceftriaxone/cefuroxime or quinolone (single dose)
Chlamydia/anaerobes: doxy 10 days (slower turnover rate)
If recurrent/chronic/fails treatment, think anaerobes. FLAGYL

Question 9
The side effects of emergency contraception meds can be reduced by:
Avoiding their use in smokers
Risk of VTE goes up with OCP use and age over 35, obesity, and smoking
Peri- or post-ovulatory administration
Actually there’s theoretical risk of ectopic here – the P might cause ciliarydysfxn.
Taking the pill before a meal
Symptoms of n/v, headache, fatigue are benign. Abd pain must get ectopic w/u
Using a progestin-only regimen
WHO ‘98 says P dosing within 72 hours is more effective than Yuzpe, fewer AE
Using combination pills with both estrogen and progestin
Yuzpe ‘74 method is two E+P doses, twelve hours apart, within 72 hours of sex.

Miscarriages (definitions old fashioned)
Threatened: if pain and bleeding but os is closed. Both internal and external have to be closed
Instructions: don’t put anything in your vagina
Inevitable: same thing, but os open
Incomplete: passed some, not all tissue (at the os)
Missed: baby dies, don’t have abortion. Not common.

Abortions, cont.
Board question: if missed situation described & pt has fever: septic abortion.
Worry about DIC in these cases
polymicrobial
Septic abortion: most common is polymicrobial (“polymicrobial” also associated with diabetic foot ulcer questions)

Question 10
A 26 year old woman who is 6 weeks pregnant presents with RLQ pain opf 10 hours’ duration. The pain began periumbilically and migrated to the RLQ. She has nausea which she attributes to pregnancy. She has a fever of 38C and elevated WBC with left shift. UA is normal. Sono shows IUP, but the appendix was not visualized. What is the next appropriate management step?
Admit for observation
Lots of overlap between appendicitis (nausea, WBC, pain) and pregnancy.
Discharge with instructions to return in 12 hours for repeat exam
This is a high-risk patient who should not leave.
CT of abdomen and pelvis
Risk to fetus is low, but specialists’ input is preferable.
Consult surgery and OB
She’s febrile and pregnant with abd pain. They’re going to need to get involved.
Start IV fluid hydration and observe in the ED for six hours
Delaying the diagnosis of appy can lead to increased M+M, fetal loss (up to 20%)

Safe imaging in pregnancy
Diagnostic Radiology in pregnancy:
If it’s indicated, do it.
D-dimer has no defined norms, just rises.
Helpful if negative…
Rad Threshold is 50 mSv. ?Others say fetus = 10.
CXR = 0.02 mSv. CTAngio = 5-30… if it’s indicated, do it.
Weeks 2-8: Organogenesis. Rads teratogen
Weeks 8-15: Neuro development at risk
Weeks 15+ … much less risk

Question 11
Which of the following conditions is most likely to be associated with a hydatiform mole?
Abdominal pain
It’s not more common than pain with normal pregnancy
Abnormally low beta-hCG
Not an ectopic! beta-hCG will actually be much higher than dates suggest
Hyperemesis
Most likely to be associated with the Mole.
Hypothyroidism
The Mole will make its own thyroid hormones, may trigger pre-eclampsia
Vaginal discharge
May present with bleeding, sure. Also see large uterus, large ovaries, may be passing grape clusters (hydropicvilli).

Molar pregnancy
Associated with Asians, first pregnancies, teens or 40’s
1st and 2nd trimester bleeding
The only possible cause of first-trimester pre-eclampsia
Chorionic villi tumor, not actually a fetus
46XX is complete, more likely to be malignant. Path needed to tell complete from incomplete (69XXXY, more benign)
No fetal heart, uterus bigger than normal.
Hcg very high (100,000s)
“Snowstorm” appearance on ultrasound

Normal pregnancy
Morning sickness: associated with good overall outcomes
12 wks: pelvic brim
20 wks: umbilicus
Highest at 36th week, then fundus descends
Increased CO 20-30%
Most women get a hydronephrosis of pregnancy
Chadwick’s sign: soft, blue cervix (venous, ok)
Rabbit done died?

Human Chorionic Gonadotropin
Doubles every 48-72 hours
Becomes positive after implantation, about a week (8-9 days) after intercourse
After first missed period, you will be positive
Miscarriage: works in reverse. Gets cut in half every 2-3 days.

Pregnancy Complications
Appendicitis: most common surgical condition in pregnancy (same incidence as in age-matched nonpregnant patients).
Difficult to diagnose: already have increased wbc, appy in RUQ
UTI in preg: consider as upper tract infections. Longer course (10 day), send culture
If pyelonephritis, admission +/- if sick

Question 12
Which of the following is a characteristic of the HELLP syndrome?
Increased LDH
Why not HELLDHLP? Hemolytic anemia implies elevated LDH
Neurologic symptoms
May help distinguish HELLP from TTP (but bad HELLP can cause seizures)
Normal antithrombin III
Helps distinguish HELLP (low) from TTP, HUS (normal)
Occurs early in pregnancy
Occurs late, and 30% postpartum (TTP occurrence is even throughout preg)
Renal symptoms
Helps distinguish HELLP from TTP (but bad HELLP can cause ARF)

Preeclampsia
Proteinuria > 300 mg in 24 hours +/- edema
Hypertension (140/90 or 30/15 over baseline)
Presents as headache, blurry vision, CNS changes, or just HTN
After 20 weeks, unless molar pregnancy
Risk Factors:
Primagravids and grand-multiparous
DM
Age
Obesity

HELLP Syndrome
Hemolysis, Elevated Liver enzymes, Low Platelets
Variant of pre-eclampsia
May present as epigastric/RUQ pain
Hemolysis: schistocytes on peripheral smear
Abnormal coagulation profile

Eclampsia
Pre-eclampsia + seizure: eclampsia
Headache, CNS, visual changes, hyperreflexia
Worse w/poor prenatal care, DM, obesity
Rx: magnesium sulfate, hydralazine
Definitive treatment is DELIVERY
Not the same as primary hypertension: more like withdrawl htn, pheo. Don’t use typical drugs!
Beta-blocker contraindicated: “unopposed alpha stimulation”

Ectopic Pregnancy
Leading cause of first trimester maternal death
2ndin $$ for claims against EM docs
Risk factors: Anything that mucks up your tubes
PID
previous ectopic
IUD
tubal surgery
Infertility treatment
?Unilateral, ?intermittent pain (95%)
bleeding (80%, not constant) 5-8 wks after LMP

Ectopic Pregnancy
Region: distal ampulla of fallopian tube (90%)
Need positive hcg
Then do ultrasound

Ectopic workup
Indicators of IUP, all should be visible on TV by 5-6 weeks:
yolk sac
fetal heart
fetal pole
Heterotopics: 1:30,000 (but 5x higher if on fertility treatment)
If not IUP
Too early
Ectopic
Abnormal IUP
Get quant hcg.
If above discrim zone (1000-2000, depending on ref), call gyn.
If lower, may be too early. You don’t know what you have. Call gyn, will likely go home to f/u in 2 days for serial HCG.

Ectopic, cont.
Happen at around 4-5 wks
Culdocentesis: rarely used. The positive is NON CLOTTING BLOOD
Indication for methotrexate: in stable ectopics/no fluid in belly. If they’ve started to leak, don’t use MTX. Failure rate 5-10%
Our job is mostly stabilization, coordination.

RhoGAM
If they’re Rh Negative, give it
Passive antibody if mother RH negative and any mixing of blood between circulations (vag bleeding, trauma)
50 mcg if <12wks, 300mcg if >12 weeks
Test for mixing: KleinhauerBetke: look for nucleated RBC (of fetus) in maternal blood

Third trimester bleeding
Placental abruption: normal placenta (in fundus, near head), painful bleeding. Takes a while to ooze out: painful, darker color.
Ultrasound CAN’T always diagnosis this
Risk factors: HTN, older, multitip, smoke, cocaine
Previa: painless, bright red.
Ultrasound always helpful
Don’t do pelvic exam in this situation
Admit, stabilize, RhoGAM if Rh-Neg, C-section if remains unstable

Question 13
A 30 year old woman presents complaining of a ‘typical’ migraine. She is 4 weeks post-partum and currently breastfeeding. Which of the following medications is contraindicated?
Thank goodness this isn’t a question on HELLP, IIH/pseudotumor, SAH, where they’d be asking about optimal imaging…
Acetaminophen
Safe in pregnancy (B) and breastfeeding (“Safe”)
Caffeine
Safe in pregnancy (C?) and breastfeeding (“N/A”)
Ergotamine
Passes through milk, causes v/d and seizures in infants.
Morphine
Passes through milk at 1% of maternal dose, no adverse affects reported
Promethazine
Phenergan is C: Safe in pregnancy, “potentially unsafe” in breastfeeding

Safe drugs in pregnancy
FDA ranked A,B,C,D,X (low risk->high risk)
Most asthma meds (steroids, albuterol, etc.)
HTN: beta blockers, calcium channel blockers
Heparin (not warfarin)
Killed vaccines (tetanus)
Antibiotics: PCN, cephalosporins, clinda, INH, ethambutol

Meds in pregnancy:
Almost nothing is category A (RCT shows no risk)
Localize, topicalize if you can.
Congestion meds: all C
Antipyretics: Mostly B at first, D for third term
Antiemetics: Doxylamine is A, ‘trons are B, all else C
Antibiotics: Pen, Cephalos, Azithro, Vanc: B
Analgesics: Oxycodone, Hydrocodone = B. Codeine C.

Question 14
A 20 year old woman presents by ambulance. EMS reports she just had a seizure. She is 7 months pregnant and has not had any prenatal care – her mother called 911 because she “wasn’t acting right.” On arrival, vital signs are 171/90, HR 90, RR 13, sat 99% on O2. She is unarousable.
Management should include:
Lorazepam 1 mg IV
Class D and not indicated for eclampsia (if pt had SE with hx of szs, sure…)
Magnesium 6g IV over 20 minutes
IV beats IM. Keep levels between 4-7 mg/dL. Drip at 2g/hr. Check reflexes.
Nifedipine 10 mg PO
Magnesium won’t control BP, but an oral agent has no role here.
Phenobarbital 1g IV
Class B but not the solution here.
Phenytoin 1g IV over 25 minutes
Class D and not indicated for eclampsia.

Midazolam, Diazepam are D
Haldol, Droperidol are D
Pentobarb, Ketamine are B
Lidocaine, Propofol are B.
ACE-I, ARBS are X or D.
Hydralazine is only C, fenoldepam, esmolol are B.
Ethanol, Phenytoin, Valproate, Tetracycline all D. Quinolones C.

Trauma in Pregnancy
Initial trauma care same as non-pregnant
Causes of fetal death: #1 maternal death, #2 abruption
Remember RhoGAM
No radiologic test should be withheld for appropriate maternal evaluation

Trauma in Pregnancy
Fetal monitoring >20 weeks
Minimum of four hours
Signs of fetal distress
> 8 contractions/hour suggest abruption
Kleihauer-Betke test (fetal-maternal hemorrhage)
For hypotension—turn pt to left side (to displace uterus off IVC), fluid bolus
Maternal stabilization is the most important factor in determining fetal survival

Safe imaging in pregnancy
Diagnostic Radiology in pregnancy:
If it’s indicated, do it.
D-dimer has no defined norms, just rises.
Helpful if negative…
Rad Threshold is 50 mSv. ?Others say fetus = 10.
CXR = 0.02 mSv. CTAngio = 5-30… if it’s indicated, do it.
Weeks 2-8: Organogenesis. Rads teratogen
Weeks 8-15: Neuro development at risk
Weeks 15+ … much less risk

Pre-term Labor
Labor at 20-35 weeks
Sterile speculum
Risk factors: multiple births, DES, cocaine, PIH, abruptio, alcohol, smoking
Admit, IV Fluids, bed rest, tocolytics (mag, terbutaline … you won’t be giving…)

Premature Rupture of Membranes (PROM)
Rupture >20 weeks and prior to labor
Nitrazine test: blue (positive)
Sterile speculum exam: ferning (due to high quantity of salts in amniotic fluid)
Avoid bimanual
Risks: Infection, premature labor, prolapsed cord
Admit them, they’re not going. Start monitoring in the ED, consider tocolytics.

Umbilical Cord Prolapse
Seen in up to 8%, but perinatalmortality: 50%
Pulsating cord on exam
Put patient in knee to chest position
Emergent c-section
Stop the delivery, elevate the presenting part, Trendelenburg can help, but call GYN

Amniotic Fluid Embolism
2nd/3rd Trimester
Immune response to amniotic fluid in circulation
First described in 1941. More like anaphylaxis?
Shock, bleeding, dyspnea, hypoxia, coagulopathy
Mortality = 50% at 1 hour, 80% at 4-5 hours
All we can really do is pressors, FFP, maybe HD, emergency C-section

Fetal Distress
Fetal hypoxia and/or acidosis
Late decels (early decels expected with contractions)
Severe variable decels are concerning
Decreased variation is concerning
Treatment: left lateral position, oxygen, IV fluids, consider delivery (emergency C-section)

Late Decelerations

Delivery
Ask yourself:
What is GA? (betamethasone if < 34 weeks)
How many feti?
Meconium + resp depression  ET intubation
History of maternal drug use? Consider narcan
8 stages: Head out by stage 3-4, then anterior shoulder, then posterior shoulder
Wait 30 min for placenta, pull gently, check it

Dystocia
Difficult labor
Abnormal fetal presention
Cephalopevlic disproportion
Gestational diabetes
Treatment:
Fetal manipulation (could cause brachial plexopathy)
Suprapubic pressure
Generous episiotomy

APGAR Score
Indicator of neonatal depression
Measured at 1 and 5 min
Appearance (color), Pulse, Grimace (reflex), Activity (tone), Respiration
Score 0-2 each

Emergency C-section
Maternal cardiopulmonary arrest
Indicators of fetal survival
Cause of maternal death
Quality of CPR
Gestational Age (>23 weeks)
Arrest to delivery time (after 20 minutes, survival is unlikely)
Vertical abdominal and uterine incision

Question 15
Which of the following is the least likely risk factor for postpartum endometritis?
Cesarean delivery
C-section is actually the biggest risk factor.
Chorioamnionitis
Really, any opportunity for bacteria to get into the uterus is a risk factor
Many vaginal exams during labor
So this is also a risk factor
Time since rupture of membranes
And this is, too.
Urinary tract infection
UTI is on the differential, naturally, but no obvious way for bacteria to go from here to uterus… thus, not a risk factor

Endometritis
Diagnosed by H+P, fever, uterine tenderness
WBC, Cx, sono/CT may support diagnosis
Polymicrobial, foul smelling, fever
High rate in c-section patients
Risks
PROM
Prolonged labor
Chorioamnionitis
Multiple exams
Internal monitoring devices
Treat outpatient with doxy or clinda, with low threshold for admission and IV cephalosporins

Mastitis
Pain, erythema, swelling
Staph infection.
Nurse with other breast, express milk, anti staph treatment (cephalosporin, erythromycin)

Question 16
A 22 year old woman who is 1 week postpartum and breastfeeding presents complaining of vaginal bleeding more than expected, that started 2 days prior.
She says the previous lochia had not been malodorous and had been light red in color. She denies fever or vomit. Vital signs are normal, save for a mild tachycardia. She has minimal abdominal pain. Pelvic shows normal vagina and cervix, no CMT. She is bleeding from the OS. Uterus feels firm and globular. The most likely diagnosis is:
Lower genital tract laceration
You would see this on exam, and there’d be no bleeding FROM os…
Normal menses
Not 1 week out, not in a breastfeeder…
Retained placenta
Many causes of postpartum hemorrhage, this one fits best. Visibile on sono. D+C indicated.
Uterine atony
Would be boggy or doughy. Most common cause of immediate postpartum hem (ie, 24 hr)
Uterine rupture
This would present as continued bleeding despite firm tone. More pain and irritation.

Postpartum Hemorrhage
Uterine atony
Most common cause in first 24 hrs
Risks: overdistended uterus, prolonged/precipitous labor, high parity
Treatment: fundal massage, oxytocin, IV fluids
Ruptured uterus
Seen with Previous c-section, excessive pressure, trauma
Tachycardia, hypotension, bleeding, absent heart tones
Fluid resuscitation, immediate c-section
Consider hysterectomy

Postpartum Hemorrhage
Retained placenta
Early or delayed post-partum hemorrhage
Sudden, brisk, painless bleeding
Boggy, enlarged uterus
Oxytocin, D&C, fluid resuscitation
Uterine inversion
Excessive traction on umbilical cord
OB emergency- IV, 02, tocolytic drugs
Do not separate placenta
Manual reimplantation or emergent laparatomy
Lower genital tract laceration
Coagulopathy (von Willebrand)

Lymphogranuloma Venereum
Organism: Chlamydia trachomatis
S/Sxs primary infection:
Uncommon in U.S.
Primary lesion followed by inguinal buboes
Buboes grow and rupture or form firm inguinal masses
Rx: Doxycycline

Lymphogranuloma Venereum (LGV)
Caused by certain serotypes of Chlamydia
1-3 week incubation (vs days with herpes)
BUBOES=painful inguinal nodes
Usual scenario: Swollen gland in groin, a little bit sick with it—fevers, chills, myalgias

BUBOES

LGV
No high fevers/non-toxic
Catchphrase: obligate intracellular organism, similar to virus. Doesn’t turn over quickly. Subacute disease process
Use doxy or macrolide
Since it turns over slowly, should do extended course (21 days)
Complications: urethral scarring

Chancroid
Organism: Haemophilus ducreyi
S/Sxs primary infection:
Tender painful papule followed by ulceration
Multiple lesions may be present, and coalesce
Painful inguinal adenopathy in 50%
May evolve to buboes and rupture
Culture Lesion
Rx: azithromycin, ceftriaxone (single dose of both)

Chancroid
Gram negative bacillus: Haemophilus ducreyi
Seen in developing countries
Incubates over 2-5 days
Vesiculo-pustulo, develops into ulcer

+
= CHANCROID

Chancroid, continued
Painful (Painless: primary syphillis)
Penis picture: must have pain clue!
Treatment: macrolide usually not wrong
Azithromycin, erythromycin, ceftriaxone

Gonococcal Urethritis
Organisms: N. gonorrhea, associated with chlamydial infection (30-50%)
S/Sxs:
Copious yellow pus
Virtually always symptomatic (dysuria)
Tests:
Gram-neg intracellular diplococci, send GC
Consider testing for syphilis
Test both partners
Rx: Treat for G & C
IM Ceftriaxone, or fluoroquinolone, or
one-dose cefixime + azithro

Non-gonococcal urethritis
Organism: usually Chlamydia (the most common STD)
Less commonly Ureaplasma, herpes, trichomonas, candida
S/Sxs:
Watery discharge, or no discharge
No leuks on smear (in 30%)
Often asymptomatic
Tests:
PCR or enzyme immunoassay
Rx: 1gm azithromycin once or doxy 100mg BID x 10d

Chlamydia
#1 sexually transmitted disease
Major cause of female infertility
Symptoms of local disease:
Discharge
Dysuria
Women: cervicitis, urethritis, PID
Men: epididymitis, urethritis, proctitis
Vag bleeding
Asymptomatic 3-20%
Rx: azithromycin, doxycycline

Condyloma Acuminatum (venereal warts)
Human Papilloma Virus
1-3 month incubation
Related to cervical carcinoma
Soft, vegetative clusters: Think cauliflower/broccoli
Transmitted through direct contact

Condyloma Acuminatum
Don’t get confused with Condyloma lata (syphilis)
Potential question: Patient presents with C.A. what is the next thing to do? (answer: look for other VDs)
Treatment:
Condylox (podofilox topical)
Aldara (imiquimod topical)
Cryotherapy

Herpes
Organism: Herpes Simplex (HSV-1 or 2)
S/Sxs of primary infection:
Painful pustular or ulcerative lesions
Constitutional sxs common (headache, fever, myalgias)
Lymphadenopathy (80%)
Rx: Acyclovir 200mg 5x/day for 10d

Genital Herpes
Type 1: above waist, type 2 below waist
This is not always true, but 60-80% of genital lesions are type 2
All primary infections present like a generalized infection: they have fever/flu/adenopathy
Lesions develop at 2-8 days: shallow, painful vesicles

HSV, continued
Differential dx: mono, primary HIV
Primary infection is worst, infection gets better, then it breaks out from nerves. Relapses associated with stress
Tzacnk smears: scraped from BASE of vesicle in epithelial cells. Multinucleate giant cell the key phrase

HSV
Active at time of birth: need GYN consult
Rx: -cyclovir. Indicated for primary symptoms, immunosuppressed. Also decreases relapse
Complications: a good question, not obvious. Young person, febrile, jaundice…not hep virus but herpes!
Hepatits, meninigitis, encephalitis, cervical CA,
Erythema multiforma also a known rash
Urinary retention: invasion of virus into sacral root ganglia. Not from pain. In young women with urinary retention, think herpes!

HSV
The classic picture of herpes lesion: Clustered vesicles on erythemetous base (Hand: herpetic whitlow)
Tzank smear confusion:
Inclusion body= Chlamydia

Gonorrhea… “The clap”
Localized disease symptoms:
Discharge
pain with urination
Cervicitis, urethritis, proctitis, PID
Vag bleeding
Abdominal/pelvic pain
Asymptomatic
Rx: single dose therapy
Cefixime, ceftriaxone, quinolone

GonorrheaComplications of untreated disease
PID
Epidiymitis/orchitis, prostatitis
Eye infection
Disseminated gonococcal disease
Skin lesion: tender pustule on erythemetous base
Arthritis/tenosynovitis
Endocarditis
meningitis

Syphillis
Organism: Treponema pallidum
S/Sxs of Primary Syphilis:
Painless chancre
Indurated borders
No constitutional sxs
Minimal adenopathy
Dx: by darkfield microscopy, VDRL, FTA-ABS (to confirm)
Rx: 2.4MU benzathine PCN G IM
Secondary Syphilis

Syphilis
Treponema pallidum (spirochete)
3 different stages
Primary
PAINLESS ULCER on penis (chancre)
RPR, FTA, VDRL negative in 1st stage
Look for the positive dark field
Resolves spontaneously
Rx: PCN

Secondary syphilis
Rash in young health person, not very sick: also think mycoplasma, pittyriasis rosea
Low grade fever, not too itchy
Palms and soles: others: gonnococcus (pustules), EM, RMSF, allergic reactions/contact dermatitis
Condyloma latum
Some fever, some painless adenopathy

Secondary Syphilis

Tertiary syphilis
Bites you when you’re an old man, 25 years after primary infection
CNS
Tabes dorsalis
Neuropathy
Meningitis
Cardiovascular syphilis
aortic aneurysm
Skin lesions: gummas
Benzathine penicillin drug of choice (Long acting penacillin: “LA” by nurses).
Strep pharyngitis the only other indication for LA.
Second line: docy, erythro, ceftriaxone. Not as good

Syphilis
Chancre- painless papule- hallmark of primary syphilis
2ndary syphilis 4-10 weeks- macular rash- trunk  extremities- palms + soles oral lesions grey painless ulcers
Tertiary syphilis-untreated for years- 2 types-neurosyphilis after 10 yrs-meningovascualar vasculitis of vertebral or spinal vessels or tabetic syphilis-demylination and ataxia
Cardiovascular only after 20-40 yrs usually thoracic aorta- aortiv valve insufficiency

STI’s
Condyloma lata-secondary syphilis- typically-large painless flat topped lesions-typically in anogenital region
Condyloma acuminata- genital warts – HPV – pink to grey keritanized with papilliform growths
Gonococcal proctitis- tenismus, anal itching and yellow discharge
Granuloma inguinale- bacterial infection with Calymmatobacterium granulomatis-painless papules beefy red ulcers with rolled edges
Chancroid- Heomophilus Ducreyi- painful genital ulcer-

Ovarian cysts
Get terminology straight!
Follicular cyst (before egg released), about 3 cm
Corpus luteum cyst (after egg released, or pregnant)
Nothing bad happens, unless >3 cm…can have torsion, rupture and bleeding!

Ovarinan/Adnexal Torsion
Twists around pedicle
Must be tumor or large cyst to do this
Dermoid cyst most common
Severe unilateral pain, nausea, vomiting
Sometimes bleeding, but not impressive
Unilateral tenderness
Diagnosis: ultrasound, laparoscopy
Differential: ectopic, IUP, appendicitis, PID

Ovarian tumor
Post menopausal
Usually advanced stage when diagnosed
2nd most common gyn malignancy
Mass on ultrasound
Refer

Endometriosis
Endometrium outside of the uterus
Abdominal pain, cyclical in nature
Most commonly on ovary, but can occur anywhere in abdomen, even in lung! Get cyclical pneumothorax
Treatment: hormonal therapy

Uterine cancer
Most common GYN cancer
The case: Old lady with vag bleeding
Risk factors
Continuous estrogen
Obesity
Diabetes
Hypertension, nulliparity
Late menopause
Pap smears don’t work for this
Refer to gyn

Uterine prolapse
Herniation into vagina
Post menopausal, multiparous women
Think they have alien in their vagina
ED Rx: reduce it! f/u gyn for possible surgery

Dysfunctional Uterine Bleeding
Think of anovulatory cycles due to hormonal imbalances.
Most with starting periods (menarche), stopping (menopause)
Consider cancer
Cycle with hormones, D&C

Sexual assault/Post-exposure prophylaxis
You have to consider it in every case, but not necessarily do it in every case
Plan B (levonorgestrel): give 1 dose now, then another in 12hrs
Not 100% effective, gets less effective with more time from assault
Works up to 3 days after sexual activity
Nausea and vomiting common
Consider in SA

SA considerations
Check for preg: underlying pregnancy
HIV test: same as above
Syphilis serology
3 ways to tell if there was intercourse with ejaculation:
Acid phosphatase (in seminal fluid)
P30 (seminal marker)
Looking for motile sperm

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OBGYN-GU.pptx - sinaiem.org - Mount Sinai EM Residents - Home Presentation Transcript