This document provides guidance for junior doctors on diagnosing and managing common obstetric and gynecological presentations in the emergency department. It reviews evaluation and treatment of PV bleeding, menorrhagia, dysmenorrhea, pelvic pain, emergency contraception, and hyperemesis gravidarum. Diagnostics include pregnancy testing, pelvic exam, ultrasound, and bloodwork. Conditions are managed initially in the ED or referred to obstetrics as appropriate based on stability and findings.

1. O&G for ED
JUNIOR DOCTOR TEACHING SESSION 2013
WANGANUI HOSPITAL
DR BETH WINN
SHO O&G

2. Aim
 To cover ED level diagnostics and management,
expected at RMO level, of common obstetric and
gynaecological presentations.

3. Topics
 PV bleed in reproductive age women
 Menorrhagia and Dysmenorrhoea
 Pelvic pain
 Emergency Contraception
 Hyperemesis

4. PV Bleed in pre-menopausal women

5. PV bleed
PV bleed
BHCG +ve
Pelvic swabs and PV exam
Pelvic USS
Intrauterine
BHCG -ve
Empty uterus
? Intermenstrual
bleed due to STI
Normal
Pregnancy
Threatened
miscarriage
Missed
miscarriage
? Irregular Period ? Due to cervical
pathology eg
due to DUB, pill etc
ectropion
Ectopic
pregnancy
NB if USS not available and no senior around, abdo exam plus PV exam to
assess external os will help with diagnosis. Suspected ectopics should NOT
go home.

6. Miscarriage Terminology Refresher...
 An inevitable miscarriage describes a condition in which the cervix has
already dilated open,but the foetus has yet to be expelled. This usually will
progress to a complete miscarriage.
 A complete miscarriage is when all products of conception have been
expelled.
 An incomplete miscarriage occurs when some tissue has been passed, but
some remains in utero.
 A missed miscarriage is when the foetus has died, but a miscarriage has
not yet occurred. It is also referred to as delayed miscarriage.
 Threatened miscarriage refers to PV bleeding in early pregnancy.

7. What are you going to do...
 23 yo female
 2 day hx of PV bleeding
 Abdo pain, suprapubic
 Nausea, no vomitting
Other hx points? Exam?
Investigations?

8. To do...
 Is she well or not?
 Normal vitals? Soft abdomen?
 Urine dip including BHCG
 Bloods including BHCG, WCC, CRP, Hb, G&S,




clotting, antenatal blood screen & rhesus status
IV access
Analgesia
Formal pelvic USS or bedside ED with senior
PV exam- check for vaginal trauma, cervical
ectropion/polyp, check os open/closed, swabs

9. Management
 If well patient with intrauterine pregnancy:
- heart beat seen, home and FU with midwife
- No heart beat, d/w O&G re home +/- repeat beta
HCG/USS
- If positive pregnancy test and no intrauterine
pregnancy seen d/w O&G re repeat studies/serial beta
HCG to exclude ectopic. If unwell, laparotomy.

10. REMEMBER!
ALL post menopausal bleeding IS endometrial
cancer until proven otherwise
REFER

11. Menorrhagia & Dysmenorrhea

12. Menorrhagia
 Most likely to occur in pre/peri menopausal women





secondary to DUB
Elicit extent of bleeding (e.g. ‘Double protection’)
Establish haemodynamic status
Check for anaemia and coagulopathy
Take G&S sample and keep in patient slot
Do PV exam for ?bulky uterus
 NB if not stable/hb <8, need ABC Mx and blood transfusion. Call O&G as
may attempt intrauterine tamponade. IV conjugated oestrogen
(premarin) 25mg IV 4hrly.

13. Management of a stable menorrhagia
 Things you can do:
 Start ibuprofen and tranexemic acid
 Start ferrograd
 Order formal USS
 d/w O&G and fill out blue form
• Things O&G can do:
 Start provera/oestrogen (high dose)
 See in clinic to discuss mirena/ablation/ hysterectomy

14. Dysmenorrhea
 Crampy suprapubic pain during period is normal!!
- Check normal abdo exam and vital signs
- Check normal bloods including beta HCG
 Mx:
- Self care (e.g. Heat pack, exercise)
- NSAIDs and paracetamol
- Ask GP to consider COCP on dx if continues

15. Pelvic Pain
Differentials...

16. Pelvic Pain 1
 Pelvic inflammatory disease:
- Secondary to STI
-
Often no Hx of infection
>90% present with abdo pain, worse with sex (ask!)
33% have irregular PV bleed
Don’t be fooled by RUQ tenderness
Full, tender adenexae are indicative of tubo-ovarian
abscess
Mx: IM or IV ceftriaxone STAT, then combination
doxycycline and metronidazole as per protocol
Advise re condoms and partner tracing

17. Pelvic Pain 2
 Ovarian incident in pre-menopausal women:
Ovarian Cyst
Ovarian Torsion:
DANGER
necrosis
Physiological
Soft abdo and normal vital
signs
Normal bHCG,WCC,CRP
complication ovarian
Pathological
Tachycardia/fever
Tender abdo +/- palpable mass
Often normal labs
Diagnosed visually at
laparoscopy!
 If suspect ovarian torsion: ABC Mx, IV access & emergency theatre
 Post menopausal women need USS and CA 125 and O&G referral

18. Emergency Contraception

19. Emergency Contraception
 Levonorgesterol or Yuzpe (levonorgesterol & estradiol)
if <72hrs
 Do not need to prescribe
 Available from pharmacies in town
(open 8:00-20:00) Cannot get from our pharmacy
 Check it was consensual sex
 If >72hrs but <120hrs can have copper IUD inserted
by gynae in Family planning centre
 If >120hrs, for medical abortion
REFER
REFER

20. Hyperemesis

21. Hyperemesis
 Hyperemesis gravidarum= >5% of pre pregnancy
body weight loss
 Hospitalise if +ve ketones
 Need bloods including bHCG, Hb, u&e, electrolytes, LFTs
 Need urine dip for ketones
 Need USS (rule out twins, molar)
o Severe: Need IV access, IV fluids and IV antiemetic, Vit B6
o Mild: PO Vitamin B6 and antiemetics

22. Conclusion
 Pregnancy test everyone
 Get Hb on everyone
 Take a G&S if someone is bleeding- you don’t have to
send it!
 Don’t be afraid to do basics to help O&G team
 Refer patients when needed