Chapter 38. Obstetric and Gynecological Emergencies and Rape

Abnormal Vaginal Bleeding

See Table 38–1. Patients with active vaginal bleeding are at risk of exsanguination and require immediate evaluation and treatment.

Emergency Evaluation and Treatment

Assess for Hemodynamic Instability

Examine the patient for hypotension or tachycardia due to depletion of intravascular volume.

Hypotension

If blood pressure and pulse are normal in the supine position, measure them in the sitting position. If they are still normal, measure them in the standing position to detect more subtle volume depletion. Supine or postural hypotension can indicate life-threatening hemorrhage.

Tachycardia

Tachycardia while the patient is resting or when she assumes the upright posture also may indicate vascular depletion.

Poor Peripheral Perfusion

Cool, mottled skin and delayed capillary refill may indicate significant volume loss.

Treat Shock, If Present

(See Chapter 11) Briefly, the procedure is as follows:

1. Insert at least 2 large-bore (≥16-gauge) intravenous catheters. A central venous catheter may be preferable if peripheral venous access is not readily obtainable. Intraosseus access is an acceptable alternative (Chapter 8).

2. Determine the amount of blood loss and draw blood for (a) typing and crossmatching (reserve four units of fresh-frozen plasma and two to four units of packed red cells), (b) platelet count, prothrombin time, and partial thromboplastin time to uncover any bleeding abnormality, (c) complete blood count (CBC), (d) renal function tests and measurement of serum electrolytes, and (e) blood gas measurements and pH (useful in assessing adequacy of ventilation and perfusion).

3. Insert a Foley catheter.

4. If the patient is of child-bearing age, obtain a serum or urinary pregnancy test.

5. Begin rapid infusion of crystalloid solution (Ringer's solution or normal saline), the rate depending on vital signs (eg, 200–1000 mL/h), to restore intravascular volume and maintain blood pressure until compatible blood becomes available for transfusion.

6. Infuse crossmatched blood as soon as possible. If the patient is unstable and crossmatched blood is unavailable, transfuse O-negative blood. Give two or more units depending on vital signs.

Determine the Cause of Bleeding

Pelvic Ultrasonography

In the evaluation of a pregnant patient with vaginal bleeding, ultrasound can be used to rapidly identify fluid in the pelvis or abdomen (presumed to be blood in the setting of shock), which is highly suggestive of ruptured ectopic pregnancy. In the setting of symptomatic vaginal hemorrhage in the first trimester of pregnancy, ultrasound may show retained intrauterine products of conception, indicative of an incomplete spontaneous abortion. For the nonpregnant patient, an ultrasound showing significant pelvic or intraabdominal fluid may be representative of a hemorrhagic ruptured ovarian cyst, which occasionally requires surgical intervention.

Treatment

The measures described here should not be used in third-trimester pregnancy.

Compression of the Uterus

Insert one hand in the vagina, elevate the uterus, and compress it against the abdominal wall and the opposite hand. Alternately, tamponade may be attempted by inserting a foley catheter into the uterine cavity and inflating the balloon until bleeding subsides.

Medical Therapy

Conjugated Estrogen therapy 25 mg q 4 hrs IV may be used alone, or in combination with direct compression until bleeding is controlled.

Treat for Trauma

If trauma has occurred, determine the extent of injury, and apply pressure to the bleeding site.

Obtain Consultation

Obtain urgent gynecologic or surgical consultation for possible emergency dilation and curettage, laparoscopy, or laparotomy in any hemodynamically unstable patient

Disposition

Patients with vaginal bleeding resulting in abnormal hemodynamics or significant anemia should be hospitalized.

Pelvic Pain with or Without Bleeding

See Table 38–2.

Clinical Findings

History

Obtain information about the following points:

• Possible pregnancy (recent amenorrhea or abnormal period, intercourse without contraception, morning sickness, or tenderness of breasts of recent onset)
• History of trauma, including rape or nontherapeutic abortion
• History of salpingitis
• History of ectopic pregnancy
• Duration of symptoms and relation to menses
• Type of pain (cramping or constant)
• Type and amount of vaginal bleeding or discharge
• Use of intrauterine device (IUD)

Symptoms and Signs

Fever is often the first sign of infection, and pelvic warmth (from local inflammation) may be noted on bimanual examination. Pelvic organs are tender and engorged.

Laboratory Tests and Special Examinations

Blood Tests

The white cell count, differential, and erythrocyte sedimentation rate may reflect inflammation or infection but are nonspecific tests.

Pregnancy Test

A pregnancy test is important if pain or bleeding is present (Table 38–3). Qualitative tests of blood or urine are sensitive and may provide positive test results within 7 days of conception. They are also relatively inexpensive, easy to do, and can be performed in 5–10 minutes. Quantitative blood tests are more sensitive and may assist in the evaluation of gestational age.

Cultures

Obtain cervical swab cultures for gonococci and Chlamydia trachomatis if infection is a possible diagnosis.

Ultrasound

Ultrasound may show an ectopic pregnancy, intrauterine pregnancy, inflamed fallopian tubes, ovarian cysts, or pelvic abscesses (Figures 38–1 and 38–2).

Laparoscopy

Laparoscopy may be helpful when the diagnosis is uncertain.

Treatment and Disposition

If the diagnosis is uncertain but either ectopic pregnancy or septic abortion is a possibility, consultation with a gynecologist for hospitalization or daily follow-up on an outpatient basis is mandatory.

Ectopic Pregnancy

Essentials of Diagnosis

• Unilateral pelvic pain in early pregnancym
• Vaginal bleeding present or absent
• Risk factor assessment
• Unilateral adnexal tenderness or mass
• Uterine size less than dates
• Quantitative human chorionic gonadotropin (hCG) and pelvic ultrasound

General Considerations

Ectopic pregnancy is the leading cause of pregnancy-related death in the first trimester. Patients with ectopic pregnancy are often encountered in the emergency department, and the disorder may be difficult to identify given the varied presentations that occur. Because ectopic pregnancy can be life threatening, it should be suspected in any patient presenting with amenorrhea, vaginal bleeding, and lower abdominal pain. For some women, the initial presenting symptom of an ectopic pregnancy is syncope. The most common presenting complaint is vaginal bleeding, often scant at first, with cramping lower abdominal pain.

The incidence of ectopic pregnancy is increased in women using an IUD and in those with a history of pelvic infection (eg, salpingitis), tubal surgery, infertility treatments, or previous tubal pregnancies. About 98% of ectopic pregnancies are tubal.

The clinical presentation of ectopic pregnancy is variable, ranging from the asymptomatic patient to the patient with hemorrhagic shock. Rupture of the fallopian tube followed by free intraperitoneal bleeding from tubal vessels is the principal cause of illness and death.

With improved resolution of ultrasound and rapidly available quantitative hCG assays, the diagnosis of ectopic pregnancy can be made more accurately and earlier than in the past (Figure 38–3).

Clinical Findings

Symptoms and Signs

Patients have a history of the following: (1) missed or abnormal menses or vaginal bleeding—however, 30% of patients with ectopic pregnancy have no vaginal bleeding; (2) pelvic pain, which may be unilateral, following amenorrhea; and (3) possible intermittent pain; rupture of the fallopian tube may bring temporary relief of pain.

Symptoms of early pregnancy (eg, breast tenderness and nausea) may be present. Unilateral abdominal or pelvic pain may be present. Referred shoulder pain, syncope, or lightheadedness may also occur. Peritoneal pain may develop after tubal rupture with bleeding into the peritoneum.

In the early stages of ectopic pregnancy, the results of pelvic examination may be normal. Initially, symptoms may be completely nonspecific, because the tubal pregnancy producing them may be in the early stages of development. In advanced cases, a tender adnexal mass, enlarged uterus, or blood in the peritoneal cavity (eg, doughy cul-de-sac) may occur.

Obtain complete vital signs, including supine, sitting, and standing pulse and blood pressure measurements to look for supine or orthostatic hypotension.

Laboratory Tests and Special Examinations

Pregnancy Test

The qualitative urine and serum pregnancy test may be positive at levels as low as 10 mIU/mL. Check with the laboratory. The most specific and sensitive test is the serum quantitative hCG. It may detect levels as low as 5 mIU/mL depending on laboratory assay. Quantitative hCG values are invaluable in the interpretation of pelvic ultrasound in this setting. In a normal intrauterine first-trimester pregnancy, the hCG level should double about every 1.5 days.

Ultrasound

Endovaginal and transabdominal sonography have become key diagnostic tools in the differentiation of normal (see Figures 38–1 and 38–2) from abnormal early pregnancy (Figure 38–4). Occasionally, a mass can be seen in the adnexa or cul-de-sac, or products of conception can be visualized outside the uterine cavity, and ectopic pregnancy can be readily diagnosed (see Figure 38–4).

Ultrasound is often useful in excluding an ectopic pregnancy by ruling in an intrauterine pregnancy. If the patient reports a history of infertility treatments, avoid making premature conclusions because the possibility of a heterotopic pregnancy (ie, simultaneous intrauterine and ectopic) has been reported to be as low as 1 in 4000. With an hCG of 6000–6500 mIU/mL, an intrauterine pregnancy can be visualized transabdominally 94% of the time. Likewise, a yolk sac can be identified at the discriminatory hCG values of 1000–1500 mIU/mL utilizing endovaginal sonography. With endovaginal scanning, a small intrauterine collection of blood, or pseudosac, may be seen associated with an ectopic pregnancy. In very early pregnancy, at levels below the discriminatory values, the uterus may appear empty. Fluid in Morison's pouch on transabdominal scanning strongly suggests ruptured ectopic pregnancy, usually requiring operative intervention (Figure 38–5).

Laparoscopy or Laparotomy

Laparoscopy or laparotomy may be necessary to make a definitive diagnosis of ectopic pregnancy.

Treatment and Disposition

Treatment of possible ectopic pregnancy is determined by the patient's risk factors for ectopic pregnancy (ie, infertility treatments, history of tubal ligation, or pelvic inflammatory disease), hemodynamic stability, and physical examination findings. Sonography is important in the evaluation of pregnant patients with either abdominal pain or vaginal bleeding (see Figure 38–3). Quantitative hCG results may help in the interpretation of ultrasound findings. In addition, Rh-negative mothers should receive Rho(D) immune globulin.

High Probability of Ectopic Pregnancy

Obtain emergency pelvic sonography if hemodynamic stability allows. If the quantitative hCG value is greater than 1500–2000 mIU/mL in a patient with an empty uterine cavity on endovaginal ultrasound, ectopic pregnancy should be strongly suspected. An adnexal mass or extrauterine products of conception may or may not be readily identified. A large amount of pelvic or intraperitoneal fluid is highly suggestive of ectopic pregnancy (Figures 38–4C and 38–5). If ultrasound is unavailable for evaluation of a patient with a positive pregnancy test, physical findings worrisome for ectopic pregnancy include adnexal tenderness or an adnexal mass. However, do not be misled by a lack of peritoneal signs during your examination.

Prevent or correct hemorrhagic shock by inserting 2 large-bore (≥16-gauge) intravenous catheters and infusing crystalloid solution for volume replacement. Type and crossmatch for 2–4 units of packed red blood cells. Insert a Foley catheter, and send urine for analysis.

Obtain emergency obstetric consultation, and prepare the patient for surgery. Obtain CBC, serum electrolyte, blood urea nitrogen, creatinine, coagulation profile, and other studies as required.

Ectopic Pregnancy Equivocal

Vaginal bleeding, pelvic pain, and tenderness without explanation may be present in a patient with a positive pregnancy test.

Insert an intravenous catheter, and send blood for CBC and crossmatching. Obtain pelvic sonogram. A transvaginal sonogram may not show definite evidence of an ectopic pregnancy, but worrisome signs include fluid in the cul-de-sac or an empty uterus with a quantitative hCG at or above the discriminatory zone. Urgent gynecologic consultation is recommended in these situations.

Low Probability of Ectopic Pregnancy

Vaginal bleeding or pelvic pain is present. The results of physical examination and laboratory studies are normal. Some authors have developed clinical criteria for prediction of ectopic pregnancy. Suggested low-risk clinical criteria (ectopic pregnancy risk <1%) for patients with pain or bleeding include absence of signs of peritoneal irritation on palpation, no cervical, adnexal, or uterine tenderness, and no abdominal or pelvic pain other than in the midline.

Send blood for quantitative hCG. If a pelvic sonogram demonstrates an intrauterine pregnancy, and the patient is at low risk for a heterotopic pregnancy (ie, no fertility medications or procedures), discharge the patient with 24–48 hours follow-up. Other patients who can be managed as outpatients with close gynecologic follow-up include those with quantitative hCG below the discriminatory zone (1000 mIU/mL) with an empty uterus and no abnormalities on endovaginal ultrasound suggestive of ectopic pregnancy. Patients with an isolated quantitative hCG below 1000 are not necessarily low risk because nearly one-third of patients with ectopic pregnancies have a quantitative hCG level below 1000 mIU/mL. A decision based only on a single hCG value below the discriminatory values lacks specificity and needs to be carefully evaluated.

Discharge the patient from the emergency department to outpatient care with a definitive follow-up appointment for reevaluation within 1–2 days. Give the patient written instructions explaining that ectopic pregnancy is a possible diagnosis and she must be alert to the following symptoms, which would require that she return to the hospital immediately: (1) increased vaginal bleeding, (2) increased pelvic or abdominal pain, or (3) syncope.

Spontaneous Abortion

Essentials of Diagnosis

• Vaginal bleeding in early pregnancy
• Pelvic and back pain common
• Variable pelvic examination findings
• Quantitative hCG and pelvic ultrasound
• Exclude ectopic pregnancy

General Considerations

At least 20% of all pregnancies terminate in abortion, usually because of serious defects in the ovum. Half of abortions occur before the 8th week of gestation and another quarter before the 16th week. Many of these early spontaneous abortions go unnoticed as a delayed menstrual period. Nevertheless, early spontaneous abortions are also a common cause of visits to the emergency department.

Fetal demise and failed expulsion of the products of conception from the uterus, with a closed cervix, is termed missed abortion. If this state persists for longer than 4–6 weeks, the patient is at increased risk for infection and disseminated intravascular coagulation. Table 36–4 describes the various types of spontaneous abortion.

Clinical Findings

Symptoms and Signs

Almost all patients have a history suggesting possible pregnancy:

• Sexual intercourse
• Period of amenorrhea or abnormal menses
• Nausea and vomiting; breast tenderness
• Uterine cramps and vaginal bleeding
• Passage of fetal or placental tissue (incomplete or complete abortion)

Caution: Pelvic examination should be performed on all patients with suspected abortion and on all pregnant patients with vaginal bleeding who have reached less than 20 weeks' gestation. Extreme care, however, must be exercised in examining patients in the second trimester; instruments should not be introduced into the cervical os. Beyond 20 weeks' gestation, pelvic examination should be done by an obstetrician because of the increasing risk of placenta previa.

Laboratory Tests and Special Examinations

In the first trimester of pregnancy, an hCG level that does not double in 48 hours suggests fetal demise or an abnormal pregnancy. Real-time ultrasonography, using abdominal or vaginal probes, can be diagnostic, for example, demonstrating a fetus without heartbeat or movement. Pathologic examination of tissue expelled by the uterus confirms passage of the products of conception.

Treatment and Disposition

Blood typing and antibody screening are required in all patients with abortion of any type. If patients are Rh-negative, give Rho(D) immune globulin (RhoGAM 300 mcg IM, many others), within 72 hours after any event in which fetal–maternal transfusion may occur, including abortion.

Threatened Abortion

Advise the patient to rest. Do not use hormones, douches, or tampons. The patient should not engage in coitus. Ultrasound may reveal a gestational sac or evidence of fetal cardiac activity. Discharge instructions must include follow-up instructions and indications for return to the emergency department, including passage of fetal tissue, severe vaginal bleeding greater than one pad per hour, significant abdominal or pelvic pain, or fever. The patient should also be given adequate analgesia.

Incomplete or Inevitable Abortion

Hospitalize the patient if hypovolemia or anemia is present or if the pregnancy is past the first trimester. Treat hypovolemia if present. An obstetrical or gynecological consult should be obtained to perform possible suction curettage or dilation and curettage.

Complete Abortion

The patient may be discharged to home care if vital signs and hematocrit are stable and if vaginal bleeding is clearly decreasing. Pain must also be clearly decreasing and the cervical os closed. A physician must differentiate a complete abortion from an incomplete abortion. Several clues can help the physician determine that a complete abortion has occurred:

• A reliable history.
• Ultrasound revealing a clean uterine stripe.
• The products of conception are brought to the physician and confirmed by pathology. If pathology is not readily available, a physician can differentiate between blood clots and products of conception by rubbing the specimen between a wet gauze pad. Unlike blood clots, true products of conception will not dissolve.

Missed Abortion (Retained Conceptus)

Obtain CBC, differential, and coagulation panel (platelet count, prothrombin time, and partial thromboplastin time). Obtain disseminated intravascular coagulation screening tests if abnormal values are found. Hospitalize the patient, and prepare to perform dilation and curettage if evidence indicates infection or disseminated intravascular coagulation or if the products of conception have been retained more than 4 weeks.

Outpatient management of early missed abortion is possible if the patient has close follow-up.

Septic Abortion

Essentials of Diagnosis

• History of gynecologic procedure or abortion
• Pelvic pain
• Systemic signs of infection
• Tender uterus
• Profuse, malodorous vaginal discharge

General Considerations

Septic abortion is a rare complication after some obstetric–gynecologic procedures. Septic abortion may also arise as a result of nonsterile nontherapeutic abortion. The usual cause of sepsis is incomplete evacuation of the products of conception. Infection is usually due to mixed aerobic and anaerobic bacteria (bacteroides, Prevotella, group B streptococci, Enterobacteriaceae, and C. trachomatis) and is rapidly progressive, extending quickly through the myometrium and involving the adnexa and pelvic peritoneum. Septic pelvic thrombophlebitis with or without septic pulmonary embolization is an uncommon but devastating complication.

Clinical Findings

Symptoms and Signs

Symptoms and signs are consistent with a history of recent pregnancy and induced abortion followed by pelvic pain and symptoms of infection. Nonjudgmental questioning in a private setting by a physician may be necessary to elicit a history of nontherapeutic abortion; in some cases, such a history is never obtained. Clinical findings include signs of infection (eg, fever and leukocytosis); diffuse pelvic tenderness; and profuse, foul vaginal discharge in most cases. Frank septic shock may be present.

Imaging

Ultrasound or other imaging techniques (computed tomography [CT], magnetic resonance imaging) may show retained intrauterine material, uterine emphysema, or intraperitoneal air from uterine perforation.

Treatment and Disposition

Evacuation of the uterine contents and administration of broad-spectrum antibiotics are the mainstay of treatment.

Note: Although antibiotic therapy alone is effective in the earliest stage of infection, many patients require emergency hysterectomy. Death may occur despite the best treatment.

Immediate Measures

Hospitalize the patient at once, and start general measures for septic shock (Chapters 11 and 42). Obtain emergency surgical obstetric–gynecologic consultation.

Laboratory Tests

Obtain samples of blood and uterine discharge for culture. Draw blood for CBC, hepatic and renal panels, serum electrolyte determination, prothrombin time, partial thromboplastin time, platelet count, and disseminated intravascular coagulation screening tests if initial findings are abnormal.

Antibiotics

After taking specimens for culture of aerobic and anaerobic organisms, give antibiotics (eg, doxycycline, 100 mg IV every 12 hours, and one of the following: cefoxitin 2.0 g every 6–8 hours IV, piperacillin/tazobactam 4.5 g IV every 8 hours, ampicillin/sulbactam 3 g IV daily, or ertapenem 1 g IV daily. An alternate regimen consists of clindamycin 900 mg IV every 8 hours, plus ceftriaxone 1 g IV daily.

Carcinoma and Other Tumors

Although gynecologic cancers seldom present as emergency situations, the emergency physician should be aware of the various presenting symptoms and risk factors associated with gynecologic cancers. Vulvar cancers are rarely sudden in onset and usually occur in women over age 50 years. They are more common in women with a history of cervical dysplasia or cancer.

Persistent unremitting vaginal pruritus is the single most common symptom of vulvar cancer and should never be dismissed as a frivolous complaint in the post-menopausal patient. Vaginal cancers are rare. Bleeding is typically the presenting complaint. The patient is usually of 50 years or older, but even teenagers have developed clear cell carcinoma (eg, girls whose mothers were given diethylstilbestrol during pregnancy). Patients with ovarian cancer may have abdominal distention from ascites, intestinal obstruction, or rarely, acute abdominal pain. Furthermore, ovarian carcinoma increases the risk for ovarian torsion.

Patients with gestational trophoblastic disease may present with heavy vaginal bleeding and symptoms similar to those of early miscarriage, but the following symptoms and signs suggest trophoblastic disease: (1) heavy vaginal bleeding with or without passage of tissue, or grape clusters of tissue aborted from the cervical os; (2) uterine size inappropriately large for dates; (3) profound anemia; (4) history of molar pregnancy; (5) first-trimester hypertension or preeclampsia; or (6) hCG remarkably elevated over the expected values. The diagnosis can be confirmed by ultrasound examination.

Any patient presenting with neurologic signs and with a recent history of molar pregnancy or trophoblastic disease may have cerebral metastasis. Central nervous system metastasis of trophoblastic disease represents a true oncologic emergency, because cerebral metastasis has the potential for cure as long as rapid growth or hemorrhage does not occur.

Patients with trophoblastic disease should be hospitalized for gynecologic consultation.

For any carcinoma, if the bleeding is severe, it is imperative to try to control the bleeding (ie, vaginal packing), volume resuscitate, and obtain emergency surgical and obstetrical consultation.

Carcinoma of the Cervix

Vaginal bleeding is the most common symptom in cervical cancer. Patients may be in their late 20s to (most commonly) early 40s. Patients often complain of persistent watery discharge. Speculum examination reveals a necrotic friable lesion on the cervix.

Uncontrollable bleeding from the cervix may be treated with applications of ferric subsulfate solution or vaginal packing. Manipulation should be kept to a minimum. Biopsy of the lesion at its margin with normal tissue usually confirms the diagnosis, but this procedure should not be performed in an emergency department.

Carcinoma of the Endometrium

Postmenopausal bleeding is the most common symptom of endometrial carcinoma. Risk factors associated with endometrial carcinoma include ingestion of exogenous estrogens, obesity, infertility, polycystic ovarian syndrome, and age over 50 years.

The physician should not try to stop postmenopausal bleeding with administration of hormones (eg, estrogens or progesterone) without confirming the diagnosis beforehand. Consultation with a gynecologist should be obtained prior to discharge for further input.

Genital Trauma

Genital trauma in women almost always occurs as a result of sexual activity, either forced (rape) or voluntary. Penile thrusts rarely produce trauma unless it is the first sexual experience.

Clinical Findings

The most common presenting complaints are vaginal bleeding and pain or dyspareunia. Examination usually reveals bleeding from a tear in the genital mucosa or skin. Bleeding is rarely brisk enough to produce signs of hypovolemia, but if these are present, replace volume losses, and provide supportive care (Chapter 11). In prepubertal patients, general anesthesia may be required for adequate examination.

Treatment and Disposition

Determine whether rape has occurred, and proceed accordingly. Provide sedation or analgesia if necessary.

Treat hypovolemia if present. Control vaginal bleeding temporarily with a vaginal pack, or direct firm pressure if the bleeding is from the external genitalia. A urethrogram may be needed if urethral trauma is suspected.

Hospitalize the patient if bleeding cannot be easily and definitively controlled, and obtain gynecologic consultation. Small lesions at the introitus may be repaired in the emergency department under local anesthesia. However, small and seemingly minor vaginal tears may communicate with either the rectum or the peritoneum; consequently, such repairs are best performed by a gynecologist in an operating room with adequate anesthesia and good exposure.

Ruptured Ovarian Cyst

Essentials of Diagnosis

• Sudden, moderate to severe unilateral pelvic pain
• Possible history of initial nausea, diaphoresis, nearsyncope
• Lack of systemic signs of infection
• Negative pregnancy test
• Unilateral adnexal tenderness without mass
• Pelvic ultrasound excludes significant hemorrhage

Clinical Findings

Ruptured ovarian cyst is associated with sudden, moderately severe pelvic or lower abdominal pain. The patient is afebrile, and leukocytosis is variable. Tenderness is found over the affected ovary, and there are no masses. A pregnancy test should be obtained because ectopic pregnancy is a possible diagnosis. Ultrasonography may show the presence of an ovarian cyst or free pelvic fluid and is useful to detect ectopic pregnancy.

Treatment and Disposition

The physician should provide adequate analgesics, including narcotics if needed. The patient should be observed and may require hospitalization if the diagnosis is uncertain or if relief is required for severe pain not relieved by narcotics. Surgery is rarely required unless there is a significant hemoperitoneum from the rupture of a hemorrhagic corpus luteum cyst with hemodynamic instability.

Ovarian Torsion

Essentials of Diagnosis

• Extremes of age
• Single or recurrent moderate unilateral pelvic pain
• Negative pregnancy test
• Pelvic mass
• Pelvic ultrasound

Clinical Findings

Torsion of ovary is associated with a history of attacks of severe unilateral pain in the lower abdomen. There is a bimodal age distribution which includes the adolescent and postmenopausal women older than 50. The symptoms may be gradual, or occur suddenly if there is accompanying intraovarian bleeding. Physical examination can be unreliable, therefore imaging studies, usually ultrasonography, is needed. Doppler studies can detect decreased or absent blood flow to the torsed ovary. If other intra-abdominal pathology is suspected, computed tomography may be the better imaging modality.

Treatment and Disposition

Hospitalize the patient, and obtain urgent gynecologic consultation. Laparoscopy is frequently required. Laparotomy is indicated if the diagnosis is confirmed or if the patient's condition deteriorates.

Endometriosis

Essentials of Diagnosis

• Recurrent pelvic, flank, or abdominal pain with menses
• Negative pregnancy test

Clinical Findings

The patient with endometriosis gives a history of attacks of crampy lower abdominal pain associated with menstruation. Symptoms may be gradual, or sudden if bleeding is present. Acquired dysmenorrhea is most commonly due to endometriosis. Other symptoms include painful defecation and dyspareunia.

Treatment and Disposition

Refer the patient for further gynecologic evaluation. Definitive diagnosis usually requires laparoscopy. Provide oral analgesia as needed.

Dysmenorrhea

Essentials of Diagnosis

• Painful menstruation
• Negative pregnancy test
• Exclude pelvic infection

Clinical Findings

Many women experience painful menstruation (dysmenorrhea). The pain is cramping in nature, may be debilitating, and is usually relieved by menses. The pain occurs because of elaboration of excessive quantities of prostaglandins by the endometrium with subsequent increased uterine tone. It is not psychological in origin.

Idiopathic dysmenorrhea usually begins at menarche and is probably more common than the acquired form. Acquired dysmenorrhea, occurring in the late teens and early 20s, may suggest endometriosis and is common in chronic pelvic inflammatory disease.

Treatment and Disposition

Both types of dysmenorrhea may be seen by the emergency physician and may be treated by prostaglandin inhibitors (eg, ibuprofen, 400 mg orally every 6 hours; naproxen, 250–500 mg twice daily; or controlled release, 750–1000 mg every day). Local application of heat to the lower abdomen may be helpful.

Mittelschmerz

Midcycle pain (mittelschmerz) is common in women with regular menstrual periods who are not taking birth control pills. These patients may commonly have mid-cycle spotting caused by an estrogen surge. There is no fever and no other abnormal bleeding such as that resulting from trauma to the cervix (eg, coitus and douching). Pain usually occurs over several cycles. There is no history of intermittent lower abdominal pain. Examination at the time of mittelschmerz may reveal some lower quadrant tenderness with or without rebound. Bimanual examination may show localized tenderness. A palpable ovary may be present, but a history of regular menses, lack of fever, and negative pregnancy tests confirm the diagnosis.

Mild analgesics and reassurance are usually adequate for these patients.

Uterine Prolapse

Essentials of Diagnosis

• Prior vaginal deliveries
• History of pelvic heaviness, low back pain
• Patient may present with urinary retention
• Firm, muscular mass in or protruding from vagina

Clinical Findings

Uterine prolapse typically occurs because of muscular defects in the pelvic floor arising from childbirth. Prolapse is characterized by variable symptoms of pelvic heaviness or a dragging sensation and lower back pain. Urinary retention of sudden onset may be a presenting complaint. Examination reveals a firm, muscular mass in the vagina or protruding from the vagina (procidentia) and having the shape and size of the uterus and cervix. Cystocele, rectocele, and enterocele are commonly associated with procidentia.

Treatment and Disposition

Uterine prolapse associated with delivery requires immediate obstetric–gynecologic consultation, as significant hemorrhage and hemodynamic instability may occur. Reversion of the uterus should be attempted by manual pressure, directing the fundus back through the introitus. Tocolytics may be used to relax the uterus if needed. After repositioning, oxytocin is given to facilitate uterine contraction and prevent further prolapse. Patients with acute urinary retention or procidentia should have urgent gynecologic consultation. Patients with mild prolapse should be referred within 5–7 days for gynecologic evaluation and possible surgery.

Salpingitis and Tubo-Ovarian Abscess

See Chapter 42.

Rape (Men and Women)

Proper care of the reported rape victim requires concern for the social and emotional consequences of the event as well as for the medical sequelae. The best care fulfills the requirements of the law while providing proper support and reassurance to the patient. Every state has its own laws and regulations concerning rape; however, some general principles apply. The physician's responsibilities include the following:

• recognizing and managing life-threatening trauma (eg, hemorrhagic shock);
• obtaining informed written consent for physical examination, collection of evidence, photographic documentation, and treatment;
• shielding the rape victim from other patients, bystanders, and visitors;
• accurately diagnosing and treating all physical injuries, both genital and nongenital;
• recording a detailed and explicit history of the event in the patient's own words;
• carefully collecting specimens for evidence, with accurate documentation and protection of the chain of evidence;
• providing psychological support and follow-up;
• offering prophylaxis against pregnancy and sexually transmitted disease;
• the physician should avoid judgmental or conclusive language;
• being willing to testify in court;
• ensuring that discharge from the emergency department is to a safe place;
• encouraging a physical examination even if the patient declines forensic examination.
• Unless required to do so by statute, the emergency physician does not have a legal obligation to notify the police when providing treatment to a victim of the rape. Notifying the police is appropriate when the patient has consented (preferably in writing) to such notification. The physician may wish to refer the patient to a counseling organization that aids rape victims.
• The responsibilities described above may be fulfilled by having a multidisciplinary team who follows an established protocol.

Management of the Rape Victim (Man or Woman)

Evaluation

Initial Steps

If required by law or with the patient's consent, inform the police (see below). Obtain written informed consent for examination.

History

Obtain and record the history in the patient's own words. Obtain answers to other specific questions including the specific time in which the reported rape occurred (if they have not already been answered). A detailed account of the events leading up to the assault, however, is not helpful and should not be documented. Record the victim's general appearance and demeanor, and note whether clothing is torn or stained.

Evidence

Collect and label relevant evidence following your state and local protocol, use a rape kit if available and protect the chain of evidence. Your examination should be complete and thorough but guided by the history of the assault to include all pertinent evidence. Most evidence includes but is not necessarily limited to

1. scrapings under the fingernails;

2. pubic hair;

3. collecting any other loose hairs or dried blood;

4. dried slides of vaginal contents as well as vaginal secretions;

5. specimens from oral cavity or rectum if penetration has occurred;

6. photograph all external lesions, but only with the patient's written consent.

Physical Examination

Thoroughly examine the patient for other signs of bodily trauma or bleeding; record the results of the examination; and photograph all lesions (the last only with the patient's written consent). Examine the mouth and the rectum for injuries. Proctoscopy may be advisable if penetration has occurred and if foreign objects were used, because peritoneal perforation may occur from rectal trauma.

Pelvic Examination

Look carefully for signs of trauma to the external genitalia. Note and record whether the hymen is intact and whether any hymenal tags are fresh (indicating trauma) or healed.

Using a warm, water-moistened speculum, carefully examine the vagina for lacerations. Topical application of toluidine blue may enhance identification of genital skin tears. Colposcopy enhances the identification of traumatic injury. Rarely, peritoneal perforation may occur. If examination must be delayed for a short while, some methods to enhance future collection include insertion of tampon (send tampon with evidence) and do not have the patient urinate, douche, or defecate.

Laboratory Tests

Obtain blood for chemistry studies (if indicated), a serologic test for syphilis, and blood typing (to compare the alleged assailant's type with that of the victim). Blood sampling may also be used for hepatitis B and C and human immunodeficiency virus (HIV) serologic testing. Rapid HIV testing in the perpetrator should also be sought if advisable. To exclude pregnancy, a urine pregnancy test is indicated.

Treatment

The physician should be empathic and concerned, never skeptical or judgmental.

Prevent Sexually Transmitted Disease

Treatment for gonorrhea, C. trachomatis, and syphilis (Chapter 40) should be offered. Only about 3% of rapes result in gonorrhea and only about 0.1% result in syphilis. Follow-up cultures for Neisseria gonorrhoeae are essential. Perform follow-up serologic tests for syphilis 1 and 3 months after the rape.

Prevent Infectious Diseases

Offer the hepatitis B vaccine as well as follow-up in 3–4 weeks for repeat hepatitis vaccination and testing. HIV is also of concern. Offer postexposure prophylactic medications based on risk factors with a follow-up for repeat HIV testing.

Prevent Pregnancy

Treatment for the prevention of pregnancy should be offered. Only about 1% of rapes result in pregnancy; the chances are much less if the victim is using an effective method of contraception. Levonorgestrel 0.75 mg, two tablets taken 12 hours apart, or Levonorgestrel 1.5 mg taken as a single dose, is approved for emergency contraception. Accepted alternate regimens include ethinyl estradiol, 200 μg, and norgestrel, 2 mg, orally over 12 hours in two divided doses (eg, norgestrel [Ovral], two tablets orally, repeating in 12 hours) to prevent implantation if it is certain that the patient is not already pregnant. Advise the patient that nausea and vomiting may occur. Give an antiemetic 40 minutes prior to the oral contraceptives.

Caution: Existing pregnancy is an absolute contraindication to the use of oral contraceptives. Warn the patient that this regimen may not be effective, and explain that a return visit within 1–2 weeks is essential for another pregnancy test.

Report the Incident

If required by law or if the patient consents, report the incident to the proper authorities before the patient leaves the emergency department because the police will want to question her. If the reported victim is a child, the incident should be reported to the appropriate child welfare authorities (Chapter 50).

Start Rape Counseling Immediately

Preferably, counseling should be directed by experienced personnel who are part of an established rape counseling program.

Arrange Follow-Up

A definite appointment (time, place, and physician or clinic) should be made.

Intrauterine Devices

Problems with IUDs

“Lost” IUD

In the emergency department, the most common problem relating to these devices is the “lost” IUD. Check to see if the IUD is still properly placed by looking for the removal string protruding from the cervix (most women soon learn to feel for it with a finger). If no string can be found, the IUD may be located by uterine sonography or abdominal X-ray (for metallic IUDs). The IUD may be in an extrauterine position, in which case it should be removed surgically by laparoscopy or laparotomy.

Emergency Removal of IUD

Infection

The principal indication for removal of an IUD in the emergency department is infection (salpingitis, endometritis, pyosalpinx, or pelvic peritonitis). The incidence of endometritis, salpingitis, and tubal abscess is increased in women using IUDs. Any of these conditions requires removal of the IUD so that infection can be completely cleared. If possible, the patient should be started on appropriate antibiotics before the device is removed (see Salpingitis section in Chapter 40).

Bleeding and Pain

Persistent vaginal bleeding or pelvic pain usually requires removal of an IUD but not often on an emergency basis. Referral to the physician who inserted the device is preferable.

If referral is impractical, grasp the string of the IUD with a Kelly clamp or other long grasping forceps and pull with gentle but increasing force until the IUD emerges from the uterus. Do not jerk the string, because it may detach from the device and make removal more difficult. If the string is not easily seen after manipulation with a speculum, use a special IUD remover to locate and grasp the string.

Serious But Rare Problems

Perforation of the Uterus

Perforation of the uterus is a probable diagnosis in patients with IUDs who have symptoms of endometritis, salpingitis, or peritonitis. Physical examination, an abdominal X-ray, and sonography show that the IUD is embedded in the uterine wall or free in the peritoneum. Emergency hospitalization is required.

Pregnancy with IUD In Place

If pregnancy is confirmed by a positive pregnancy test, and an IUD is still in place, seek emergency obstetric consultation. Ectopic pregnancy is a distinct possibility in the pregnant patient with an IUD still in place.

Postcoital Emergency Contraception

Postcoital emergency contraception, also known as the morning-after pill, can be given to prevent implantation. The US Food and Drug Administration has approved plan B (levonorgestrel 0.75 mg) within 72 hours of intercourse and repeated again 12 hours later. Several prescriptive equivalents are available. Nausea and emesis frequently occur, and an antiemetic should be prescribed. Although the morning-after pill is reported to be 98% effective, a pregnancy test should be performed if menstruation does not occur within 21 days of treatment.

Disorders of the Vulva and Vagina

Vaginal and vulvar cancers and other lesions are discussed earlier in this chapter. Vaginitis, gonorrhea, genital herpes virus infection, and genital abscesses are discussed in Chapter 42.

Warning About Discontinuing Contraception

Treatment of gynecologic problems in the emergency department may require discontinuing the patient's current form of contraception. The emergency physician advising this course of action must warn the patient of the possibility of pregnancy and offer appropriate contraceptive advice. Discontinuation of oral contraceptives or IUD use because of treatment in the emergency department should not result in an unwanted pregnancy.

Pregnancy

Clinical Findings

The physician should have a high index of suspicion for the diagnosis of pregnancy even with the patient's denial, history of contraception, or recent menses. Initial presentation of pregnancy may be at the exact time as a presenting pregnancy complication.

Early Symptoms and Signs

Amenorrhea, nausea and vomiting, syncopal attacks, breast tenderness or tingling, and urinary symptoms (especially frequency) are early symptoms of pregnancy. Early signs of pregnancy include cervical cyanosis and softening, vaginal cyanosis, softening and enlargement of the uterus, and breast enlargement and tenderness.

Laboratory Tests

Urinary tests for pregnancy may occasionally be negative early in the pregnancy. False-positive results are rare at any time, unless trophoblastic tumors are present.

Ectopic pregnancies and spontaneous abortions may rarely cause false-negative results on urine immunologic pregnancy tests.

Differential Diagnosis of Pregnancy

The differential diagnosis of pregnancy includes disorders producing secondary amenorrhea (endocrinopathies, emotional stress, drugs, malnutrition, and menopause) and those producing abdominal or uterine enlargement (obesity, tumors, pseudopregnancy [pseudocyesis]).

Discomforts of Pregnancy

Pregnant women are subject to many discomforts, any of which may cause a visit to the emergency department. Common discomforts include vomiting, backache, syncopal attacks, urinary symptoms (with and without demonstrable urinary tract infection), heartburn, constipation, hemorrhoids, varicose veins, leg swelling, and cramps.

If drug therapy of these complaints is contemplated, only drugs generally recognized as safe in pregnancy should be used, and the patient should be informed of potential benefits and risks. Rarely, pregnant women may have severe abdominal pain localized to one or another quadrant. Patients with round ligament pain may present in this manner. The pain tends to be fairly constant, not cramping. Temperature and white blood cell count are usually normal. Treatment consists of oral analgesics and bed rest.

Nausea and vomiting are common in the first trimester and usually occur in the morning. Symptomatic treatment of nausea and vomiting is preferred, for example, eating soda crackers immediately on arising in the morning, or consuming small, frequent, low-fat meals.

Hyperemesis Gravidarum

Clinical Findings

Hyperemesis gravidarum presents with persistent vomiting and dehydration, elevated specific gravity of urine, ketonuria, and hemoconcentration. Patients may require hospitalization for parenteral hydration and nutrition. Other causes of vomiting, such as infection, diabetes mellitus, or abdominal disorders must be excluded.

Symptoms and Signs

Patients who are known to be pregnant or have symptoms and signs of pregnancy (see above) complain of persistent vomiting, often with postural dizziness, presyncope, weight loss, or other signs of dehydration. Hyperemesis gravidarum usually resolves early in the second trimester. Physical examination reveals signs of dehydration: hypotension or postural hypotension, tachycardia, dry mucous membranes, and collapsed neck veins. Patients are rarely in severe shock.

Laboratory Tests

The test for pregnancy usually is positive, although rarely urinary tests may be negative early in pregnancy. Blood tests may show hemoconcentration, elevated blood urea nitrogen or creatinine, hypokalemia, or metabolic alkalosis. The urine usually appears concentrated with high specific gravity and ketonuria. Initial liver function tests may be mildly elevated.

Treatment

Initial Steps

Insert an 18-gauge intravenous catheter (a larger bore is rarely needed). Draw blood for CBC, electrolytes, and renal/liver function. Infuse crystalloid solution containing glucose (eg, 0.9% saline with 5% dextrose) to correct hypovolemia. Consider thiamine replacement prior to glucose containing solutions, as Wernicke's Encephalopathy is a rare but serious complication. The amount and rate of administration depend on the severity of dehydration. Replace potassium as needed.

Antiemetics

If emesis persists, administer an antiemetic. Ondansetron (Class B safety in pregnancy) 4–8 mg IV every 8 hours or promethazine (Class C safety in pregnancy)12.5–25 mg IV every 6 hours can be used. While controlled, randomized studies of these medications are limited, they are both generally accepted as safe in pregnancy. Alternately, vitamin B6 10–25 mg orally three times daily has been shown to reduce nausea in pregnancy.

Medications should be avoided during the first 10 weeks of pregnancy because of fetal organogenesis, but a risk-to-benefit ratio must be weighed on a case-by-case basis. The patient should be made aware of such risks before being given antiemetics.

Disposition

Hospitalize patients who have persistent vomiting or ketonuria. Patients whose emesis is controlled and whose ketonuria resolves may be discharged with follow-up in 1–2 days. Antiemetic tablets or suppositories may be prescribed for the patient to use only as needed.

Third-Trimester Bleeding

General Considerations

The most common causes of third-trimester bleeding are abruptio placentae, placenta previa, lower genital tract bleeding, or systemic coagulopathy. The least severe cause, lower genital tract bleeding, should be diagnosed only after the more severe conditions have been excluded systematically.

Third-trimester bleeding must be treated as a grave emergency threatening the life of both the mother and the fetus. Digital pelvic examination should be deferred until the relationship of the cervical os and placenta can visualized on ultrasound.

Clinical Findings

Placental Disorders

Abruptio Placentae

Premature separation of the placenta from the endometrium, with hemorrhage into the subplacental space (between the uterus and the placenta). In most cases, patients present with vaginal bleeding. Pelvic pain may or not be present depending on the level of uterine irritability. Risk factors include advanced maternal age, multiparity, smoking, hypertension, external abdominal trauma, cocaine use, and prior history of abruption. Signs and symptoms include uterine tenderness, vaginal bleeding, and back or abdominal pain. Tocometry may demonstrate increased uterine contractility and signs of fetal distress. Ultrasound may miss early abruption. Larger placental abruptions are associated with disseminated intravascular coagulation, fetal demise, and/or maternal exsanguination.

Placenta Previa

A placenta implanted in the lower uterine wall usually causes painless bleeding in small volumes that occurs regularly over a short period of observation. Such seemingly small blood loss may produce a false sense of security, because sudden massive hemorrhage can occur at any time. Risk factors for placenta previa include increased age, increased parity, multiple gestations, and previous cesarean sections or abortions. Abdominal or transvaginal ultrasound is safe and is imaging modality of choice.

Systemic Coagulopathies

Coagulation disorders are uncommon as the sole cause of third-trimester bleeding. Diagnosis is confirmed by routine coagulation studies.

Treatment

Initial Steps

Obtain emergency obstetric consultation. Evaluate the patient for hypovolemia (as shown by supine or postural hypotension), and if present, correct it with intravenous infusion of crystalloid solution or whole blood.

Laboratory Tests

Insert a large-bore (≥16-gauge) intravenous catheter. Draw blood for CBC, coagulation studies (prothrombin time, partial thromboplastin time, fibrinogen, and platelet count), and measurement of blood urea nitrogen and serum creatinine. Type and crossmatch for four units of blood.

Monitor fetal heart tones and toxicology especially looking for the presence of cocaine. Obtain urine for urinalysis, and monitor urine output with an indwelling urinary catheter.

Other Considerations

Ultrasound should be used to determine the placental location, but this should not delay delivery if the fetus is in distress.

The pregnant patient should never be maintained for any length of time in the supine, recumbent position (see Trauma in Pregnancy section).

Disposition

Hospitalize the patient immediately, and move her to a delivery unit as soon as possible. Fetal bradycardia increases the urgency of the need for cesarean section.

Pregnancy Induced Hypertension (Preeclampsia–Eclampsia)

Clinical Findings

Pregnancy induced hypertension describes a condition that covers a spectrum of symptoms and a continuum of severity. Gestational hypertension is defined by a blood pressure measurement of 140/90 or higher. Preeclampsia is characterized by pregnancy-induced hypertension and proteinuria. Eclampsia manifests as seizures in a patient with signs of preeclampsia. Blood pressure measurements should be checked and urinalysis performed in every pregnant patient that presents to the emergency department to detect early signs of preeclampsia–eclampsia.

Symptoms and Signs

Symptoms and signs are variable and may include headache, various visual symptoms, and vertigo. Nausea and vomiting, hyperreflexia, and abdominal pain may occur. Especially alarming is pain in the upper right quadrant and epigastrium (so-called hepatic pain), which is due to compression of the swelling liver by its capsule. Nervousness, irritability, and even frank seizures may occur.

Hypertension or rising blood pressure relative to the patient's normal blood pressure is a significant sign. Note that blood pressure may not be sufficiently elevated to be considered abnormal because of the physiologic decline in blood pressure usually associated with pregnancy.

Peripheral edema is usually present. Spasm of retinal arterioles and hemorrhage may occur. Hepatomegaly or hepatic tenderness (or both) may be present.

Laboratory Findings

Critical laboratory findings supporting the diagnosis of preeclampsia–eclampsia are decreased urine output, elevated blood urea nitrogen and serum creatinine levels, decreased creatine clearance, proteinuria, and evidence of disseminated intravascular coagulation.

Treatment and Disposition

Patients with suspected preeclampsia–eclampsia should be emergently evaluated by an obstetrician.

Gestational Hypertension

Gestational hypertension is defined as a blood pressure measurement above 140/90. There should be no proteinuria, and liver function and coagulation panels should be normal. Physical examination should demonstrate normal deep tendon reflexes and mental status. The patient with gestational hypertension may be appropriate for discharge with short term follow up after consultation with an obstetrician.

Mild Preeclampsia

Mild preeclampsia is characterized by diastolic blood pressure under 105 mm Hg, trace to proteinuria >300/24 hrs, good urinary output, and absence of other symptoms. Obstetric consultation should be obtained, and if not admitted, instructions for patient bedrest should be given at discharge with and short term follow-up arranged.

Severe Preeclampsia

Severe preeclampsia is characterized by proteinuria, diastolic blood pressure greater than 110 mm Hg, headaches, vision changes, anuria, or severe edema. Signs of end organ damage are often present. HELLP Syndrome is a severe form of preeclampsia in which laboratory findings of Hemolysis, Elevated Liver enzymes, and Low Platelets. The patient is said to have eclampsia when the above finds are present with seizures.

Hospitalization is indicated for patients with signs of moderate to severe preeclampsia. Treat hypertension with intravenous hydralazine (Alazine, Apresoline), 5–10 mg intravenously followed by 5–10 mg intravenously every 20–30 minutes as needed for blood pressure control. Labetolol can be used as an alternative. Do not reduce blood pressure to “normal” levels (120/80 mm Hg), because end organ hypoperfusion may result. Magnesium sulfate is indicated for seizure prophylaxis., given 4–6 g given over 30 minutes as an intravenous loading dose, followed by 2 g/h. Continued seizure activity raises the possibility of intracranial pathology such as a cerebral hemorrhage, and a CT scan of the head may be in order.

When neurologic and cardiovascular status is stable, transfer the patient to a hospital equipped to manage high-risk obstetric patients.

Trauma in Pregnancy

Trauma due to gunshot wounds, assault, or automobile accident may cause abruptio placentae, ruptured fetal membranes, or direct fetal trauma.

Normal Physiologic Changes

An awareness of the normal physiologic changes in pregnancy is important in evaluating and providing treatment to the mother and fetus:

• Systolic and diastolic blood pressure decreases approximately 10 mm Hg by the middle of the second trimester.
• Resting heart rate increases by 10–15 beats.
• Uterine blood flow increases to 17% of the cardiac output.
• Hematocrit decreases to a range of 30–36%.
• Tidal volume increases by 30–40%.
• Residual volume and functional residual capacity decrease.
• Leukocytosis is common by the second trimester.
• Pco2 decreases to approximately 35 mm Hg (mild respiratory alkalosis).

Injuries

Blunt Abdominal Trauma

Motor vehicle accidents account for most trauma. Be aware of abruptio placentae or uterine rupture.

Penetrating Abdominal Injuries

During pregnancy, the physical response to intraperitoneal irritation may be decreased. Also, a cephalad and lateral displacement of maternal intraabdominal viscera occurs.

Laboratory Findings

Rh blood typing is indicated. The Kleihauer–Betke test detects fetal blood cells in the maternal circulation and placental disruption; it may help identify fetal hypovolemia before obvious fetal distress occurs.

Treatment

Blunt Abdominal Trauma

Beyond 24 weeks' gestation the patient should be placed in the left lateral decubitus position unless potential spinal injury is a concern. Maintain spinal immobilization on a long, rigid spine board tilted slightly to the left when necessary. Ensure that ventilation and resuscitative measures are adequate. Anticipate rapid oxygen desaturation and aggressively treat any acidosis. A complete physical examination including a bimanual examination for evaluation of the cervical os should be completed. Maternal vital signs, vaginal bleeding, and any abdominal tenderness should be the focus of examination.

For a pregnancy greater than 20 weeks' gestation, use a standard fetal monitor to monitor fetal heart tones and contractions. A sonograph should be used for confirmation of gestation age. Fetal distress may precede maternal hemodynamic instability as an indicator of inadequately resuscitated shock. The need for aggressive resuscitation measures cannot be overemphasized because blood loss is easily underestimated. Early notification of surgical and obstetrical consultants is important. Radiologic studies should proceed as indicated.

Because of the possibility of a fetal–maternal transfusion with even minor blunt trauma, Rh negative patients should receive RhoGAM™ to prevent a serious isoimmunization reaction which could severely complicate the current or future pregnancies.

Penetrating Trauma

Most gunshot wounds to the abdomen should be explored surgically. In a pregnant patient, unstable vital signs with any penetrating abdominal wound is an indication for a laparotomy. However, not all penetrating trauma requires surgery. For instance, stab wounds to the lower abdomen are less likely to cause visceral injuries than upper abdominal wounds and may not need exploratory laparotomy. Although generally considered contraindicated in pregnancy, diagnostic peritoneal lavage (Chapter 8) may help diagnose hemoperitoneum and the need for surgery.

The decision to perform surgery with or without delivery should be made in conjunction with a surgeon and an obstetrician. Several factors are used to make an interventional decision, including gestational age, penetration of amniotic cavity, and fetal injury. This needs to be a multidisciplinary approach to include obstetrics and surgery.

Perimortem Cesarean Delivery

Indications

A fetus has been reported to survive up to 30 minutes after maternal cardiac arrest, but the greatest likelihood for fetal survival is if delivery occurs within 4–5 minutes after maternal cardiac arrest. Another indication for a perimortem cesarean section is to improve the possibility of returning spontaneous maternal circulation as part of her ongoing resuscitation.

Technique

1. Cardiopulmonary resuscitation should continue throughout the procedure.

2. Make an abdominal incision approximately 4–5 cm below the xiphoid to 2–3 cm above the pubis.

3. Separate the rectus muscles bluntly in the midline and enter the peritoneum with a midline incision usually below the umbilicus.

4. Make a vertical incision from the top of the uterine fundus to above the opaque insertion of the bladder.

5. Remove the fetus.

6. Remove the placenta.

7. Close the uterus in one or two layers using large sutures.

Labor and Delivery

In many hospitals, patients in active labor are seen initially in the emergency department. A calm and orderly approach to evaluation of these patients—as well as established policies for transfer of responsibility from emergency department staff to obstetric staff—is essential for proper management.

Evaluation

History

If records from prenatal visits are not available, ask the patient about recent or intercurrent illness and risk factors such as diabetes mellitus, valvular heart disease, or previous cesarean section delivery. Ask whether the membranes have ruptured. Determine parity and multiparity gestation. Estimate the due date and gestational age of the fetus.

Physical Examination

Record complete maternal vital signs. Perform brief physical examination of the mother. Determine frequency and intensity of uterine contractions.

Check for vaginal discharge by speculum examination (blood or meconium). The presence of amniotic fluid may be detected by an alkaline reaction (yellow turning to blue) with Nitrazine paper.

Determine fetal position. Determine the fetal heart rate during and between uterine contractions.

Perform vaginal examination. Note: Do not perform digital examination if vaginal bleeding is present. Determine the presenting part and the degree of dilation and effacement of the cervix by speculum.

Clinical Findings

Progressive labor is characterized by uterine contractions occurring every 3 minutes and dilation of the cervical os. Abnormal signs requiring emergency obstetric consultation include fetal bradycardia (<100 beats/min during or after uterine contractions, vaginal bleeding (on history or examination), transverse, breech, or cord presentations, and maternal illness (eg, eclampsia, coma, major trauma).

Treatment

Premature Birth

Infants under 36 weeks' gestational age are likely to require neonatal intensive care. If there is no such nursery in the facility where the mother has sought treatment, consider transferring her to another facility unless she is in active labor and delivery is imminent or likely during transport (ie, baby is crowning or very low station). See Chapter 5 for further discussion.

Give crystalloid solution, 1000 mL over 3–4 hours, and monitor cardiovascular status carefully. In consultation with an obstetrician, decisions can be made about the use of tocolysis, administration of maternal betamethasone for fetal lung maturity, and prophylaxis against group B streptococci by administration of penicillin G.

Emergency Department Delivery

If delivery is imminent, give nothing (or sips of clear fluids only) by mouth. Maintain or reinstate adequate hydration with intravenous fluids. Give analgesia if there are no contraindications. Obtain a baby warmer, a precipitous delivery kit, and try to have a labor and delivery nurse present.

Delivery

Analgesia may be given as needed to the mother with an uncomplicated term pregnancy. Delivery may be accomplished in either the lithotomy or the Sims position. Prepare a clean field (wash the vulva and perineum). Prevent sudden uncontrolled delivery of the fetal head.

Suction the infant's nasal passages and airway with a suction bulb (or DeLee suction trap, if available) after the head is delivered but before the body is delivered. If thick meconium staining of the amniotic fluid is present, you may use direct laryngoscopy and subglottic suctioning techniques. The physician may need to intubate the infant immediately, before spontaneous respirations occur, and apply suction to the trachea.

Cut the umbilical cord after ligating it about 2–3 in (5.0–7.5 cm) from the infant's abdomen.

Within 20–30 minutes, deliver the placenta with gentle traction on the cord if it comes out easily. Massage the fundus to help obtain hemostasis and uterine tone. If the patient is not bleeding vigorously, the placenta may be left in place while the patient is sent to the delivery room for further measures (eg, suture of lacerations). Delivery of an incomplete placenta is an obstetrical emergency.

Postpartum Measures

Dry and examine the infant, and resuscitate if necessary. Keep the baby warm.

Monitor the mother's blood pressure every 5 minutes for 15 minutes and then every 15 minutes for 1 hour. Uncontrolled bleeding from vaginal lacerations may be packed to await definite repair from an obstetrician. A sample of the infant's clotted cord blood should be sent for ABO and Rh typing and a serologic test for syphilis.

Disposition

Hospitalize the newborn infant and mother for evaluation and supportive care.

Postpartum Hemorrhage

Essentials of Diagnosis

• History of recent delivery
• Painless, sudden, brisk vaginal bleeding

Clinical Findings

Rarely, a patient returns to the hospital a few days after delivery with brisk vaginal bleeding that may or may not be associated with hemorrhagic shock. The usual causes of postpartum hemorrhage are uterine atony, retention of products of conception, or uterine rupture following cesarean section. Other possible causes are subinvolution of the placental site, vaginal tears, or bleeding from an episiotomy. Signs of postpartum hemorrhage may include an enlarged uterus suggestive of atony, a vaginal mass suggestive of an inverted uterus, or uterine bleeding with good uterine tone and a normal size suggestive of retained products of conception.

Treatment and Disposition

Initial Steps

Treat hemorrhagic shock, if present (Chapter 11). If bleeding is brisk, insert the fingers of one hand into the vagina, and compress the uterus against the abdominal wall.

Laboratory Tests

Draw blood for CBC, coagulation studies (prothrombin time, partial thromboplastin time, and platelet count), blood urea nitrogen, and serum creatinine. Type and crossmatch for 4 units of blood.

Consultation

Obtain emergency obstetric–gynecologic consultation.

Medications

Oxytocin, 10–40 units in 1 L normal saline for intravenous infusion at 20–40 milliunits per minute, may be used for uterine atony. After an obstetrical consult is obtained, methylergonovine (Methergine) by mouth may be recommended prior to discharge.

Definitive Treatment

The definitive treatment is dilation and curettage, which should be performed by an obstetrician, because post-partum surgery may result in uterine perforation.

Disposition

If the cause of bleeding is definitively treated and the patient is otherwise stable, she can be discharged with close follow-up in 2–3 days. All other patients should be hospitalized and obstetric consultation obtained as needed.

Puerperal Sepsis and Endometritis

Essentials of Diagnosis

• History of recent delivery
• Systemic signs of infection
• Abdominal pain, vaginal discharge
• Peritoneal signs
• Boggy, tender uterus and purulent lochia

Clinical Findings

Symptoms of puerperal sepsis in the early postpartum period are fever, peritoneal pain, and vaginal discharge. Examination reveals abdominal tenderness, exquisite uterine tenderness, and purulent lochia with leukocytes and bacteria on Gram stain.

Treatment and Disposition

If signs of sepsis are present, obtain obstetric–gynecologic consultation, and hospitalize the patient immediately. Patients with minimal symptoms may be managed as outpatients. Obtain samples of blood and discharge for diagnostic culture and sensitivity testing. Start antibiotics in accordance with the following recommendations as follows.

Severely Ill Patients

Give cefoxitin 2 g every 6–8 hours intravenously, ticarcillin–clavulanate 3.1 g every 6 hours intravenously, imipenem–cilastatin 500 mg intravenously every 6 hours, or meropenem 1 g intravenous every 8 hours.

Puerperal Mastitis

Essentials of Diagnosis

• Postpartum breast infection
• Increased localized breast pain
• Variable systemic signs of infection
• Localized tenderness, redness, induration, or warmth

Clinical Findings

Postpartum infection of the breast is almost always due to infection with Staphylococcus aureus. Pain, induration, redness, and warmth in the affected breast characterizes mastitis. Fever, chills, malaise, and axillary adenopathy may be present.

The diagnosis of puerperal mastitis is based on systemic signs of infection, pain, and tenderness of the involved breast. Abscess formation may occur, and blood cultures are occasionally positive.

Treatment and Disposition

Mild Cases (Afebrile)

Apply warm compresses to the affected breast. The patient may continue to breast feed. The patient should be given dicloxacillin, 500 mg by mouth four times a day, or cephalexin, 500 mg by mouth four times a day. Consider trimethoprim-sulfamethoxazole double strength two tablets twice daily, or clindamycin 300 mg four times daily in patients with risk factors for community-acquired methicillin-resistant staphylococcus aureus (MRSA). Close follow-up with the obstetrician is recommended, and consultation with a lactation expert may be in order. Analgesia may be indicated.

Severe Cases (Suspected Abscess)

Hospitalize the patient, and obtain surgical consultation. Give nafcillin 2 g every 4 hours intravenously. Penicillin-allergic patients may be given clindamycin, 450 mg intravenously every 8 hours, or erythromycin, 0.5 g intravenously every 6 hours.