Obs & Gynae in the Emergency Department




Background

The Obstetric Dept must be informed on all pregnant patients admitted. All pregnant patients attending the ED (no matter what condition or injury) should undergo simple ante-natal checks. These should include:

  • pulse
  • blood pressure
  • examination of the ankles for ankle swelling
  • testing the urine for protein
  • confirm Rhesus status in ALL
    • All Rh Neg women must have a Kleihauer test
    • ALL Rh Neg women will need a dose of anti D immunoglobulin details and dose)

Obs / Gynae cover for CUH

Contact details

CUMH Switch 20500

CUMH Emergency Room 20545

CUMH Labour Ward 20544

1st on call SHO Bleep 907

1st on call Registrar bleep 905

2nd CUMH Switch 20500

Obs / Gynae History & examination

Pain and bleeding

  • Pregnancy
    • Miscarriage
    • Ectopic
    • Hyperemesis
    • Ovarian hyperstimulation
  • Infection
  • Pelvic
  • Bartholin's abscess
  • Vulval abscess
  • Post-operative
  • Ovarian cyst incidents
  • Endometriosis
  • Dysfunctional uterine bleeding
  • Malignancy
    • Bleeding
    • Pain
    • Retention
    • Distension
    • Terminal care
  • Pelvic masses
  • Prolapse
  • Surgical / urological disorders
  • Pain ? Cause

History : 4 p s

Pregnancy

  • LMP
  • Cycle
  • Contraception
  • Pregnancy tests
  • Sexual activity

Pain

  • Onset, cyclicity
  • Character, Radiation
  • Dyspareunia
  • GUT / GIT
  • Emotional

PV loss

  • Bleeding : IMB, PCB, PMB
  • Discharge
  • Products

Past history

  • Pregnancies
  • PID / STD
  • Ovarian cysts
  • Surgery

Examination

  • shock:
    • resuscitate with O2, large iv access,x-match & fluids, theatre
  • pyrexia
  • rebound
  • ovarian point tenderness cervical os
  • cervical excitation
  • uterine size and mobility
  • adnexal masses/tenderness

Investigation

  • Urinary βHCG
  • Serum βHCG
  • FBC
  • MSU
  • HVS
  • Endocervical swab
  • Urethral/rectal swabs
  • Pelvic ultrasound
  • Laparoscopy
  • X-ray /CT / MRI

Bleeding in early pregnancy

Ectopic - pain first, Miscarriage - bleeding first

Miscarriage

  • Expulsion of products of conception (poc) before viability
  • 1 in 4 women
  • 12-15% clinically recognised pregnancies
  • Recurrent miscarriage 1%
  • Sequential miscarriage : after 1 = 20%; after 2 = 28%; after 3 = 43% (worst data)

Management

  • Resuscitate - Bloods for Grouping and FBC
  • Vaginal speculum exam - remove products from vagina and cervix
  • Operation : ERPC
  • Conservation

Anti-D

  • Support

Ectopic pregnancy

  • Implantation outside uterine cavity
  • Rate 0.5-2% and increasing, 95% tubal
  • 10% of maternal deaths
  • Cause/predisposing factors : reduced tubal patency or motility
  • Outcome : mole; abortion; rupture

Clinical

  • missed period, positive pregnancy test, pain, vaginal bleeding
  • associated symptoms (fainting, shoulder pain)
  • VE - controversial, mass in fornix, Cx excitation, Reference

Differential

  • Early on-going intrauterine pregnancy, (in)complete miscarriage

Investigations

Management

  • Resuscitate, Cross match, FBC & βHCG, Inform Gynae SHO/SpR, Correct blood loss, Laparotomy life-saving (if collapsed), laparoscopy
  • Anti - D

Pelvic infection

Ascending ( primary)

  • STD
  • Endogenous
  • Iatrogenic
  • Post pregnancy

Secondary ( 1% only)

Incidence

  • 1% of ages 15 - 34
  • 2% of ages 15 - 24

Organism

  • 50%   Chlamydia
  • 15%   Gonococcus
  • 10%   Mycoplasma
  • 5%    Anaerobes
  • 20%   unknown

Diagnosis

  • Clinical
  • Microbiological
  • Laparoscopic

Management

  • Antibiotics
  • Fluids
  • Surgery
  • Prevention

PID sequelae

  • Infertility, chronic pelvic pain, menstrual irregularity, ectopic pregnancy

Ovarian cyst Incidents

Presentation

  • Torsion / Rupture
  • Haemorrhage
  • Infection
  • Pressure symptoms
    • Retention, Frequency, Pain
  • Malignant change)

Diagnosis

  • Clinical
  • FBC
  • βHCG
  • Ultrasound
  • Laparoscopy

Management

  • Surgery
  • Laparoscopic v open

References

Margara. R.A. & Trew G.H. (1997) Ectopic Pregnancy - Chapter 22. in Gynaecology 2nd Edition Pg 329-341. Editors Shaw R.; Soutter. P. & Stanton. S. Churchill Livingstone. London


Content by Dr Íomhar O' Sullivan 18/06/2004. Reviewed by Dr ÍOS 12/12/2005. 30/05/2007. Last review Dr ÍOS 18/10/18