OB/Gyn

A Tale of Two Bleeders

The following are two cases of vaginal bleeding seen in the a community Emergency Department during the same shift.

CASE 1:

HPI: 30 year old G3P1 female at 5 weeks pregnancy by LMP who presents to the ED with vaginal spotting. She states it started this morning while urinating. She reports about “a spoonful” of dark red blood with no clots. Associated symptoms include transient, lower abdominal cramping. Her pregnancy has had no complications so far, and she just established pre-natal care. Her second pregnancy was complicated by preterm delivery, for which she underwent C-section.

PE: Hemodynamically stable. No abdominal tenderness, guarding, rebound, or distention. On speculum exam, there is a mild amount of dark red blood and clot in the vaginal vault. No fetal tissue. The cervical os is closed. No CMT. No uterine or adnexal tenderness.

Bedside TVUS: No IUP

What now?

In any case of vaginal bleeding, the first step is determining if the patient is pregnant or not! In this case, we know our patient is pregnant. At this point, we develop our differential:

  1. Ectopic Pregnancy

  2. Abortion

  3. Gestational trophoblastic disease

  4. Implantation bleeding

Unlike our Miranda Rights, your patient is guilty of ectopic pregnancy until proven innocent! This is one of the “can’t-miss” diagnoses that we should all feel comfortable working up and managing.

Ectopic Pregnancy:

  • This occurs when there is conception outside of the uterine cavity. Risk factors include a history of STIs (especially PID), assisted reproductive techniques, history of pelvic surgery, advanced maternal age, previous ectopic pregnancy, and cigarette smoking.

  • The vast majority of ectopics take place in the fallopian tubes (ampullary portion), with about 1% taking place in the abdominal cavity, and <1% are cervical.

  • Most patient’s report a history of missed menses, although up to 15% of patients will report normal menses.

  • Abdominal pain is present in up to 90% of patients with ectopic pregnancies (secondary to tubal distention or rupture), although the absence of pain does not rule out ectopic pregnancy!

  • The physical examination in ectopic pregnancy is variable. In cases of ruptured ectopic pregnancy, the patients may be peritoneal with adnexal tenderness and possibly present in shock. Most patients, however, present with stable vital signs. An adnexal mass or tenderness could be an ectopic, although can also be a corpus luteum cyst in the setting of normal pregnancy and/or recent ovulation. Blood may be appreciated in the vaginal vault, although pelvic examination may be normal as well.

  • Definitive diagnosis of ectopic pregnancy is by ultrasound or direct visualization during laparoscopy or surgery.

  • But what about the beta-HCG level? Although absolute levels and “doubling times” are typically longer in ectopic pregnancy, it turns out that no level can reliably distinguish between a normal and pathological pregnancy.

  • The literature describes a discriminatory zone, or beta-HCG level at which you would expect to see an IUP at 1,500 mIU/mL for transvaginal scanning and 6,000 mIU/mL for transabdominal scanning. That being said, if ectopic is suspected, ultrasound should still be performed even with low beta-HCG levels.

  • The goal of ultrasound is to locate a viable IUP and exclude ectopic pregnancy. Visualizing an IUP is reassuring, although does not definitively exclude ectopic pregnancy if the patient is at high risk for a heterotopic pregnancy. Heterotopic pregnancy (both IUP and ectopic) has increased in the general population, largely in the setting of assisted reproduction technology (currently about 1:3,000 pregnancies).

  • An empty uterus with an embryo visualized outside the uterus is diagnostic, however this is only seen in up to 10% of transabdominal scans, and up to 25% of transvaginal scans. A pelvic mass (especially adnexal) in the setting of free fluid (evaluated in the cul de sac, posterior to the uterus) is highly suggestive of ectopic pregnancy.

  • If an ultrasound is indeterminate and the patient is hemodynamically stable, the patient should have close OB/GYN follow up in two days for a repeat beta-HCG level and be given strict return precautions. However, if the patient’s beta-HCG was above the discriminatory zone, it is advisable to seek consultation in the ED prior to disposition.

  • For ruptured ectopic pregnancies, surgical treatment is the preferred treatment modality.

  • For unruptured ectopic pregnancies, in the absence of contraindications, patients who are hemodynamically stable with minimal symptoms and who have appropriate OB follow up, medical treatment with methotrexate can be considered. This is typically given as a single IM dose, although the success rate of a multiple dose regimen was shown to be higher (92.7% vs 88.1%, p<0.05).

  • Treatment failure overall occurs in about 1/3 of cases. There is about a 5% chance of ectopic rupture and patients should avoid sexual intercourse for 2-3 weeks given the risk for this.

  • Abdominal pain 3-7 days after treatment with methotrexate is a common side effect, often attributed to tubal abortion/distention, although is difficult to differentiate from treatment failure and ectopic rupture. It is suggested that these patients undergo repeat laboratory testing (CBC) and pelvic ultrasound.

Figure 1: Ectopic pregnancy within the left adnexae. Source: Radiopaedia.org

Figure 1: Ectopic pregnancy within the left adnexae. Source: Radiopaedia.org

Figure 2: Fluid appreciated in the cul-de-sac posterior to the uterus. Source: Radiopaedia.org

Figure 2: Fluid appreciated in the cul-de-sac posterior to the uterus. Source: Radiopaedia.org

CASE 2:

History: 36 year old female G3P2 s/p D&C for a missed abortion at 7 weeks who presents to the ED with three days of worsening vaginal bleeding. Today, she reports “a large amount” of dark, red blood with clots. She reports using a pad every 10-15 minutes. Associated symptoms include intermittent, lower abdominal cramping and fatigue. No other associated symptoms. No pregnancy complications in the past.

Pertinent PE: No abdominal tenderness, guarding, rebound, or distention. On speculum examination, there is a moderate amount of blood in the vaginal vault with clots. No fetal tissue. The cervical os is closed. No CMT. No adnexal or uterine tenderness.

Bedside TVUS: No IUP. Heterogenous material appreciated within the uterine cavity.

What now?

This is a case of a patient with retained products of conception (RPOC) following an abortion.

  • Patient’s will often present with vaginal bleeding and pelvic pain, which are expected symptoms typically associated with low morbidity.

  • In patients with heavy vaginal bleeding, prolonged bleeding greater than three weeks, fever, uterine tenderness, and/or pain not controlled by over the counter medications, further evaluation is indicated to rule out other potential etiologies (or rule in RPOC).

  • Ultrasound is the best imaging modality to assess for RPOC

  • In patients with RPOC and bleeding greater than three weeks, hemodynamic instability, or sepsis, surgical treatment is preferred.

  • Patients can otherwise opt for expectant management or medical management, which typically consists of a dose of misoprostol (intravaginally or oral), especially given its low cost, low side effect profile, and easy availability. Notably, after consultation with the patient’s OB/GYN, our patient went home on methergine (an ergot alkaloid and uterotonic medication).

And for both cases, don’t forget the rhogam for your Rh negative patients! The dose is generally 300 micrograms given IM.

Faculty Reviewer: Dr. Kristy McAteer

REFERENCES:

  1. Carusi, Daniella et al. Retained Products of Conception. UptoDate. <www.uptodate.com>. 2018.

  2. Ibrahim, Dalia, Gaillard, Frank, et al. Ectopic Pregnancy. Radiopaedia. <https://radiopaedia.org/articles/ectopic-pregnancy>. 2018.

  3. Tintinalli, et. al. Ectopic Pregnancies and Emergencies in the First 20 Weeks of Pregnancy. Emergency Medicine. 8th Edition. 2016. 628-633.HHHf

FURTHER READING:

  1. 1st Trimester Pregnancy Ultrasound Podcast Part I: http://www.ultrasoundpodcast.com/2014/10/pregnancy-ultrasound-part-1-foamed-back-back-basics-cabo-update/

  2. 1st Trimester Pregnancy  Ultrasound Podcast Part II: http://www.ultrasoundpodcast.com/2014/10/1st-trimester-pregnancy-ultrasound-part-2-ectopic-topics-foamed/

  3. EM in 5: First Trimester Bleeding https://emin5.com/2015/11/09/vaginal-bleeding-in-1st-tm-pregnancy/

  4. EM Updates: Ruling out Ectopic Pregnancy http://emupdates.com/2013/06/03/rule-out-ectopic-in-the-emergency-department/

Asynchrony EM: GYN Sampler

BLEEDING, TWISTING AND INFECTION

...in the non-pregnant female patient

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM, with digital content curated into topic modules following our curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM professional community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section. Click here for more about us and for other curated teaching modules!

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

A very interesting ornament....tis the season!

A very interesting ornament....tis the season!

  

This week in our OB/GYN block, we're surveying a smattering of GYN conditions in the non-pregnant patient. Bleeding, torsion, PID/TOA, and a little bit on newer long-term contraception methods.  At the end we've got a little blurb on STIs and expedited partner therapy. 

Do we have a theme song? Of course we do!

Here's Chaka Khan with her famous "I'm Every Woman."  A reminder to not be biased by age or socioeconomic status in your differential diagnoses of gyn pathology...e.g., she may look like your Nonna, but she could still have chlamydia. (See the extras below!)

 

OK, let's get some knowledge flowing. ;)

1) First question up for discussion: Is Pelvic Exam in the Emergency Department Useful? From ALiEM, 1/30/14, by Salim Rezaie, MD.  Please read the comments that follow the post. For practical purposes, I like the notion of treating the pelvic exam as a test one orders judiciously. Most seasoned ED docs will be able to tell you a story about when their pelvic exam actually changed their management, so don't throw it out. My two cents: you're much more likely to be faulted in hindsight for skipping it than being diligent, so when it could add to my differential in a woman with significant symptoms, I do it. (Also, the more we use bedside Gyn ultrasound, the more this will just become one exam, right?)

 

2) "Not Pregnant and Vaginal Bleeding for Two Weeks."   Even more awesome than the title makes it sound! From FreeEmergencyTalks.net, featuring the 2012 AAEM Scientific Assembly -- lectures in podcast form. Did you know tampons are approved as medical devices?  Me neither!

You'll want to jot some notes on the various regimens for temporizing bleeding (put them in your phone for access on your next shift.) You can skip the first minute in which the speaker (Dr. Joelle Borhart) collects a speaking award from a previous lecture. (We only pick award-winning speakers for lectures on vaginal bleeding.) And you can skip the last 4 minutes of Q&A, too.  So about 20 minutes on menorrhagia, and things we can do about it in the ED, besides checking a CBC and telling patients to follow up with their gynecologist. Some very useful tips in the latter half.

 

3) EM Lyceum has a nice review of answers to your torsion questions. Because you definitely had torsion questions. 

 

4) And you also definitely had questions about PEDIATRIC ovarian torsion, didn't you?  (Such as: "Um, that really happens?!') FromPediatric EM Morsels -- a quick blog post. I love how, in the twisted (pun intended) way of the universe, pediatric torsion is more often right sided.  As if the diagnosis were not difficult enough. The universe does not seem to be concerned with making our job any easier.

 

5) Put 3 and 4 together to review, and then add in tubo-ovarian abscess and a tad on PID for a nice podcast review from CORE EM (March 7, 2016).  (Ever heard of in utero ovarian torsion? Now you have.) Thirteen minutes. Ovarian Pathology, Episode 37.0

 

6a)  Pelvic Inflammatory Disease: Pearls and Pitfalls from EM Docs (November 21, 2016.) Brings us back to part 1: don't dump the pelvic exam entirely. 

b) Because you might never see it, but you'll definitely be asked about it: a tad more on Fitz-Hugh-Curtis syndrome, from Radiopaedia. 

c) We're not doing a full STI review today, but just FYI: Expedited Partner Therapy (i.e., prescribing antibiotics for sexual partners without seeing them as a patient) is LEGAL in many states and encouraged by the CDC, particularly for treatment of male partners of women with chlamydial infection or gonorrhea.  Expedited Partner Therapy

Here's a map of where it's legal (last updated October 2016): http://www.cdc.gov/std/ept/legal/ 

(Check out the discussion question at the end.)

 

7) Just a little primer on long acting birth control methods, which you may or may not be familiar with, and which are becoming increasingly more popular. 

a) From Medscape: Long-Acting Reversible Contraception: Comparing Methods

b) It is true that, as stated in part A, the risk of 'injury' from a Nexplanon implant is very small -- but if someone says they have a birth control implant, and you can't feel it, perhaps you should go look for it. You might just find a Nexplanon pulmonary embolus. FDA Safety Information: Nexplanon Implants

c) One more thing you might incidentally find on pelvic exam: you don't see IUD strings when the patient says you should. Again, you should consider looking for them. From Radiopaedia: IUCD related uterine perforation. Amazingly, patients can be asymptomatic! This recommends US as first choice for testing, although I have found extra-pelvic IUDs on a gyn-recommended KUB in the past.

 

And now...The OPTIONAL OB/GYN EXTRAS:

MRI safety, Transgendered Patients, and "Aliens" with an HCG > 1 million, and Grammies with Chlamydia.

1) Recent JAMA (2016 Sep;316(9):952-961) article on safety of MRI in early pregnancy. Bottom line: so far MRI seems safe, but gadolinium doesn't, so avoid the contrast.  https://www.ncbi.nlm.nih.gov/pubmed/27599330

2) Health Issues to Consider in the Transgender Patient from ACEP Now, March 6, 2014.

3) "There's An Alien Inside Me!"  Just when you think you've seen everything. An interestingly layered OB/Gyn case from EP Monthly with valuable teaching points. 

4) She might remind you of your Nonna, but it doesn't mean she can't have chlamydia. Sex and the Single Senior; NYT 1/18/24. 

THAT'S IT! (Brown EM residents, remember you have to complete the discussion section and quiz in Canvas in order to receive credit.)

Tell us in the comments:

  • Expedited Partner Therapy is LEGAL in many states. Is this your practice, if you are in a state where it is legal (it's legal where we are in Rhode Island)? If not -- why not?
  • Any interesting relevant cases to share?
  • Any other #FOAMed resources on these topics that you find helpful?

Click, engage, learn, comment, query, teach, share.  See you next time!

 

 

 

Asynchrony EM: The Difficult Delivery

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions -- and leave us your thoughts in the comments section.

Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.

 

OB/GYN: THE DIFFICULT DELIVERY

Here in Asynchrony EM --being asynchronous and all -- we're a little late for Halloween. So we're serving up the scariest stuff we can think of now, as we enter our new curricular block (OB/Gyn.)

Welcome to: THE DIFFICULT DELIVERY.

Happy Ending! But how do we get here?

Happy Ending! But how do we get here?

It's all terrifying. Even more so if you wind up working somewhere where OB isn't in house 24/7. And the delivery doesn't even need to be 'difficult' per se -- any unexpected delivery in the ED is a pulse-quickening event (and we'll discuss normal deliveries, too.)

But before we start, as always: this week's theme song! Here's Motown queen Diana Ross and -- "I'm Coming Out."  

(You got other theme song ideas? Tweet me at @GitaPensaMD.)

 

OK, no more pun and games -- back to the scary stuff at hand. 

1) Let's start with the mother of all procedures (fine, one more pun) -- the peri-mortem C-section -- also now known as resucitative hysterotomy. (Disclosure: I have never done one. Never even seen one. In fact, just thinking about it makes me twitch, especially working community single-doc-coverage nights with no in-house OB or peds. Murphy's law dictates that if it's gonna happen, it's gonna happen when you have the fewest hands available to help.)

Peri-Mortem C-Section: from EM:Crit. The actual videocast (at the very bottom, the "Wee") is 10 minutes. Watch it. The St Emelyn's link is no longer working, but do click through and read Dr. Press's posts on his personal experiences doing PMCS. (You'll see he doesn't set much store by the numbers 24 or 4.) The more times you read about it, think about it, envision it, list the steps out loud, do it in SIM--the more ready you will be. (Me too.)  Also, WATCH the 3-minute life-identical simulation video, because it's AWESOME--just remember they do not demonstrate the mother being bounced around with CPR while they spend forever closing the uterus, which is why Dr. Press, in his post, suggests just packing it all with towels and moving on. 

Now one more: From Mayo Clic EM, A New Mindset: From Peri-mortem C-Section to Resuscitative Hysterotomy (August 2015). The proposed algorithm (published in Am J Obstet Gynecol, July 2015) is both reasonable and helpful. 

 

2a) Now that I've got your attention with a rare and horrible event, let's do a review of what will undoubtedly happen to you at some point in your career, if it hasn't happened yet: the precipitous delivery in the ED (or in the parking lot, a car backseat, or -- I swear, it really did happen, and it was quite problematic--a revolving door.)  Unlike the peri-mortem C-Section, this usually ends with a good outcome and a nice story to tell over a beer. Usually... (Cue scary soundtrack....)

- First an overview: First 10 EM: Precipitous Delivery in the ED

- Now, as much detail as you want -- peruse this Medscape article to fill in your gaps, but what I really want you to do is click on "Multimedia Library" at the bottom of the left-hand menu, and then go through the slide show. Watch the video at Image 6. Take note that once the shoulder is coming, you better be ready to catch! If you're lucky, it happens fast.

Medscape: Normal Delivery of the Infant

b) And what if it doesn't happen fast? What if the shoulder is stuck?

-First 10 EM: Shoulder Dystocia 

-That's the overview. Now read this for more detail: CoreEM: Shoulder Dystocia

c) And what if the presenting part is....a butt?!

If you see the butt coming out first...butt out. Meaning: be as hands-off as you can (see below).

-Start with this video. You can skip the end bit with the forceps, as you will not be using them (unless you have had significant training.)

Vaginal Breech Birth

 

-Then read some more detail here: Jacobi EM: Breech Delivery

-Then back to First 10 EM for the step by step. (He does a nice, concise job with these. Save them in your phone somewhere...)  First 10 EM: Breech Presentation

(Aside: Not covering footling/incomplete breech presentations today. Those are even scarier!)

 

3) A five minute review video of postpartum hemorrhage from EM in 5 Because sometimes it happens.

 

4) Lastly: important, but somewhat fuzzy stuff. How do we best train for these situations? What the heck is 'metacompetence'? Read a Resus M.E. post about it. Then let's talk about it (hit the comment section below.)

 

5) The OPTIONAL (slightly tangential) EXTRAS:

a) Because you also have to worry about the baby...In October 2015, the AHA updated their Neonatal Resuscitation guidelines. The Full Text of this update is available here: Neonatal Resusciation  

b) Aspiration of Neonatal Pneumothorax -- In case you didn't know it was a thing.

c) I've had to play clean-up crew in the ED after a nasty home birth gone wrong, and would never have considered trying to give birth at home myself-- but home births are apparently en vogue again. Here's a well known OB blogger's take on it:

2015: This year in homebirth deaths and disasters from The Skeptical OB

d) Did you know there's a whole TV series called "I Didn't Know I Was Pregnant?" (O.M.G.)

 

That's it for this week! Keep tuned for our next module in OB/Gyn.

**Brown EM Residents, remember you have to complete your modules in Canvas (hit the discussion board, and pass the quiz) to claim credit.**

Other EM Readers, let us know in the comment section:

  • Are there other #FOAMed resources about these topics that you would recommend?
  • Have you performed a resucitative hysterotomy? Tell us about it, and give us some pointers.
  • Done a breech delivery in triage? Brag about it here--and leave us some teaching points.
  • Discussion regarding the concept of metacompetence: how do you summon the courage to do what needs to be done when a rare procedure (cricothyrotomy, resuscitative hysterotomy, burr hole, etc.) is needed? What advice do you have for residents?