Obs & Gynae in the Emergency Department
Obs & Gynae Section
Introduction
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 History & examination
Pain and bleeding
- Pregnancy
- Miscarriage
- Ectopic
- Hyperemesis
- Ovarian hyperstimulation
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
- 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
Investigation
- Urinary HCG
- Serum HCG
- FBC
- MSU
- HVS
- Endocervical swab
- Urethral/rectal swabs
- Pelvic ultrasound
- Laparoscopy
- X-ray /CT / MRI
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
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
History
- missed period, positive pregnancy test, pain, vaginal bleeding
- associated symptoms (fainting, shoulder pain)
Examination
- VE - controversial, mass in fornix, Cx excitation, Reference
Differential
- Early on-going intrauterine pregnancy, (in)complete miscarriage
Investigations
- Ultrasound, Laparoscopy Reference
Management
- Resuscitate, Cross match, FBC & HCG, 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
- HCG
- 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
