LGI_Obstetrics

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4.3 Obstetrics & Gynaecology
PAC 7/2005

General Notes

Admission & Assessment of Pregnant Women

Trust Policy dictates that;

Gynaecology services are responsible for women who are <14 weeks

Obstetrics are responsible for women who are > 14 weeks

NB hyperemesis gravidarum is the only exception to this and should be discussed with Obstetrics regardless of gestational dates

In any woman >14 weeks unless it is clear that the ED presentation is unrelated to preganacy (e.g a minor injury)

it is worth discussing their care with the the Obstetric Registrar

Pregnant women or those who have recently given birth who are ?PE or? DVT should ideally be

discussed with the Obstetric team and admitted to Antenatal Care

(PAC 6.7.7)

4.3.1 Management of Lower Abdominal Pain in Females of Reproductive Age

Introduction:
Abdominal pain is a common presenting symptom in A/E departments (5-10 % of all patients). Delineating the origin of abdominal pain is complicated in males, but becomes increasingly difficult in women, and more complex again in those of reproductive age. This is simply due to the increasing number of organ systems that can be involved in these groups. i.e. they have more bits that can go wrong. The sequelae of a misdiagnosis or late treatment may range from the benign to the disastrous.
This advice will focus on acute presentation to A/E of females of reproductive age with lower abdominal / pelvic pain. This group includes females who are threatening to or actually miscarrying. Please remember that both of these eventualities are distressing to both patient and family.

Background:
There is a wide range of differential diagnoses with LAP

• Gynaecological and obstetric 61%
• PID, mittleschmerz, ovarian torsion, endometriosis, ovarian cysts, chronic undifferentiated pelvic pain, malignancy.
• Ectopic pregnancy, threatened or spontaneous miscarriage, placental abruption, preterm labour, or post partum complications.
• GIT 23%
• Appendicitis, gastroenteritis, diverticulitis, IBS, IBD, malignancy, constipation.
• Urological 7%
• UTI, pyelonephritis, ureterolithiasis.
• Miscellaneous 9%
• Herniae, AAA, aortic dissection, herpes zoster, musculoskeletal, psychosomatic, neurological.

Time of onset may be useful
• Acute - tubo-ovarian rupture or torsion, AAA, Ureterolithiasis.
• Gradual (hours to days) – appendicitis, shingles, miscarriage, GE
• Slow (days to weeks) – UTI, ectopic gestation, PID, diverticulitis, miscarriage, malignancy.
• Chronic – endometriosis, fibroid, IBS, IBD, psychosomatic.

First Principles

• All females presenting to the ED of reproductive age with abdominal pain must have with a urine pregnancy test (a well as urinalysis). (See below)
• If patients are unstable then they should transferred to the resuscitation room for immediate care.
IV access should be gained with Hb and crossmatch essential (Rhesus status). (See algorithm)

In general in a female patient with abdominal pain
- a negative pregnancy test
refer to surgeons if admission is required
- a positive test
requires gynaecology referral

Do not get involved in inter-specialty discussions as to which way to refer

Pregnancy Testing in the ED

The urine hCG tests we use in the ED are very sensitive (<20mIU/Ml) but like all tests are not 100% accurate. They are also operator dependent. They should be able to correctly identify pregnancy 1- 2 days after a missed period. However for the test to be deemed negative the test strip needs to be left for at least 5 minutes (not more than 10 minutes) before being examined.
They are most sensitive in an early morning urine. Conversely they are less sensitive if the patient has been drinking alot and late at night.
The manufacturers recommend re-testing a ‘negative result’ 2-3/7 later to be sure of the accuracy. This is not always possible in the ED setting, but please advise a patient to repeat the test them selves at home after 2-3/7 if they still have concerns. Patient information leaflets explaining this are being drawn up.

If you get an ‘unexpected negative’ result i.e. the patient says they have performed a previous positive test ask the nurses for a repeat test and ensure that the test is conducted correctly with a 5 minute wait before reviewing the result.

This may help avoid patients being exposed to inadvertent x-rays or told that they may be miscarrying.

NB
There is also the possibility of a false negative result in ectopic pregnancy where the hCG levels are abnormally low. See below

Pelvic Inflammatory Disease
• Infection that has spread from the cervix and may include the uterus, tubes, ovaries, or peritoneum.
• Can be acute and very severe to chronic more benign
• 90% sexually transmitted
Sexually active 15-20 year olds are most at risk
• 10% follow TOP or D&C
• Common pathogens include Nisseria gonorrhoea, Chlamydia trachomatis, Gardenella vaginalis, E. coli, and anaerobes.
• Features include lower abdominal pain, vaginal discharge, nausea and vomiting classically with fever, cervical motion tenderness, and adnexal tenderness (chandelier sign).
• If severe will require IV access analgesia, resuscitation and antibiotics

• If you are very confident of the diagnosis in an otherwise well patient consider OPD care under GUM clinic or taking appropriate high vaginal and endocervical swabs (see LTHT website) and oral antibiotics (doxycycline 100mg PO BD for 14 days and metronidazole 400mg PO BD for 14 days) with GUM follow up

PID vs. Appendicitis

• There will always be a question of whether a female is suffering from appendicitis as opposed to PID.
• The history and some clinical differences will help to make the decision.
• Both usually have a raised white cell count but PID will average 15, appendicitis around 13. Appendicitis usually accompanies anorexia with pain localised to the RIF. Both may be pyrexial but PID tends to be higher (>38) vs. (~37.5)

Ovarian Problems
Torsion/ Ovarian Bleed
Acute, sharp, unilateral pain
Abdo or PV tenderness may be present
Difficult clinical diagnosis
If suspected refer to Gynae for USS

Key Messages

• All females of reproductive presenting with abdominal must have pregnancy status checked.

• Consider PID if not pregnant and treat appropriately.

• There must be a high suspicion of ectopic gestation unless already excluded.

• <20 wks refer to Gynae , >20 wks to OB.

4.3.2 Ectopic Pregnancy

• The commonest cause of maternal death in the first trimester
• Occurs in ~ 1% of all pregnancies
• Is missed by doctors because it is difficult to diagnose
• Only 50% of acute presentations have the classic triad of
Lower abdominal pain,
Vaginal bleeding,
Amenorrhoea (usually 8 weeks)
• 15% present before they have ‘missed’ a period
• PV bleeding may be profuse, ‘prune juice’ bleeding, trace or absent.
• Can be acute including syncope or chronic

• Therefore, there must always be a clinical suspicion of ectopic pregnancy in all females with a +ve pregnancy test (and occasionally with a negative urine test) who present with any or all of the above symptoms and do not have a proven intrauterine gestation require urgent referral to Gynaecology.

4.3.3 Bleeding in Pregnancy

Early Bleeding

Consider ectopic pregnancy

Pregnancy Related		Non-Pregnancy Related
1st Trimester	Spontaneous Abortion Ectopic Pregnancy Trophoblastic disease	At any stage	Infection Vaginal Ulcer Vaginal Inflammation Cervical Erosions Cervical Polyps Coagulation Disorders Trauma
2nd Trimester	Spontaneous Abortion Trophoblastic disease Abruption Placenta Praevia
3rd Trimester	Abruption Placenta Praevia ‘Show’ of pregnancy Vasa praevia

General Principles

Patients who present with PV bleeding +/- LAP who have a known intrauterine gestation must be treated with care and sympathy

Their care in A/E should be quick and appropriate for the circumstances

They require an internal examination by either an A/E clinician of some seniority or through the gynaecology service if the gestation is <20 wks.

Refer all PV bleeds in pregnancy if they are >12/40
2-14 weeks Gynae
14-40 weeks Obstetrics

Threatened or Impending Miscarriage

• Any pain should be light and crampy
• If the cervical os is closed, they have light bleeding and are not in marked pain. Then the patient can be offered the choice of an OP scan (by definition this is a threatened miscarriage)
• 50% will eventually miscarry so tell the patient that you cannot be ‘sure’ that the baby is OK until a scan is done.
• If the managing as Out-patient book a scan through the ‘Early Pregnancy Unit’ (Ext. 23427),
• Provide the patient with a copy of their notes to take to the EPU
• Advise Paracetamol for analgesia
• Advise to return to the ED if pain worsens or bleeding becomes heavy.

• If patient discharged they still require FBC and G&S (rhesus +/-).
• If referring, include IV access.

Inevitable Miscarriage
• The os is open and may contain products
• If the patient has severe pain, hypotension and bradycardia products in the Os may be causing cervical shock. Remove them carefully with sponge forceps

• Refer these patients to gynaecology

Adnexal or cervical tenderness suggests ectopic pregnancy or septic abortion

Vaginal Bleeding in Later Pregnancy

Trophoblastic Disease
• 12-16/40 uusually
• frogspawn like issue loss PV
• +/- abdo pain
• uterus large for dates

manage with fluid resuscitation and send a serum hCG (abnormally high)

Antepartum Haemorrhage
Bleeding after 20/20 occurs in 2.5% pregnancies
Abruption
• 1% pregnancies
• can be concealed or revealed bleeding
• may be abdo pain and tenderness
• a large bleed can precipitate labour, DIC and collapse
Placenta Praevia
• Commoner in mums >35, twins, previous praevia or C-sections
• 15% present in labour
• Bright red blood PV
• DO NOT DO A PV or SPECULUM EXAM

Management
Call an Obstetrician (senior)
Fluid Resuscitate
Take bloods for X-Match and clotting

What is best for Mum is best for the baby

3.4 Eclampsia

Pre Eclampsia
A poorly understood condition presenting with
2 of Hypertension (>140/90)
Proteinuria
Oedema

Variant Haemolysis, Elevated LFTs, Low platelets,(HELLP syndrome)

Progression to Eclampsia is heralded by confusion, headache, tremor, twitches, abdo pain , visual disturbance

Eclampsia
‘Fits after 20/40’
2% maternal mortality
15% perinatal mortality

Management
Resus room with monitoring and oxygen
IV access
If Fitting
Call an anaesthetist and obstetrician
Check BM
Give Magnesium Sulphate 4-6g over 25 min followed by maintenance 1-2g/h IVI
Consider Labetolol (10mg slow bolus then 1-2mg/min)
Urgent delivery required

Refer all patients with hypertension, proteinuria, and oedema to obstetrics.