CCFP(EM) Academic Half Day
Obstetrical and Gynecological Emergencies:
Women’s Health on the Fly
APRIL 4, 2013
ELIZABETH SHOULDICE, MD CCFP(EM)
Agenda
 Who am I?
 Case Based
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Gynecological Emergencies
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Obstetrical Emergencies
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Group Discussion
Who am I?
Conflict of Interest
 None
Acknowledgments
 Dr. Liisa Honey
 Dr. Sunita Lal
 Dr. Kimberley Creaser
Objectives
 Vaginal bleeding/complications in the first 20 weeks of
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pregnancy
Vaginal bleeding/complications in the second 20 weeks of
pregnancy
Obstetrical Emergencies
Preeclampsia and eclampsia
Postpartum emergencies
Sexually transmitted infections
Case #1
 Queensway Carleton Hospital
 26 y.o. female presents to triage after “fainting” at
work
 Accompanied by her partner
 Vitals: 37.5, 110, 85/50, 20, 100% ORA
 Resuscitation room
Case #1
 Brief history:
 On Alesse
 No medical problems
 Recent GI illness, vomiting/diarrhea
 No pregnancies
 LMP 2 weeks ago
 Nurses: 2 large IVs, NS,
 Labs: CBC, lytes, BUN, Cr, Type cross match,
quantitative βHCG
Case #1
 Abdomen soft, tender diffusely
 Bimanual exam, tender R adnexa, + blood on glove
 EDE: Free fluid RUQ, no IUP
 What do you do?
Case #2
 Hay River, NWT
 18 year old female
 Presents to ED with abdominal pain
 Vitals within normal limits
 Recent treatment for ectopic pregnancy in referral
centre, discharged 5 days ago
 What would you do?
Case #2
 Treated with single dose methotrexate in Yellowknife
 Has not had serial βHCG
 Vitals: 37.5, 85, 105/70, 20, 100% ORA
 Abdomen soft, non tender
 Bimanual exam no adnexal tenderness, no bleeding
 EDE: No free fluid, no IUP, no formal U/S available
for a week, unless you ship her out
 Hb stable, βHCG decreasing
 What now?
Ectopic Pregancy
 ~2% of all pregnancies
 Unless IUD in place, risk increases to 1/20
 Risk factors:
 PID, surgical procedures, previous ectopic, DES exposure,
assisted reproduction
 Treatment with methotrexate becoming more
common

Beware of ruptured tube, can happen days after mtx
ISRN Obstet Gynecol. 2012;2012:637094. Epub 2012 Feb 19. The evolution of methotrexate as a treatment for ectopic pregnancy and
gestational trophoblastic neoplasia: a review.
Skubisz MM, Tong S.Prescrire Int. 2009 Jun;18(101):125-30.
Intrauterine devices: an effective alternative to oral hormonal contraception. Acta Obstet Gynecol Scand. 2009;88(12):1331-7.
Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies: a
randomized trial.
Krag Moeller LB, Moeller C, Thomsen SG, Andersen LF, Lundvall L, Lidegaard Ø, Kjer JJ, Ingemanssen JL, Zobbe V, Floridon C, Petersen J,
Ottesen B.
Case #3
 Queensway Carleton Hospital
 29 y.o. female
 CC: PV bleeding x 10 days, G2P2
 HPI:
 Delivery of healthy male child October 26
 Light PV bleeding in December
 At time of assessment PV bleeding x 10 days
Case #3
 HPI (cont’d):
 LLQ pain 3/7 before ED visit

Positive home pregnancy test on day of ED visit
Case #3
 O/E
 Triage Vitals: 36.6 86 128/76 97%ORA
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Looks well, no distress
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Normal abdo and PV exam
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EDE: deferred
Case # 3
 Labs:
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βHCG 284223
Case # 3
 Patient returned next day:
 Formal U/S:
Mildly thickened endometrium
 R/O molar pregnancy
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EDE
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Equivocal
Case # 3
 Called obs/gyne:
 ?trophoblastic tissue elsewhere
 Repeat βHCG, add liver enzymes, coags and CXR
 Resident will be down to see patient
Case # 3
 CXR
Case # 3
 Resident assessment
 Ordered CT head/chest/abdomen/pelvis in a.m.
 Revealed 5cm splenic metastasis
 Discussed with gyne onc at OGH
 Will see urgently
 Arranged urgent D&C for next day
 Diagnosis metastatic choriocarcinoma
Case #3
 Admitted to gyne onc at OGH Feb 9 for expedited
treatment
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Stage IV
High risk, requiring combination chemotherapy
Goal of cure
5-7 % chance of infertility
First & Second Trimester Bleeding
 Gestational Trophoblastic Diseases (GTD)
 Disorders of fertilization

Hydatiform mole
• Noninvasive, localized
• 90% of cases
• Starts with empty egg, fertilized by two sperm
Placental site trophoblastic tumor
 Choriocarcinoma
 Gestational trophoblastic neoplasia

Learning Points (cont.)….
 Arise from trophoblastic epithelium of placenta
 All are characterized by high βHCG
 Maternal tumor arises from gestational tissue, not
maternal tissue
 Can develop from molar pregnancy or from TA/SA,
ectopic, term or preterm pregnancies
 Very rare, hydatidiform mole 23-1299/100 000
pregnancies, other types even more rare
Learning Points (cont.)….
 Risk factors
 Extremes of maternal age (>35 and <20)
 History of previous GTD
 Smoking
 History of infertility
 Nulliparity
 OCP use
Learning Points (cont.)….
 Presentation
 PV bleeding
 Enlarged uterus
 Pelvic pain
 Theca lutein cysts
 Anemia
 Hyperemesis gravidarum
 Hyperthyroidism (βHCG has thyroid stimulating activity)
 Preeclampsia before 20 wks gestation
Learning Points (cont.)….
 Monitoring of βHCG after molar pregnancy is often
how GTN is diagnosed

Must be monitored for at least 6 months
 Ultrasound can have characteristic appearance, but
often misdiagnosed as incomplete or complete
abortion
Learning Points (cont.)….
 Management
 Initial management is always D&C, useful for pathology
 Very common to have increased hemorrhage, need to have
blood on hand
 Thorough work up for distant metastases
 Chemo, at times prophylactically for high risk disease
 Contraception
Learning Points (cont.)….
http://radiographics.rsna.org/content/21/6/1409/F11.expansion.html
Learning Points (cont.)….
 Consider quantitative βHCG
 Even if you’re somewhere where this is difficult!
 Even if U/S shows nothing, with very high βHCG
consider GTD
 Look for trophoblastic tissue elsewhere (CXR, liver
enzymes, CT)
 High propensity for bleeding

Consider transfer for D&C to centre with blood and ICU
Quick Points – First Trimester Bleeding
 Notes from our gynecology consultants:
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Spontaneous miscarriage – patients with severe pain or
vasovagal response, examine for products of conception in the
cervical os
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Retained products of conception <8 weeks gestation can often
be managed by two doses of misoprostol 800ug q24 hours
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Don’t forget to give miscarrying patients pain control for
home, narcotics are often required
Second & Third Trimester Complications & Bleeding
 Vaginal bleeding in the second 20 weeks of pregnancy
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Placental abruption
Placenta previa
Uterine rupture
Vasa previa
Preterm labour
Second & Third Trimester Complications & Bleeding
(cont.)….
 Key Points:
 Evaluation of Preterm Labor
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Pelvic pressure, vaginal discharge, vaginal bleeding, or low-back pain
Many hospitals require patients with pregnancies less than 20 weeks
gestation to be evaluated in the emergency department
A detailed history of symptoms can help differentiate between
spontaneous and evoked preterm labor
A complete obstetric history, including gestational age, is important
to determine the risk for possible recurrent preterm birth
Maternal vital assessment, especially temperature and blood
pressure
Prim Care. 2012 Mar;39(1):95-113. Third-trimester pregnancy complications. Newfield E
Second & Third Trimester Complications & Bleeding
(cont.)….
 Fetal vital assessment
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Documentation of normal fetal heart tones is sufficient for fetuses < 23 wks
Continuous external fetal heart rate monitoring for all > 24 wks
Continuous tocometry is recommended
Informal (bedside) US should be performed
 Physical exam of should be performed, including ultrasound before sterile PV
exam
 Fetal fibronectin
 Invalid if the cervix has been manipulated in the prior 24 hours
 A glycoprotein present at the maternal-fetal interface, absent between 24
and 34 weeks’ gestation.
 The negative predictive value of the test approximates to 99%; symptomatic
patients with a negative result of fetal fibronectin test are very unlikely to
deliver in the following 7 days
Second & Third Trimester Complications & Bleeding
(cont.)….
 Causes of preterm labour….
 Neisseria gonorrhoeae and Chlamydia trachomatis,
bacterial vaginosis, trichomoniasis, or Candida infection
 Urine analysis and culture is recommended
 Cocaine and amphetamines are associated with preterm
labor, often secondary to placental abruption
 Other considerations….
 Group B Streptococcus (GBS) testing should be performed
Case #4
 Perth and Smiths Falls District Hospital, Perth Site
 February 19, 2013
 0330 Nurse Calls the On Call Room:
 32 year old, G6P4SA1, 41W1D
 3 hours of contractions
 1 minute apart, lasting 30 seconds
 In the department, midwife told her she wouldn’t make it to
Almonte
 Nearest obstetrical unit 20-30 minutes away
 You’re the only MD in the hospital
 What do you do?
Case #4
Obstetrical Emergencies
 Emergency Delivery
 Equipment
 Personnel
 Rest of the department
 OB unit on the phone!
 Neonatal consideration
Case #5
Dominican Republic, 2011
Case #5
 18 year old woman
 Presents to “clinic”
 Reports being 8 months gestation and concerned re:
decreased fetal movement and wanting refill of
medication
 One previous pregnancy, complicated by preterm
birth for seizure, baby did not survive
 Limited family support, as family have all moved to
US
 Shows box of labetolol given in neighbouring town
Case #5
 Vitals: 37.5, 70, 160/110, 20, 100% ORA
 Further history:
 Denies headache or blurred vision, but reports increased ankle
edema (does the ankle edema matter??)
 On examination:
 Gravid uterus
 No abdominal pain
 FHT >120, with bell of stethoscope
 What now?
Preeclampsia & Eclampsia
 Hypertensive disorders account for 15% of maternal deaths
 Four categories:
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chronic hypertension
preeclampsia/eclampsia
gestational hypertension
preeclampsia superimposed on chronic hypertension
 Preeclampsia:
 Affects 3 to 5% of pregnant women
 Can result in maternal and perinatal morbidity and mortality
 Higher rates in developing countries
 No single screening test used for preeclampsia prediction has gained
widespread acceptance into clinical practice
Rev Bras Ginecol Obstet. 2011 Nov;33(11):367-75. Early screening for preeclampsia.Costa Fda S, Murthi P, Keogh R, Woodrow N.
Preeclampsia & Eclampsia (cont.)….
 Severe preeclampsia 1 of the or signs in the presence of preeclampsia:
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SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2 occasions
at least 6 hours apart
Proteinuria of more than 5 g in a 24-hour collection or more than 3+ on 2
random urine samples collected at least 4 hours apart
Pulmonary edema or cyanosis
Oliguria (< 400 mL in 24 h)
Persistent headaches
Epigastric pain and/or impaired liver function
Thrombocytopenia
Oligohydramnios, decreased fetal growth, or placental abruption
Preeclampsia & Eclampsia
 The HELLP syndrome (Hemolysis, Elevated Liver
enzymes, Low Platelets) can be considered a
variant of severe preeclampsia
 May present independently of hypertension and
proteinuria
 Risk for severe maternal and fetal complications;
perinatal mortality has ranged from 7% to 60% and
maternal mortality is high
Case #6
 The Ottawa Hospital, Civic Campus
 37 year old woman, 5 weeks post partum
 First pregnancy
 No complications
 Baby at home with father
 Presents as blood pressure “high” at postpartum visit with
family physician
Case #6
 Vitals: 37.5, 70, 160/110, 20, 100% ORA
 O/E…..
 Patient has generalized tonic clonic seizure
 Treatment??
 IV MgSO4 4g IV Bolus, then 2g IV/hour
 Further management?
 Benzos prn
 Close monitoring
Case #7
 Queensway Carleton Hospital
 33 y.o. female presents to triage with R lower
quadrant abdominal pain, 17 weeks pregnant
 Vitals: 37.2, 88, 97/61, 20, 100% ORA
 Cubicles
Case #7
 G3P2
 No PV bleeding
 Pain worse with movement
 No fever, chills, urinary symptoms
 EDE - + FHT, fetal movement
 Discussed with gyne ?round ligament pain, ?MSK
 Formal U/S – + FHT, small amount of free fluid, appendix
not visualized, normal flow to R ovary, but + tender during
exam
 General surgery consulted, clinically not appendicitis,
return for R/A prn
Case #7
 Next day, patient returns, pain worse
 Now vomiting
 U/S repeated – SLIUP, appendix normal, simple cyst
R ovary, larger than previous, no definite flow,
ovarian torsion on DDx
 Patient taken to OR by general surgery and gyne
 Right ovarian torsion, tube and ovary remained
necrotic after being untorted
 Right salpingo-oophorectomy
Case #7
 What are the key points?
 Can mimic appendicitis
 Can have nausea, vomiting and fever (caused by necrosis)
 ~20% of ovarian torsion occurs in pregnancy
 Torsion most commonly occurs in women under 30
 Was this a missed torsion?
 What do you think?
Sexually Transmitted Infections
 http://www.phac-aspc.gc.ca/std-mts/sti-its/
Thanks!
QUESTIONS? COMMENTS? CONCERNS?