Induction Book 2 – Gynae

Author: Abdo Jason Imseeh / Editor: Charlotte Davies / Codes: CAP34, HAP27 / Published: 31/07/2018

Gynae presentations to the emergency department are fairly common, yet fill everyone with dread. The management is similar to any other medical problem

History

Take a thorough but concise history. Your seniors won’t appreciate you knowing how many pets your patient has if they’ve come with leg pain, but won’t be impressed if you don’t know if they’re sexually active or not if they’ve presented with abdominal pain.

Examination

Examine the abdomen carefully. The role of the vaginal examination, and the speculum examination in the emergency department is much debated. Generally, do a vaginal examination/ speculum examination if it’ll change your management. That means look for adnexal tenderness if you suspect PID. Look and examine if there’s a retained foreign body. And do a speculum examination if you think there’s cervical shock.

Special Tests

Always consider ectopic pregnancy, and do a pregnancy test. It’s unlikely your department will arrange an ultrasound scan most of the time, any patients that need ultrasounds get them arranged via the GP, or the acute gynae team.

Abdominal Pain

You’ll get adapt at knowing which patients need admission, and which need referring. If you think there is a gynaecological cause of the abdominal pain, and the patient needs to see gynae, it always helps to suggest some differentials:

  • Ovarian torsion (sudden onset) escalate and refer. Until proven otherwise, treat as ectopic pregnancy.
  • Cyst rupture (sudden onset).
  • Degenerating fibroids (usually presents with PV bleed).
  • Cervical shock (see vaginal bleeding in early pregnancy).
  • Pelvic inflammatory disease.

Abdominal Pain in Pregnancy

Always give analgesia at the earliest opportunity. Paracetamol and dihydrocodeine are both safe in pregnancy. NSAIDs including ibuprofen are contraindicated.

In early pregnancy always assume ectopic, escalate and refer. There are other causes of bleeding in pregnancy covered in our first induction iBook.

In later pregnancy, always request an obstetric review but keep your mind open to non obstetric causes, like appendicitis.

Differentials include:

Always consider ectopic pregnancy.

Urinary tract related

Urinary tract infection (most common)

Increased susceptibility in pregnancy due to increased bladder volume, decreased detrusor tone, increased ureteric dilatation and glycosuria. Treat empirically in the absence of positive urine dip if symptomatic (dysuria/frequency). Start appropriate antibiotics as per local antimicrobial guidelines and send MSU.

Nitrofurantoin is safe in the first trimester. Trimethoprim is associated with teratogenic risk in first trimester, so avoid.

Pyelonephritis. Admit all suspected cases of pyelonephritis under medical team.

Renal colic. Arrange for USS in ED if apyrexial, colicky pain characteristic of a renal colic. Admit all cases with hydronephrosis, obstruction, infected stones under urology. Remember NSAIDs are contraindicated in pregnancy.

Surgical including cholecystitis, biliary colic and of course appendicitis. Just because a woman is pregnant doesn’t mean she can’t have appendicitis as well! Diagnosis can be challenging as the appendix is upwardly displaced with advancing gestation making clinical signs less reliable. Referral to surgical team can be even more challenging.

Consider STIs refer to GUM.

Admit if haemodynamically unstable or pain does not settle with analgesia.

Hyperemesis gravidarum

Hyperemesis gravidarum is a complication of pregnancy, mainly in the first trimester, causing severe nausea and excessive vomiting that can lead to further complications including dehydration, ketosis, electrolyte imbalance and weight loss. Your trust will have a guideline on treatment check out our podcast for more information.

The mainstay of treatment is rehydration and antiemetic therapy as well as control of other symptoms such as pain. Admit to CDU if local pathway allows. Start treatment as soon as possible.

You will be asked about urine ketones when you refer. 4+ seems to be the magic number for referral (16mmol/L or 160mg/dL). Do urine ketones before and after IV fluids (but do not delay treatment if patient is unable to provide sample). There is no hard and fast rule. Check local guidelines regarding urine ketones and discharge/admission criteria as these differ.

Generally admit irrespective of ketonesthose who are haemodynamically unstable and/or not tolerating fluids after combination antiemetics or those with acute kidney injury.

Discharge patients who have Ketones <4+, able to tolerate fluids and are haemodynamically stable. Ensure they have EPAU follow up if no previous scan confirming intra-uterine pregnancy. Discuss: Ketones 4+ but tolerating oral fluid and haemodynamically stable: assess patient, most can be safely discharged but discuss with senior ED or gynae on call.

Chickenpox & Pregnancy

Chicken pox is caused by varicella-zoster virus (VZV).

Potential exposure to chickenpox in pregnancy

Clarify significance of the contact: length, type of exposure (in same room for >15minutes, face to face) and duration since contact.

If previous history of chickenpox, then reassure and discharge.

If uncertain about previous chickenpox, check blood VZV IgG (varicella-zoster Immunoglobulin G, check booking sample if available)

Immune: reassure and discharge.

Not immune: give VZIG (varicella-zoster immunoglobulin) ASAP up to 10 days from exposure, refer to normal antenatal care. Advise potentially infectious from 828 days after contact.

If exposure to chickenpox or shingles (regardless of whether they have received VZIG), advise the patient to inform their GP or midwife as soon as possible early if a rash develops.

Confirmed chickenpox in pregnancy

Most are referred to their GP from antenatal clinic. However, some are still referred to ED. Check with a senior and discuss with gynae on call if in doubt. Remember that Acyclovir is not licenced for use in pregnancy.

RCOG recommends:

Symptomatic treatment and hygiene is advised to prevent secondary bacterial infection of the lesions.

Presents < 24 hours of the appearance of the rash and 20+0 weeks of gestation, prescribe acyclovir 800mg 5 times a day for a week. o If the woman presents < 24 hours of the appearance of the rash and she is < 20+0 weeks of gestation, consider acyclovir. Check with senior ED or gynae on call. Will require foetal medicine specialist referral. When to admit Admit all with dense rash with or without mucosal lesions Chest/neurological symptoms Haemorrhagic rash Immunosuppressed patient Generally, if in doubt, remember the basics, and speak to an ED senior1

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