CPT Kurt E. Belk, MD, US Army
Darnall Army Community Hospital
Fort Hood, Texas

The female presenting to the emergency department is one of the most emotionally charged and complex entities confronting the emergency physician, and health care team. Among the various complaints, vaginal bleeding and pelvic pain are the two most common. The complex anatomy, vast differential, and potential life threatening complications make the female patient most challenging and difficult to assess, and diagnose.

Today's lecture is about obstetric and gynecological emergencies. It is not the intent to make you all experts in the field, but to make you more aware of the various problems you may encounter, and more comfortable in your assessment and diagnosis. I will discuss the initial approach to the female patient, the important points in taking a good history and physical, different laboratory data and procedures, differential diagnoses, and finally disposition. It would be exhaustive to try and present all the material essential to obstetrics and gynecology. This lecture will discuss vaginal bleeding, pregnancy induced hypertension, pelvic pain, and trauma in pregnancy.

The initial approach is most important. It is the only time you have to make a first impression and set the tone for the rest of the encounter. Patients are nervous, and frightened, or they may present a lot of displaced anger. Read the nursing triage note and talk to the EMS provider. Size up the patients potential problems and needs before you enter the patients room.

As with all things in emergency medicine the ABC's come first. Walk into the patients room and get a Geshstalt on the patients condition. I like to ask myself the question, "sick, or not sick." Think like an emergency physician and prioritize disease. Address what will kill the patient the fastest, and/or what diagnosis can I not afford to miss?

Vaginal bleeding is the most common gynecologic complaint. Placing the vaginal bleeding patient into one of three categories: pre-childbearing, childbearing, and post-childbearing, becomes useful in terms of worst case scenarios, the work up, when to get OB/GYN involved, and finally disposition.

The pre-childbearing patient is easily broken down into two categories, traumatic or non-traumatic. This can usually delineated by the history. In the traumatic patient it is important to remember the entire physical, and not neglect the potential for head and abdominal injuries. Think about assault and molestation as potential etiologies, and remember the traumatic patient may need to be sedated or taken to the operating room for an adequate exam, so get OB/GYN involved early. The non traumatic patient presents a more challenging test. These patients require a complete evaluation, and initial workup with OB/GYN/pediatric follow-up. This patient should be evaluated for tanner stage, hormone exposure, maturation, and infective symptoms. The non-traumatic differential should include precocious puberty, infection, molestation, and foreign bodies. Get ancillary support staff in on the case. Notify social work and child protective services as indicated.

The women of childbearing age (8-65) who have vaginal bleeding should be considered pregnant until proven otherwise. ABC's and OMMILTVS are essential to minimizing the morbidity and mortality. This patient will represent the bulk of the vaginally bleeding discussion.

The last category, the post-childbearing female, has the lowest risk for immediate problems, but has the highest risk for future catastrophes. In this patient vaginal bleeding is cancer until proven otherwise. But only approximately 10% of per menopausal, and 25% of postmenopausal vaginal bleeding is cancer, however. These patients need evaluation, stabilization, and OB/GYN follow-up.

Remember all females of childbearing age are pregnant until proven otherwise. In a study of women interviewed in the emergency department who denied any possibility of being pregnant, 11% were mistaken.

The patient history and physical exam are the two best tools at the physicians disposal. The patients appearance and age immediately put the patient in an assessment category. The gavida and para of the patient assigns a risk element to the patient. Gravida refers to the number of pregnancies, and multiple gestations count as one pregnancy. Pfpal refers to the child. "F" equals number of full term births, "p" refers to number of preterm births, "a" equals number of abortions(to include miscarriages), and "l" refers to number of living children. The last known menstrual cycle gives the examiner an estimation of gestational age, and it is important to know if the cycle was normal. Gestational age can be estimated by using the "wheel", or using the last menstrual period date minus three months, plus seven days. The last time of intercourse is important as a factor in first trimester bleeding, as coitus is associated with bright red spotting. Bleeding assessment is crucial to determine the overall severity of the patient complaint. The onset, quality, and severity is important to ask and document. Remember one soaked pad equals 20 - 30cc of blood. The presence of clots or tissue can aid the examiner in determining diagnosis and disposition. Clot size is an estimation of severity, and tissue supports the diagnosis of intrauterine pregnancy with probable miscarriage. Send the tissue to the lab for proper evaluation by pathology.

Remember that fibrinolysis takes place in the uterus and cervix, which is why blood does not clot in normal menses. Therefore if clots are forming the bleeding is significant, and clot size is an estimate of the bleeding severity. The patients associated symptoms can support and rule in certain diagnoses while ruling out others. Past medical, surgical and social histories are mandatory in a thorough evaluation, and vital to your consultants. A past history of a tubal ligation with a new positive bHCG on urine analysis is an ectopic pregnancy until proven otherwise. Get obgyn involved early. It is important to know if the patient is on any oral contraceptives, and/or teratogenic medications so the patient can be properly counseled and informed of the potential risks involved.

The physical exam, as in any patient, aids the examiner in supporting or denying the historical data presented by the patient, EMS provider, or other witnesses. Always document the physical appearance, vital signs, and mental status of the patient. Pay attention to the anxiety level and reassure the patient of the importance of a complete exam. Many pregnant women will have a systolic murmur of pregnancy. Fetal heart tones and estimation of uterine size are vital. A patient with positive fetal heart tones has less than a 5% incidence of miscarriage, and they should be audible by the 10-12th week. Absence of fetal heart tones after 12wks, should indicate the need for ultrasound. The uterus is approximately 20wks at the umbillicus. Peritoneal signs, pelvic and rectal exam are mandatory in examining the female patient with abdominal or pelvic pain.

After the history and physical exam you should have a good handle on the patients problem, or at the very least a plan on how to proceed. Most of the time surgical diagnoses do not require laboratory data, but the consultant will want them to assist in the proper course of action. In general a type and screen, CBC, Rh and quantitative bHCG should be sent on all emergency patients. Waiting on laboratory data should not delay indicated studies or consultation, however. An ultrasound can be invaluable in the hands of an experienced examiner. With a bHCG level of greater than 1500, a sac should be visualized trans-vaginally by four weeks, and trans-abdominally by five weeks. If an ultrasound is not available, or the patient is too unstable a culdocentesis can be performed. A positive result is determined if non clotted blood with a hematocrit greater than 15% is elicited. A negative result occurs with straw colored fluid. Infection can be diagnosed if purulent fluid obtained (send for culture). And the test is non-diagnostic if clotted blood or no fluid is recovered.

After completion of history, physical, laboratory data, and proper studies a complete differential should be ascertained and thought through. The following is a complete list of the emergency physicians differential diagnosis: ectopic pregnancy, appendicitis, ovarian torsion, ruptured cyst, pelvic inflammatory disease, abortion (threatened, inevitable, incomplete, and complete), gestational trophoblastic disease, leiomyomata, dysfunctional uterine bleeding, endometriosis, renal and ureteral infection or colic, and various gastrointestinal disease. The remainder of the talk will center around specific disease entities pertinent to obstetrics and gynecology.

Ectopic pregnancy is known as the great imitator. It must be included in the differential of any female patient of childbearing age with abdominal pain. Its incidence has risen in each of the past two decades to a level of approximately 1:200 pregnancies. It is defined as implantation of a gestational sac outside of the uterus. One must also consider heterotopic pregnancy which is defined as both intrauterine, and ectopic pregnancy. This is classically thought to occur in 1:30,000 pregnancies, but with the advent of medical advances in infertility the incidence is thought to approach 1:4000 in certain high risk patients. The etiology is due to anything that delays ovum transport. This fact allows us to determine certain risk factors such as: prior history of ectopic, history of pelvic inflammatory disease, prior gynecologic surgery, infertility, use of an intrauterine device, progestin only contraceptives, and endometriosis. These patients require prompt recognition, aggressive management and stat obgyn consultation. Assess ABC's, and set up a safety net. Put patients on oxygen and a monitor. Insert two large bore IV's and titrate to vital signs. Send stat labs for CBC, type and screen, Rh, quantitative bHCG, and urine analysis with qualitative bHCG. Get support studies as indicated and again consult early.

If the patient has a documented intrauterine pregnancy and has vaginal bleeding the diagnosis of abortion, or miscarriage is entertained. The patients are treated promptly and aggressively, but there is not the urgency once the documentation of IUP is known. Reassure the patient. Bleeding occurs in approximately one third of all pregnancies. Of the third that have bleeding, approximately 50% will go on to have normal pregnancies, but of course that means that 50% of the time there will be complications. The most important of which is the potential for abortion or miscarriage. Assure the patient that nothing they have done or have not done has caused the bleeding and potential miscarriage. Do a complete exam as indicated above and treat accordingly. If the patient is Rh negative, the patient needs rhogam (anti D immune globulin) 50ug IM if less than 12wks, or If greater than or equal to 12wks give 300ug IM. The discharge diagnosis is dependent on the pelvic exam. Threatened miscarriage implies bleeding with a closed cervical os. Inevitable miscarriage is diagnosed when the os is open. Incomplete miscarriage means that products of conception are in the os or the vaginal vault. Finally, completed miscarriage occurs when products of conception are expelled and the os is closed with the uterus contracted, this is a diagnosis best made by the obgyn consultant. These patients need close obgyn follow-up and instructions on pelvic rest (no intercourse, tampons, or douching so as not to introduce infection), bleeding (return if increased bleeding of greater than one pad per hour for three hours), and pain (return if increased pain).

In evaluation of the pregnant, bleeding patient gestational age is very important. This assessment will put the patient in a differential category. This is most important for the diseases we will be discussing next, placenta previa and abruptio placentae. These become important in the differential after 20wks gestation. They are also important because there are now two lives at stake. Most hospitals have a protocol set up for dealing with the advanced trimester bleeder, but the emergency physician may be confronted with these patients if they are involved in a trauma, do not realize they are pregnant, or deny that they are pregnant. In any case, the health care provider must be familiar with the emergency management of such patients.

Placenta previa is defined as implantation of the placenta such that it obstructs all (total), part (partial), or right up to the edge (marginal) of the internal cervical os. It is important to remember that percent of the cervix covered changes with dilation. Most all pregnancies have some degree of obstruction early on in the pregnancy with over 90% resolution by term even when there is complete obstruction. It is still important to realize that vaginal delivery can occur in all but total placental previa, in most cases. The incidence of previa is 1:100-250 pregnancies, with multiparty, advanced maternal age, previous uterine surgery, and multiple gestation being predisposing factors for previa implantation. Classically these patients present with painless, bright red, vaginal bleeding around the 34th week. The initial episode is often limited with 10% of patients having evidence of abruption, and 20% with associated uterine contractions that are often premature. The differential should include abruption, genital or cervical lacerations, trauma, bloody show, rectal or bladder bleeding, and incompetent cervix. To safely diagnose placenta previa you must be prepared for the treatment. Attend to the ABC's and set up a safety net. Start two large bore IV's, type and screen, CBC, Rh, and coags. Get a stat obgyn consult and remember a pelvic exam is contraindicated in the vaginal bleeding, third trimester, patient until previa is ruled out. Get an ultrasound, but remember false negatives and positives approach 7-10%, let obgyn make the diagnosis. In case you are not getting the hints, get obgyn involved early. If life threatening hemorrhage exists, as indicated by maternal hemodynamic instability or fetal distress, then a stat c-section is indicated. A double set up exam is done when fetal maturity is appropriate for survival and possibility of emergent delivery exists. This occurs when the ultrasound is equivocal and successful vaginal delivery is in question. Ideally two surgical teams are prepared, one for the digital exam and anatomy, and the other for the c-section.

Abruptio placentae is the other third trimester emergency of the bleeding pregnant patient. It is described as premature separation of the normally implanted placenta. This accounts for approximately one-third of all third trimester bleeding, with an incidence of 1:100-150 pregnancies. Of note is that up to 15% have no bleeding at all externally. The risk factors include: hypertension, prior history(5-15%), high parity, trauma, uterine anomaly, tumors, smoking and cocaine use. Basically, anything that causes bleeding in the decidua basalis. Smoking and cocaine use cause vasoconstriction and necrosis of the decidua. These patients usually present with abdominal or uterine pain associated with dark vaginal bleeding (painful bleeding). The patient may experience contractions with the bleeding, but the amount of bleeding is not a good indicator of the severity of separation so treat all patients emergently. ABC's and OMMILVS are a great place to start, with type and screen, cbc and platelets, electrolytes, wall clot, and dic panel for laboratory data. Aggressive fluid replacement with PRBC's, crystalloid, FFP and platelets to stabilize the patient until obgyn consultation and delivery are accomplished. The best way to save baby is to save mom. The treatment for DIC is delivery. The wall clot is a cheap test to estimate clotting time. As blood is being drawn to send to lab, tape one red top tube with the patients name on it on the wall. If no clot has formed in 5 minutes be aware, if no clot forms in 8-10 minutes, order your platelets and FFP right away.

Uterine rupture is a rare phenomenon, but one that bears mentioning. The uterus becomes an abdominal organ after 12wks, and therefore becomes more vulnerable to the environment, especially trauma. Rapid deceleration causes elongation and increased pressure that can result in rupture. The greatest risk factor for rupture is previous c-section. The patient presents in shock, with asymmetry of the uterus, and peritoneal irritation. A "free fetus" in the abdomen can sometimes be seen on ultrasound. Treatment is ABC's and OMMILVS, obgyn consultation, and preparation for surgery.

Pregnancy induced hypertension is defined as a third trimester blood pressure >140/90, or increase in systolic blood pressure >30, diastolic >15, on two occasions 6hrs apart, proteinuria >300mg over 24hrs and/or generalized edema. Pre-eclampsia, like most diseases, has a spectrum of presentation. Severe pre-eclampsia is defined as systolic blood pressure >160, or diastolic >110, protein > 5g in 24hrs, oliguria < 500cc in 24hrs, pulmonary edema or epigastric pain, and increased liver function tests or decreased platelets. The HELLP syndrome is a severe form of pregnancy induced hypertension that occurs in 5- 10% of pre-eclamptic females. HELLP syndrome is characterized by hemolysis, elevated liver function tests, and low platelets. The worst complication of pregnancy induced hypertension is eclampsia. Eclampsia is defined as the occurence of seizures or coma in a patient with symptoms of pre-eclampsia. One must entertain the diagnosis of eclampsia in any unconscious or seizing patient that is obviously pregnant. Also, suspect eclampsia in any auto accident involving a pregnant patient without any other obvious cause. Pregnancy induced hypertension can also be seen in the second trimester, but it is associated with special circumstances. These are as follows: molar pregnancy, chronic hypertension, drugs(cocaine and heroin withdrawl), and triploidy. One should obtain baseline blood pressures from first trimester to compare. There are certain risk factors that can help the clinician identify certain higher risk patients. Nulliparity, age <15 or >35, positive family history, multiple gestation, and black race are most often noted. These patients present with a variety of symptoms but those most specific for preeclampsia are headache, visual changes, epigastric pain, liver dysfunction, thrombocytopenia, proteinuria, and hyperreflexia. It is also important to remember that these patients also can present up to two weeks postpartum. The treatment of preeclampsia/eclampsia echoes a familiar tune in emergency medicine. ABC's and OMMILVS will establish a safety net. Then get a stat obgyn consult. Order CBC, electrolytes bun and creatinine, renal panel, liver function tests, fibrinogen and fibrin split products with PT and PTT, urine analysis, and patient weight The real challenge of preeclampsia/eclampsia is the recognition of the disease and then prompt treatment of the seizures and/or hypertension.

Seizures are treated with magnesium sulfate. Magnesium stabilizes membranes and vasodilates vasculature. It also maintains uterine and fetal blood flow. The dose is 6g iv bolus over 5-10min, then 1-2g qhr. Alternative dosing intramuscular is 10g IM, then 5g q4hr. Monitoring levels of magnesium is important. The goal is a level of 5-8mg/dl. Toxicity starts at levels of grater that 8.4mg/dl which result in loss of patellar reflexes, and at levels above 12mg/dl respiratory depression can occur. If the patient begins to exhibit signs of toxicity, calcium gluconate can be given slow iv push at a dose of 1g. If magnesium fails to control the seizures then another source should be entertained, consider a CT scan. Dilantin can be given, but at a reduced dose. In eclamptic patients there is an altered clearance and a decreased albumin. The altered dose is 10mg/kg iv at a rate of no greater than 50mg/min, followed by a 50mg/kg dose iv after 2hrs. Usually treatment of seizures with magnesium also will solve the problem of hypertension. If hypertension still exists hydralazine given at a dose of 5mg iv, with repeat doses at 5-10mg q20min can be attempted. Alternative routes of administration include 10-50mg IM. Hydralazine is an arteriolar dilator, that also increases maternal blood flow. Labetalol is gaining favor as more physicians become acquainted with its use. The dose is 20mg iv q10min up to 300mg. Diuretics are usually not used secondary to the vasoconstriction and intravascular depletion seen with their use. C-section, thought to be curative for preeclampsia/eclampsia, is usually only attempted after cessation of seizures and control of blood pressure.

Pelvic pain is the second most common complaint in the emergency department behind vaginal bleeding. For this reason alone this topic bears discussion. I have included two algorithms that may be of some assistance in evaluating the female patient with pelvic pain. It is important to distinguish the surgical from non-surgical causes and address them appropriately.

Ovarian torsion is most commonly due to an ovarian cyst or tumor. The patients present 1-2d after a sudden onset of sharp, unilateral, intermittent adenexal pain. The pain is the result of twisting of a vascular pedicle that usually occurs secondary to a large cyst or tumor (greater than 6cm). As the vascular compromise increases necrosis takes place with loss of compromised tissue and ovary. The associated symptoms of nausea, vomiting, leukocytosis, and fever can confuse the clinical picture with appendicitis. Torsion patients can usually describe the exact moment of the onset of pain. They are usually afebrile, and have a normal urine. The differential diagnosis includes ectopic pregnancy, ruptured cyst, PID, and appendicitis. The morbidity of missed diagnosis is high, so the physician must maintain a high index of suspicion, do a complete workup and consult obgyn. These patients often need diagnostic laparoscopy and surgical correction of the underlying disease process.

Mittelschmertz (mid month pain) is associated with the rupture of the follicular cyst during mid cycle. It occurs in as many as 25% of women. The pain is unilateral, lasting hours to days, and associated symptoms include malaise, nausea, and lower abdominal pain. Although vaginal bleeding is usually absent there can be "withdrawal" spotting associated with sudden decline of estrogen levels. These two scenarios can be confused with appendicitis, and ectopic pregnancy. Diagnosis and disposition depend on bHCG and a good history and physical.

Uterine fibroids are the most common gynecological tumor. They occur in 20% of women over the age of thirty, and have an increased incidence in black females. Their growth is stimulated by high estrogen levels that occur late in pregnancy, and in the postpartum/post-abortion periods. They rarely cause pain or undergo sarcomatous change, and acute pain occurs secondary to ischemia seen in three instances. First, in degeneration of the fibroid, second, in torsion on its vascular pedical, and third, from infection and necrosis of an aborting submucous fibroid. The diagnostic workup includes bHCG and appropriate laboratory studies, ultrasound, and occasionally laparoscopy. Obgyn follow up is necessary to rule out carcinoma, and treatment of fibroid.

Endometriosis is defined as a growth of endometrium outside of the uterus. It occurs in 10-25% of third decade females, but it has been reported to occur in up to 50% of adolescent females with chronic pelvic pain. It is thought to arise from embryonic cells or by retrograde tubal transmission. Females present with menstrual cramps, dysmenorrhea, dysparuenia, and infertility complaints. Other emergent causes of pelvic pain need to be ruled out, and diagnosis is via laparoscopy. Disposition is pain control and obgyn follow up.

Now lets look at specific injuries pertinent to pregnancy trauma.

Contractions are the most common side effect of trauma. In 90% of cases the contractions stop spontaneously without therapy. The only concern is that contractions may indicate underlying pathology. Abruptio placenta, discussed earlier, occurs in 3% of minor trauma, but in up to 40% of major trauma accidents.

The presence of vaginal bleeding and tetanic or hypertonic contractions is very suggestive of abruption. Fetal mortality approaches 100% if more than half of the placental
surface is involved. Thus all patients need cardiotocographic monitoring for a minimum of four hours after the patient has been stabilized. Penetrating abdominal trauma represents less than 5% of all traumas, but deserves mentioning because of diagnostic peritoneal lavage (DPL).

The indications are the same, but only an open/semi open technique above the uterus should be used. The interpretation of the DPL aspirate is more conservative compared to non pregnant patients. In any significant trauma the possibility of fetomaternal hemorrhage exists. This can be evaluated using the Kleinhauer Betke test.

The test quantifies the volume of fetal blood. The majority of hemorrhages involve a blood volume of less than 30cc. It should be remembered that the average blood volume of a fetus at 16wks is approximately 30cc. Also 300ug of Rho (D) immune globin should be used for every 30cc_f fetal hemorrhage.

Radiographic testing in pregnancy is a necessary evil. Special attention should be placed on shielding the abdomen when possible, but x rays should not be avoided if indicated. It is important to realize that the fetus is most susceptible during organogenesis (7 12wks), but routine x rays pose little risk. There is no significant increase risk with exposures less than IOrads. 10 15 rads is controversial, and with greater than 1Srads an increased risk is documented. A CT scan with shielded abdomen delivers less than Irad. An abdominal CT
above the uterus less than 3rads, and a pelvic CT approximately 3 9rads.

The last specific case to review is peri mortem cesarean section. The best chance at fetal survival is maternal survival, but when maternal death is apparent or imminent priorities switch to the fetus. The best chance for survival is if delivery is within 5 minutes of maternal death. Chances decrease for each Smin interval thereafter, with survival unlikely after 20min.

Finally we will discuss the management. The physician most learned in the anatomy and physiology of pregnancy is the physician most likely to save the traumatic pregnant patient. One thing does not change in pregnancy and that is the ABC's and OMMILVS, with special attention to the relative changes in vital signs. An immediate obstetrical consultation should be sent. The patient should be placed in the left lateral decubitis position. Mast pants can be used if less than 20wks, but are normally used to only stabilize lower extremity fractures or hemorrhage. Fetomaternal hemorrhage should be assessed in all Rh negative women. Tetanus can be given without fetal risk. Hypotension should be treated with volume and vasopressor agents avoided. Vaginal delivery is not contraindicated in pelvic fracture, and can usually take place in over 90% of cases. The rest of patient management is not unique to pregnancy and will not be discussed . Ultimately care of the pregnant patient provokes a lot of emotion. But with an
understanding of the anatomic, physiologic, and laboratory changes that take place the emergency physician is better armed to treat the traumatic pregnant patient. With concerted efforts and close team work morbidity and mortality can
be minimized.