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Emergency Medicine Atlas > Part 1. Regional Anatomy > Chapter 10. Gynecologic and Obstetric Conditions > Gynecologic Conditions >

Vaginitis

Associated Clinical Features

Candidal vaginitis is characterized by a thick, curdy, white discharge (Fig. 10.1) and vulvar discomfort. Intense vulvar erythema, pruritus, or burning are often present. A microscopic slide prepared with 10% potassium hydroxide yielding characteristic branch chain hyphae and spores establishes the diagnosis (Fig. 21.16). The pH of the discharge is less than 4.5. Predisposing factors that should be considered include oral contraceptive, antibiotic, or corticosteroid use; pregnancy; and diabetes. Sexually transmitted diseases are not usually associated with isolated candidal vaginitis.

Figure 10.1

Candidal Vaginitis Thick, curdy white discharge secondary to candidal vaginitis. (Courtesy of Kevin J. Knoop, MS, MD.)

Trichomonas vaginitis presents as a persistent, thin, copious discharge that is often frothy (Fig. 10.2), green, or foul-smelling. The pH of these secretions is greater than 4.5. The amount of vaginal and cervical erythema and inflammation varies considerably; thus the diagnosis depends on the presence of motile flagellates on normal saline wet-mount microscopy. Occasionally, multiple petechiae on the vaginal wall (strawberry spots) or cervix (strawberry cervix) are seen.

Figure 10.2

Trichomonas Vaginitis Thin vaginal discharge suggestive of Trichomonas vaginitis. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Bacterial vaginosis (previously termed Haemophilus or Gardnerella vaginitis) is characterized by a malodorous, homogeneous discharge (Fig. 10.3) with a pH greater than 4.5 and a transient amine (fishy) odor when mixed with a drop of KOH solution (positive sniff test). The presence of clue cells on normal saline wet mount establishes the diagnosis (Fig. 21.13). Other associated vaginal or abdominal complaints are minimal and, if significant, may represent another disease process.

Figure 10.3

Gardnerella Vaginitis Thin, milky white discharge suggestive of Gardnerella vaginitis. (Courtesy of Curatek Pharmaceuticals.)

Differential Diagnosis

Vaginal foreign bodies, especially in prepubescent girls, may present with a heavy white discharge but would be unaccompanied by vulvar erythema or the microscopic appearance of hyphae. Atrophic vaginitis is commonly found in postmenopausal women and is distinguished from candidal vaginitis by mucosal dryness, atrophy, dyspareunia, minimal discharge, and itching. Other considerations include contact dermatitis, local irritation secondary to tight-fitting underwear, and contact dermatitis from toiletry items.

Emergency Department Treatment and Disposition

For candidal vaginitis, various regimens of topical antifungal agents are the mainstay of treatment (clotrimazole 1% cream, one applicatorful inserted high into the vaginal vault for 7 nights, clotrimazole, two 100-mg vaginal tablets for 3 nights or one 500-mg vaginal tablet for single-dose treatment). Oral fluconazole (Diflucan, 150 mg as a single dose) is also effective. Nystatin vaginal tablets (100,000 U daily for 2 weeks) are generally considered safe for use in the first trimester of pregnancy.

For Trichomonas vaginitis, a single, one-time dose of metronidazole (2 g) is generally curative. Alternatively, 500 mg given twice daily can be used for recurrent or refractory cases. Metronidazole is contraindicted in pregnancy and is associated with an Antabuse-like reaction when taken with alcohol. For the pregnant patient, clotrimazole (100-mg vaginal suppositories daily for 7 to 14 days) may provide symptomatic relief.

For bacterial vaginosis, metronidazole (500 mg twice daily for 7 days) is recommended in the nonpregnant patient. Amoxicillin (500 mg tid for 7 days) or clindamycin (300 mg bid) for 7 days is a safe but less effective alternative during pregnancy. Treatment for asymptomatic infection or for male sexual partners is not generally recommended.

Clinical Pearls

1. Diabetes mellitus or immunosuppression should be considered in refractory or recurrent cases of candidal vaginitis.

2. A history of balanitis in the sexual partner should be sought and treated if present.

3. Trichomonas should be considered a sexually transmitted disease. It is generally recommended, therefore, that concomitant culturing for gonorrhea and Chlamydia be performed. Serologic testing for syphilis, HIV, and hepatitis B should be considered.

4. Patients treated with metronidazole should abstain from alcohol for the duration of treatment and for at least 24 h after their last dose.

Mucopurulent Cervicitis

Associated Clinical Features

The patient's chief complaint is often a purulent vaginal discharge. Speculum examination reveals a purulent, viscous discharge emanating from the cervical os (Fig. 10.4). Otherwise, a purulent discharge may be seen on a cervical swab. A Gram's stain may reveal either gram-negative intracellular diplococci consistent with Neisseria gonorrhoeae (Fig. 21.11) or be nonspecific, consistent with Chlamydia trachomatis, a coinfectant with the gonococcus about 50% of the time. The diagnosis of pelvic inflammatory disease should be considered, when accompanied by symptoms of lower abdominal pain and signs of pelvic peritonitis such as cervical motion and adnexal tenderness.

Figure 10.4

Mucopurulent Cervicitis Viscous, opaque discharge emanating from the cervical os, consistent with mucopurulent cervicitis. The string from an intrauterine device is seen descending through the os in this patient. (Courtesy of Sue Rist, FNP.)

Differential Diagnosis

Physiologic cervical mucous discharge at the time of ovulation may occur but is generally clear, with few white blood cells on Gram's stain.

Emergency Department Treatment and Disposition

Cultures for Chlamydia trachomatis and N. gonorrhoeae should be obtained prior to initiation of therapy. Ceftriaxone (125 mg as a single intramuscular dose) provides coverage for N. gonorrhoeae. Single-dose oral quinolones (ciprofloxacin, 500 mg, or ofloxacin, 400 mg) can be used in penicillin-allergic patients. Doxycycline (100 mg) or ofloxacin (300 mg) bid for 7 days or a single 1-g dose of azithromycin provides coverage for Chlamydia. Erythromycin (base 500 mg qid for 7 days) is the alternative for pregnant patients.

Clinical Pearls

1. The discharge of candidal, trichomonal, or Gardnerella vaginitis is almost never limited solely to the cervix.

2. Mucopurulent cervicitis is almost always secondary to a sexually transmitted disease; thus sexual partners should be treated as well.

3. Refer all patients for formal gynecologic follow-up after culture and treatment, since early cervical neoplasia may have a similar appearance.

Bartholin's Gland Abscess

Associated Clinical Features

Bartholin's glands and ducts are located over the lower third of the introitus near the labia minora. A cyst or abscess can result from an obstructed duct, which usually occurs secondary to scarring from trauma, delivery, or episiotomy. Infection of the cyst is usually with mixed vaginal or fecal flora (Escherichia coli) but may also contain Neisseria gonorrhoeae and Chlamydia trachomatis. Progressive enlargement and infection lead to increasing pain, swelling, and dyspareunia. A tender, fluctuant cystic mass with surrounding labial edema is easily appreciated on examination (Fig. 10.5).

Figure 10.5

Bartholin's Gland Abscess Typical appearance of a Bartholin's gland abscess with the labial fluctuance pointing medially. (Courtesy of the Medical Photography Department, Naval Medical Center, San Diego, CA.)

Differential Diagnosis

Epidermal inclusion cysts and sebaceous cysts of the labia majora may look similar but are generally smaller. When they are inflamed or infected, maximal fluctuance generally points toward the external aspect of the labium, as opposed to Bartholin's gland cysts, which point medially. Occlusion and infection of apocrine sweat glands can lead to subcutaneous abscess formation—known as hidradenitis suppurativa. Vulvar hematoma, leiomyoma, lipoma, and fibromas may occasionally be confused with a noninfected Bartholin's cyst. Vulvar cancer usually arises in postmenopausal women and is generally either ulcerated, excoriated, or exophytic.

Emergency Department Treatment and Disposition

Simple incision and drainage (Fig. 10.6) followed by sitz baths provide the most effective and expeditious relief on an emergency basis. Unfortunately, reocclusion and reaccumulation of cystic swelling are common. Definitive therapy of recurrent Bartholin's gland cysts involves marsupialization by suturing the introital mucosa to the inner cyst wall.

Figure 10.6

Bartholin's Gland Abscess Medial incision of the cyst yielding purulent fluid, consistent with a Bartholin's gland abscess. (Courtesy of the Medical Photography Department, Naval Medical Center, San Diego, CA.)

Clinical Pearls

1. Antibiotics, although commonly used, are usually not required.

2. Placement of a Word catheter into the cyst cavity (Fig. 10.7) decreases the incidence of reocclusion, but it must be allowed to remain in place for up to 6 weeks to ensure epithelialization of the drainage tract.

Figure 10.7

Bartholin's Gland Abscess Insertion and inflation of a Word catheter into the cyst cavity. The free end of the catheter can be tucked into the vagina for long-term placement, allowing for epithelialization of the incision site. (Courtesy of the Medical Photography Department, Naval Medical Center, San Diego, CA.)

Spontaneous Abortion

Associated Clinical Features

Spontaneous abortion is associated with vaginal bleeding and abdominal discomfort. Severe pain, heavy bleeding with the passage of clots or tissue (Fig. 10.8), and hypotension may also be present. Threatened abortion is diagnosed when mild cramping and vaginal bleeding are not accompanied by the complete or partial extrusion of tissue, cervical dilation, or ectopic pregnancy. Uterine cramping with progressive dilation of the cervix, with or without partial extrusion of the products of conception, indicates the presence of an inevitable abortion (Fig. 10.9). In an incomplete abortion, some elements of the conceptus have passed, yet retained intrauterine tissue leads to ongoing uterine cramping, cervical dilation, and persistent bleeding.

Figure 10.8

Spontaneous Abortion Passage of tissue in a spontaneous abortion at 4 weeks. (Courtesy of Lawrence B. Stack, MD.)

Figure 10.9

Spontaneous Abortion Dilation of the cervical os with partial extrusion of tissue in the setting of an inevitable abortion. (Courtesy of Robert Buckley, MD.)

Differential Diagnosis

Ectopic pregnancy should be considered in all first-trimester females with lower abdominal pain or vaginal bleeding. The presence of frank tissue passage or cervical dilation essentially excludes this diagnosis. Large blood clots or an intrauterine decidual cast (Fig. 10.10), however, may occasionally be mistaken for products of conception.

Figure 10.10

Decidual Cast A decidual cast or organized clot may occasionally be mistaken for products of conception. (Courtesy of the Medical Photography Department, Naval Medical Center, San Diego, CA.)

Emergency Department Treatment and Disposition

Intravenous access, fluid resuscitation, cross-matching of blood, and urgent gynecologic consultation should be implemented in the presence of severe pain, heavy bleeding, or hypovolemia. All tissue should be sent to pathology for definitive identification. Occasionally, patients who initially have an open cervical os will rapidly expel the remaining products of conception, with subsequent resolution of all pain and bleeding. These patients may be discharged from the ED with the diagnosis of completed abortion if otherwise clinically stable. Anti-Rh immunoglobulin (RhoGAM) should be administered in all cases of vaginal bleeding in the pregnant patient where the mother is Rh-negative and the father is Rh-positive.

Clinical Pearls

1. The passage of large clots usually indicates rapid heavy bleeding.

2. Completed abortion is characterized by the passage of tissue, followed by resolution of bleeding and closure of the cervical os.

3. Fever, leukocytosis, pelvic tenderness, and malodorous cervical discharge should suggest septic abortion.

Genital Trauma and Sexual Assault

Associated Clinical Features

Patients who present for examination and treatment following an incident of sexual assault are ideally cared for by a multidisciplinary team capable of addressing the immediate medical and psychosocial needs of the patient in concert with forensic and legal requirements. A thorough general examination may reveal associated contusions and other soft tissue injuries. A meticulous inspection of the perineum, rectum, vaginal fornices, vagina, and cervix is required to identify inflicted injuries. Toluidine staining and colposcopy are often useful in enhancing less apparent injuries such as those to the posterior fourchette following sexual assault (Fig. 10.11). These are most commonly found between the 3 and 9 o'clock distribution when the patient is examined in the dorsal lithotomy position. Perianal lacerations (Fig. 10.12) may also be seen as toluidine-enhanced linear tears (Fig. 10.13). Examination of the cervix and posterior vaginal vault may reveal injuries to those structures (Fig. 10.14).

Figure 10.11

Genital Trauma (Posterior Fourchette) Linear tears to the posterior fourchette—due to sexual assault—enhanced by toluidine staining. (Courtesy of Hillary J. Larkin, PA-C, and Lauri A. Paolinetti, PA-C.)

Figure 10.12

Genital Trauma (Perianal) Perianal lacerations following sexual assault. (Courtesy of Hillary J. Larkin, PA-C, and Lauri A. Paolinetti, PA-C.)

Figure 10.13

Genital Trauma (Toluidine Staining) Toluidine staining showing subtle perianal lacerations following forceful anal penetration. (Courtesy of Aurora Mendez, RN.)

Figure 10.14

Genital Trauma (Cervix) Cervical trauma in an elderly victim of sexual assault. Petechiae and freshly bleeding abrasions are noted from 10 to 3 o'clock. (Courtesy of Hillary J. Larkin, PA-C, and Lauri A. Paolinetti, PA-C.)

Differential Diagnosis

Perineal injuries from accidental trauma may be indistinguishable from those of sexual assault and should be interpreted in the context of the history. The assessment of assault or rape is technically a legal one; therefore the examiner should be careful to document the medical appearance of the wounds rather than speculate as to the specific mechanism by which each injury occurred.

Emergency Department Treatment and Disposition

Treatment is preceded by forensic evidence gathering, consisting of a Wood's lamp examination to identify semen for collection, pubic hair sampling and combing, vaginal and cervical smears (air-dried), a cervical and vaginal wet mount to identify sperm, vaginal aspirate to test for acid phosphatase, and rectal or buccal swabs for sperm. A prepackaged kit with directions may be available to facilitate the collection of evidence.

Cervical cultures for Chlamydia and Neisseria gonorrhoea should be obtained as well as serum testing for syphilis, hepatitis, and HIV. Empiric antibiotic coverage against sexually transmitted diseases should be provided and an oral contraceptive offered (after confirming a nonpregnant state) to prevent unwanted pregnancy.

Clinical Pearls

1. The medical care of the patient who has been sexually assaulted should ideally be performed by experienced supportive staff familiar with the details of forensic evidence gathering and colposcopic photography.

2. Normal findings on physical examination and no sperm on wet preparation do not exclude the possibility of assault.

Uterine Prolapse

Associated Clinical Features

Uterine prolapse is defined as the propulsion of the uterus through the pelvic floor or vaginal introitus. In first-degree prolapse, the cervix descends into the lower third of the vagina; in second-degree prolapse, the cervix usually protrudes through the introitus; whereas in third-degree prolapse, or procidentia, the entire uterus is externalized with inversion of the vagina (Fig. 10.15). Symptoms include a sensation of inguinal traction, low back pain, urinary incontinence, and the presence of a vaginal mass.

Figure 10.15

Third-Degree Uterine Prolapse Note the protrusion of the entire uterus with cervix visible through the vaginal introitus. (Courtesy of Matthew Backer, Jr., MD.)

Differential Diagnosis

Uterine prolapse can occasionally be confused with a cystocele, enterocele, or soft tissue tumor. These disorders, which may all be accompanied by introital bulging, are easily distinguished by the absence of cervicouterine descent.

Emergency Department Treatment and Disposition

Patients with first- or second-degree prolapse should be referred to a gynecologist for pessary placement or surgical correction. With procidentia, the uterus should be manually reduced into the vaginal vault and the patient placed at bed rest until evaluated by a gynecologic consultant.

Clinical Pearl

1. With procidentia, the exposed uterus is prone to abrasion and possible secondary infection.

Cystocele

Associated Clinical Features

A cystocele occurs when there is relaxation and bulging of the posterior bladder wall and trigone into the vagina (Fig. 10.16) and is usually due to birth trauma. Patients complain of bulging or fullness over the introitus that is worsened with Valsalva (Fig. 10.17) and relieved with recumbency. It is often associated with urinary incontinence or symptoms of incomplete emptying. Most cystoceles, however, are asymptomatic. Examination reveals a thin-walled bulging of the anterior vaginal wall, which, in severe cases, may pass through the introitus with Valsalva.

Figure 10.16

Cystocele Cystocele with bulging of the posterior bladder wall into the vagina. (Courtesy of Matthew Backer, Jr., MD.)

Figure 10.17

Cystocele Cystocele worsening with Valsalva. (Courtesy of Matthew Backer, Jr., MD.)

Differential Diagnosis

An enterocele may lead to a similar bulging of the anterior vaginal wall but is much less common and is generally limited to those patients who have had a hysterectomy. Rectocele, uterine prolapse, and soft tissue tumors should also be considered.

Emergency Department Treatment and Disposition

Larger cystoceles or those associated with urinary symptomatology, pain, or bothersome bulging should be referred to a gynecologist for further evaluation.

Clinical Pearl

1. Most cystoceles are asymptomatic and are detected incidentally at the time of pelvic examination.

Rectocele

Associated Clinical Features

Most small rectoceles are completely asymptomatic, though symptoms of introital bulging, constipation, and incomplete rectal evacuation may occur. Bulging of the introitus can be seen grossly on physical examination (Fig. 10.18) and can become worse with Valsalva (Fig. 10.19). Rectovaginal examination reveals a thin-walled protrusion of the rectovaginal septum into the lower part of the vagina.

Figure 10.18

Rectocele This is characterized by bulging of the posterior vaginal wall at the introitus. (Courtesy of Matthew Backer, Jr., MD.)

Figure 10.19

Rectocele Worsening of the rectocele with Valsalva. (Courtesy of Matthew Backer, Jr., MD.)

Differential Diagnosis

Cystocele, enterocele, uterine prolapse, and soft-tissue tumors should all be easily distinguished by careful inspection.

Emergency Department Treatment and Disposition

Supportive measures with hydration, laxatives, and stool softeners are generally all that is needed to relieve the patient's symptoms. Those patients with large symptomatic rectoceles who do not desire further childbearing are candidates for posterior colpoperineorrhaphy.

Clinical Pearl

1. A rectocele is the herniation of the rectovaginal wall and is usually due to childbirth.

Imperforate Hymen

Associated Clinical Features

The hymen is a membrane visible at the introitus that separates the vestibule externally from the vagina internally. The opening of the hymen can take on a variety of shapes—annular, semilunar, cribiform, and septate. The congenital absence of a hymenal orifice is called an imperforate hymen (IH). This condition may become evident in infants or young children as a smooth, glistening, protruding membrane due to the buildup of vaginal secretions known as a mucocolpos. More commonly, an imperforate hymen presents in adolescent girls with primary amenorrhea and recurrent abdominal pain. The buildup of menstrual blood and secretions behind the hymen is called hematocolpos and may become large enough to cause urinary retention by pressing on the bladder neck.

Physical examination reveals a smooth, dome-shaped, bluish-red bulging membrane (Fig. 10.20). A large, smooth, cystic mass can often be palpated anteriorly on digital rectal examination. Occasionally, the buildup of blood may spill over through the fallopian tubes into the peritoneal cavity, resulting in signs of pelvic or abdominal peritonitis.

Figure 10.20

Imperforate Hymen A bulging mass at the introitus is seen in this patient with abdominal distention and amenorrhea. The imperforate hymen was diagnosed, with subsequent incision and drainage of the hematocolpos. (Courtesy of Mark Eich, MD.)

Differential Diagnosis

A complete transverse septum, located in the midvagina, presents similarly to IH but is generally not visible to simple inspection. Partial and complete vaginal agenesis may be confused with IH in preadolescents. Both cystocele and rectocele present as bulging masses at the introitus (see Figs. 10.16, 10.18) but occur almost exclusively in multiparous women, thus excluding IH from consideration. The presentation of a bulging membrane at the introitus may be briefly confused with a bulging amniotic sac—history and abdominal examination, however, should allow this possibility to be quickly excluded.

Emergency Department Treatment and Disposition

Imperforate hymen as well as other abnormalities of the vaginal outlet should be referred to a gynecologist for definitive treatment. This includes incision of the hymen to allow drainage of the hematocolpos. Those instances detected in preadolescence should ideally be referred to a practitioner who specializes in pediatric cases.

Clinical Pearl

1. An imperforate hymen presents in adolescent girls with primary amenorrhea and recurrent abdominal pain.

Ectopic Pregnancy: Ultrasonographic Imaging

Associated Clinical Features

Ectopic pregnancy is the leading cause of maternal obstetric morbidity in the first trimester of pregnancy. Presentations commonly include mild vaginal bleeding and lower abdominal pain, but patients can present in shock secondary to massive hemorrhage. The menstrual history, although often unreliable, may reveal a missed or recent abnormal menses. The presence of early signs of pregnancy (breast changes, morning sickness, fatigue) is variable. On examination, the uterus may be slightly enlarged, and adnexal tenderness is not always present. The visualization of an intrauterine pregnancy (IUP) by ultrasound (US) essentially excludes the diagnosis of ectopic pregnancy, the exception being a rare dual pregnancy (IUP and ectopic). The appearance of a gestational sac at about 5 weeks (Fig. 10.21) is the first significant finding on US suggestive of an IUP; however, definitive diagnosis of IUP should be deferred until a yolk sac is present (Fig. 10.22). A fetal pole develops next and can be seen on part of the yolk sac (Fig. 10.23). The double decidual sac sign is evidence of a true gestational sac and should be differentiated from the pseudogestational sac formed from a decidual cast in ectopic pregnancy (Fig. 10.24). When no gestational sac is visualized ("empty uterus") (Fig. 10.25), ectopic pregnancy cannot be distinguished from an early IUP too small to be seen on US.

Figure 10.21

Intrauterine Gestational Sac Discrete ring of an intrauterine gestational sac seen on transvaginal ultrasound. No yolk sac is visualized. A double decidual sac sign is seen, however, lending evidence of a true gestational sac versus a pseudogestational sac formed from a decidual cast in ectopic pregnancy. A thorough look in the adnexa is important in diagnosing ectopic pregnancy when a gestational sac is the only finding. (Courtesy of Janice Underwood.)

Figure 10.22

Intrauterine Yolk Sac Discrete ring of an intrauterine yolk sac within the gestational sac seen on transvaginal ultrasound. Definitive diagnosis of IUP should be deferred until a fetal pole is present in the sac. (Courtesy of Janice Underwood.)

Figure 10.23

Intrauterine Fetal Pole Ultrasound image of an intrauterine pregnancy with a fetal pole consistent with an 8-week gestation. An umbilical cord can be seen interposed between the yolk sac and the fetal pole. (Courtesy of Robert Buckley, MD.)

Figure 10.24

Ectopic Pregnancy Transvaginal ultrasound image of a right ectopic pregnancy with a decidual reaction in the uterus resembling a gestational sac, or "pseudosac." Visualization of a pseudogestational, or "single," sac sign could be consistent with an early gestational sac or an ectopic pregnancy with a uterine decidual cast. (Courtesy of Janice Underwood.)

Figure 10.25

Empty Uterus Transvaginal ultrasound image of an apparently empty uterus. Ectopic pregnancy should be strongly suspected if a transvaginal ultrasound reveals an empty uterus in the setting of a serum quantitative hCG level above the institution's discriminatory zone. (Courtesy of Janice Underwood.)

Differential Diagnosis

Ectopic pregnancy should be considered in all first-trimester females presenting to the emergency department with either lower abdominal pain or tenderness or vaginal bleeding. A spontaneously completed abortion with an empty uterine cavity may lead to confusion if the beta human chorionic gonadotropin (hCG) level is elevated above the institution's or sonographer's discriminatory zone [generally between 1000 and 2000 mIU/mL (Third International Standard)] and clinical evidence for the passage of products of conception is lacking. Alternative causes of first-trimester lower abdominal pain or vaginal bleeding include threatened or incomplete abortion, molar pregnancy, ruptured corpus luteum cyst, adnexal torsion, urinary tract infection, appendicitis, pelvic inflammatory disease, and ureteral calculi.

Emergency Department Treatment and Disposition

Unstable patients require aggressive resuscitation with fluid and blood followed by surgery. Stable patients with an ultrasound diagnosis consistent with ectopic pregnancy (Fig. 10.24) warrant immediate gynecologic consultation. Definitive therapeutic options range from observation in asymptomatic patients with declining hCG levels, traditional or laparoscopic surgery, to pharmacologic therapy with methotrexate. Despite the diminished diagnostic accuracy of ultrasound at lower levels (up to half of all ectopic pregnancies have a serum hCG level less than 2000 mIU/mL), if there is a strong clinical suspicion for ectopic pregnancy, gynecologic consultation should be considered. Those patients in whom a normal IUP is visualized can be safely discharged with early outpatient follow-up.

Clinical Pearls

1. Ectopic pregnancy should be considered in all women of reproductive age presenting with vaginal bleeding, abdominal pain or tenderness, or a missed menstrual period.

2. Failure to visualize an intrauterine pregnancy by transvaginal ultrasonography by the time the serum hCG level has reached approximately 1000 mIU/mL or by abdominal ultrasound once it has reached a level of approximately 6000 mIU/mL is highly suggestive of the diagnosis of ectopic pregnancy.

3. The ability of ultrasound and quantitative hCG to diagnose ectopic pregnancy is highly dependent on the resolution of the machine, the skill of the examiner, and the hCG assay used. Thus, every institution and examiner must develop a specific "discriminatory zone," the level of hCG on which to base diagnostic decisions.

4. A decidual cast in the uterus of an ectopic pregnancy may resemble a gestational sac of an intrauterine pregnancy on ultrasound.

5. Consider ectopic pregnancy in any female of reproductive age presenting with syncope.

Molar Pregnancy (Hydatidiform Mole)

Associated Clinical Features

Molar pregnancy is part of a spectrum of gestational trophoblastic tumors that include benign hydatidiform moles, locally invasive moles, and choriocarcinoma. The classic clinical presentation is painless first- or early second-trimester vaginal bleeding with a uterine size larger than the estimated gestational age based on the last menstrual period. Additional clinical findings include nausea and vomiting, though this is often indistinguishable from that found in normal pregnancy.

Signs of preeclampsia in the first trimester or early second trimester (hypertension, headache, proteinuria, and edema), are highly suggestive of this diagnosis. Hyperthyroidism can be found in roughly 5% of cases. Acute respiratory distress may occur owing to embolization of trophoblastic tissue into the pulmonary vasculature, thyrotoxicosis, or simply fluid overload.

Moles commonly produce serum hCG levels greater than 100,000 mIU/mL. The diagnosis is made by ultrasound. Figure 10.26 demonstrates the classic finding of multiple intrauterine echoes with no fetus.

Figure 10.26

Molar Pregnancy "Snowstorm" pattern demonstrating multiple intrauterine echoes with no fetus is seen on transvaginal ultrasonography in a patient with a molar pregnancy. Serum HCG was > 180,000 mIU/mL. (Courtesy of Robin Marshall, MD.)

Differential Diagnosis

Spontaneous abortion and ectopic pregnancy are much more common that molar disease and can generally be differentiated based on typical ultrasound findings accompanied by markedly elevated serum hCG levels.

Emergency Department Treatment and Disposition

Gynecologic consultation for dilatation and curettage (D & C) should be obtained in all cases. For patients who are reliable for follow-up, suction curettage may be performed in an outpatient setting when the uterine size is less than 16 weeks and there is no evidence of preeclampsia, hyperthyroidism, or respiratory distress.

All cases must have close outpatient monitoring of serum hCG levels to rule out the presence of malignant gestational trophoblastic disease.

Clinical Pearls

1. All patients with pregnancies of less than 20 weeks' gestation with clinical findings of preeclampsia should have gestational trophoblastic disease ruled out.

2. A "snowstorm" pattern on ultrasonography demonstrating multiple intrauterine echoes with no fetus coupled with a high hCG level is typical of molar pregnancy.

Third-Trimester Blunt Abdominal Trauma

Associated Clinical Features

Trauma is a major cause of maternal and fetal mortality. In addition to the common injuries to a solid organ and/or hollow viscus associated with blunt abdominal trauma, special consideration should be given to the possibility of preterm labor, fetal-maternal hemorrhage, uterine rupture, and, most importantly, abruptio placentae. Abruptio placentae is defined as the premature separation of the placenta from the site of uterine implantation. It is found in up to 50% of major blunt trauma patients and up to 5% of those with apparent minor injuries. There are generally signs of uterine hyperactivity and fetal distress when significant placental detachment occurs. Most patients have vaginal bleeding, although the margins of detachment are above the cervical os in up to 20%, who therefore have little or no vaginal bleeding. Laboratory evidence of a consumptive coagulopathy is occasionally seen with significant abruption. Electronic fetal monitoring is of paramount importance in all cases of significant trauma in patients beyond 20 weeks' gestation. As the pregnancy progresses toward term, a normal heart rate averages between 120 and 160 bpm. Rapid, frequent fluctuations in the baseline are characteristic of normal "reactivity" (Fig. 10.27). The loss of this reactivity can occur during a normal sleep cycle, following narcotic administration, or, most importantly, in the setting of fetal hypoxia or distress (Fig. 10.28). Decelerations are transient reductions in the fetal heart rate. Late decelerations begin after the contraction begins and return to baseline well after it ends, with the nadir of the deceleration occurring after the peak of the uterine contraction. Late decelerations should suggest fetal hypoxia, especially when they are accompanied by a loss of normal baseline beat-to-beat variability (Fig. 10.29). Variable decelerations are characterized by deep, broad decreases in fetal heart rate, often falling below 100 bpm (Fig. 10.30). They can occur slightly before, during, or after the onset of a uterine contraction, hence the term variable. Variable decelerations are caused by the transient compression of the umbilical cord during a contraction and are rarely associated with significant hypoxia or acidosis unless they are frequent or prolonged. They are most commonly appreciated during the second stage of labor, when forceful uterine compression transiently occludes the umbilical cord as the infant is propelled through the birth canal.

Figure 10.27

Normal Beat-to-Beat Variability (BBV) A normal reactive fetal monitor strip showing a baseline heart rate between 120 and 160 with fluctuations in the short- and long-term heart rate. (Courtesy of Timothy Jahn, MD.)

Figure 10.28

Loss of BBV Loss of beat-to-beat variability (BBV) in the fetal heart rate, which may forewarn of fetal distress. This same pattern may also be seen during a normal sleep cycle or following maternal narcotic administration. (Courtesy of Gerard Van Houdt, MD.)

Figure 10.29

Late Deceleration The nadir of a late deceleration always follows the peak of the uterine contraction with the heart rate approaching the baseline after the completion of the uterine contraction; this is suggestive of hypoxia. (Courtesy of James Palombaro, MD.)

Figure 10.30

Variable Deceleration Variable decelerations are due to cord compression. They are characterized by a rapid onset and recovery and may occur slightly before, during, or after the onset of the contraction. (Courtesy of John O. Boyle, MD.)

Differential Diagnosis

Another alternative cause of bright red vaginal bleeding in the third trimester of pregnancy is placenta previa. This can generally be differentiated from abruption by the visualization of a low-lying placenta on ultrasound.

Emergency Department Treatment and Disposition

An obstetrician should be consulted immediately in all trauma patients beyond 20 weeks' gestation. Blood for type- and cross-matching, complete blood count, prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, and fibrin degradation products or D-dimer should be obtained. It is generally recommended that patients undergo continuous tocofetal monitoring for a minimum of 4 h to rule out preterm labor or fetal distress. Ultrasound is essential in visualizing placental abruption. Indications for emergency cesarean section include placental abruption, signs of ongoing fetal distress, or uncontrolled maternal hemorrhage.

Clinical Pearls

1. Ecchymotic markings imparted by a significant blunt force (Fig. 10.31) are not always present on a gravid abdomen; thus, a careful history of the mechanism of trauma and associated complaints is essential.

2. Anti-Rh immunoglobulin should be administered for all cases of significant third-trimester blunt abdominal trauma if the mother is Rh-negative and the father is Rh-positive.

Figure 10.31

Gravid Abdomen A third-trimester gravid abdomen with ecchymotic markings imparted by a significant blunt force. Fetal assessment should occur simultaneously with maternal resuscitation. (Courtesy of John Fildes, MD.)

Ferning Pattern of Amniotic Fluid

Associated Clinical Features

Patients beyond the 20th week of pregnancy presenting with a history of uncontrolled leakage of fluid should undergo sterile speculum examination to determine the presence of amniotic fluid. The diagnosis of membrane rupture can be made by observing the passage of fluid from the cervix or pooling in the vaginal vault. Without gross evidence of rupture, secretions from the vaginal vault can be placed on a slide and allowed to air dry. The characteristic arborization, or ferning pattern (Fig. 10.32), is diagnostic of amniotic fluid, thus rupture of the membranes. In addition, the secretions can be applied to nitrazine paper. The pH of normal vaginal secretions generally falls between 4.5 and 5.5, whereas amniotic fluid generally ranges between 7.0 and 7.5, yielding a dark blue tint.

Figure 10.32

Ferning Pattern The arborization pattern found when a drop of amniotic fluid is allowed to air dry on a microscope slide, known as ferning. (Courtesy of Robert Buckley, MD.)

Differential Diagnosis

Urinary incontinence is the most common alternative diagnosis in a third-trimester patient who presents with a history of possible membrane rupture. The passage of the cervical mucous plug, known as bloody show, may rarely be confused with the passage of amniotic fluid. Although a small, subclinical amniotic fluid leak can never be completely excluded, the presence of an acid pH, the absence of gross fluid in the vaginal vault, and ferning all point against the diagnosis of membrane rupture.

Emergency Department Treatment and Disposition

All patients with confirmed ruptured fetal membranes should be admitted to the labor and delivery area and the obstetric consultant notified, irrespective of the presence or absence of uterine contractions. The greatest risk to the fetus before 37 weeks is preterm delivery. The fetus at term is at risk for infection secondary to chorioamnionitis if the time from membrane rupture to vaginal delivery exceeds 24 h.

Clinical Pearls

1. With a strong suspicion of membrane rupture by history and no objective evidence of amniotic fluid on examination, a large sterile pad may be placed on the perineum and the patient reexamined after brief ambulation. This assumes the absence of uterine contractions and the presence of a reactive fetal monitor strip.

2. Umbilical cord prolapse should be excluded with a speculum examination in all cases of membrane rupture.

Emergency Delivery: Imminent Vertex Delivery—Crowning

Associated Clinical Features

The second stage of labor begins when the cervix is fully dilated, allowing for the gradual descent of the head toward the vaginal outlet. As the head approaches the perineum, the labia begin to separate with each contraction and then recede once the contraction subsides. Crowning is the term applied when the head separates the labial margins without receding at the end of the contraction (Fig. 10.33).

Figure 10.33

Crowning Descent of the fetal head with separation of the labia is known as crowning and heralds imminent vertex delivery. (Courtesy of William Leninger, MD.)

Emergency Department Treatment and Disposition

The appearance of crowning heralds imminent vaginal delivery. Equipment for delivery and neonatal resuscitation should be brought to the bedside. Both the on-call obstetric consultant and pediatrician should be notified while preparations are being made for ED delivery.

Clinical Pearls

1. Primigravida patients may still require multiple sets of contractions and pushing to fully expel the head through the vaginal outlet.

2. If meconium secretions are detected well before delivery, continuous electronic tocofetal monitoring should be begun and the obstetric and pediatric consultants notified.

Emergency Delivery: Normal Delivery Sequence

Associated Clinical Features

A gravid female with regular forceful contractions and the urge to strain (push) can present without warning. Crowning may be present and heralds imminent vaginal delivery. Important historical questions include the number of previous pregnancies, a diagnosis of twin gestations, and whether there is a history of prenatal care or complications. The presence of greenish brown fetal stool, known as meconium, is associated with fetal hypoxia and is a clinical indicator of fetal distress. Fetal bradycardia or late decelerations (Fig. 10.29) may be present and are also evidence of fetal distress.

Differential Diagnosis

Complications (discussed below) should be considered when the progress of delivery is altered or when the presenting part is something other than the occiput. Twin gestations should be considered in all emergency deliveries and asked about early in the history.

Emergency Department Treatment and Disposition

Intravenous access, oxygen, and equipment for delivery and neonatal resuscitation (suction, oxygen, warming light, etc.) are immediately obtained as preparation for the impending delivery.

Delivery of the Head

As the vertex passes through the vaginal outlet, extension of the head occurs, followed by the appearance of the forehead and chin. Extension and delivery of the fetal head can be facilitated by applying gentle pressure upward on the chin through the perineum—known as the modified Ritgen maneuver (Fig. 10.34). Simultaneously, the fingers of the other hand can be used to elevate the scalp to help extend the head. Once the head has been delivered, the occiput promptly rotates toward a left or right lateral position. At this stage, the nuchal region should be swept to detect the presence of a nuchal umbilical cord (see Fig. 10.45). Before the delivery of the shoulders, the nasopharynx should be gently suctioned with a bulb syringe to clear away any blood or amniotic debris. If thick meconium is present, deeper and more thorough suctioning of the posterior pharynx and glottic region should be accomplished with a mechanical suction trap, since aspiration of thick meconium by the newborn can lead to pneumonitis and hypoxia.

Figure 10.34

Modified Ritgen Maneuver Modified Ritgen maneuver: upward pressure is applied on the fetal chin through the perineum. (Courtesy of William Leninger, MD.)

Delivery of the Shoulders

Delivery of the shoulders generally occurs spontaneously with little manipulation. Occasionally, gentle downward traction applied by grasping the sides of the head with two hands eases the delivery of the anterior shoulder (Fig. 10.35). The head can then be directed upward to permit the delivery of the posterior shoulder (Fig. 10.36). Following delivery of both shoulders, the body and legs are easily delivered. Attention is then directed toward the immediate care of the newborn. The cord is doubly clamped and ligated (Fig. 10.37) and inspected for three vessels: two umbilical arteries and one umbilical vein (Fig. 10.38). The child's pediatrician should be notified if a two-vessel umbilical cord is found at delivery. The newborn is immediately placed under a warming lamp for drying and gentle stimulation while being observed for signs of distress (heart rate < 100, limp muscle tone, poor color, weak cry).

Figure 10.35

Anterior Shoulder Delivery Delivery of the anterior shoulder is facilitated with downward traction. (Courtesy of William Leninger, MD.)

Figure 10.36

Posterior Shoulder Delivery Delivery of the posterior shoulder with upward traction. (Courtesy of William Leninger, MD.)

Figure 10.37

Clamping the Cord The cord is clamped immediately after delivery. (Courtesy of William Leninger, MD.)

Figure 10.38

Normal Umbilical Cord Cross-sectional view of the two arteries and single vein of a normal three-vessel umbilical cord. (Courtesy of Jennifer Jagoe, MD.)

Delivery of the Placenta

Following delivery, gentle traction can be placed on the cord while the opposite hand is used to massage the uterine fundus (Fig. 10.39). The placenta will generally be delivered within 15 to 20 min (Fig. 10.40) and should be grossly inspected. Retention of small fragments should be suspected when inspection of the placenta reveals evidence of a missing segment or cotyledon (Fig. 10.41). The attending obstetric consultant should be notified, since retained placental fragments often warrant manual exploration of the uterus, especially in the context of persistent postpartum bleeding.

Figure 10.39

Placenta Delivery Gentle traction is applied to the cord while the opposite hand massages the uterus. (Courtesy of William Leninger, MD.)

Figure 10.40

Placenta Delivery Delivery of the placenta. (Courtesy of William Leninger, MD.)

Figure 10.41

Placenta Placenta with a missing segment or cotyledon. The missing placental tissue can be seen in the upper left-hand corner of the photograph. (Courtesy of John O. Boyle, MD.)

Clinical Pearls

1. Both obstetric and pediatric consultants should be alerted that preparations are being made for ED delivery.

2. A two-vessel cord may be found in about 1 in 500 singleton deliveries and is associated with an increased incidence of congenital defects.

3. Retained placental fragments should be considered in the setting of postpartum hemorrhage or endometritis.

Umbilical Cord Prolapse in Emergency Delivery

Associated Clinical Features

In an overt cord prolapse, a loop of umbilical cord is visualized either at the introitus (Fig. 10.42) or on speculum examination following membrane rupture (Fig. 10.43). Alternatively, a small loop of cord may be palpated at the cervical os. In a funic cord prolapse, a loop of umbilical cord is palpated directly through intact fetal membranes. Occult prolapse occurs when the umbilical cord descends between the presenting part and the lower uterine segment but is not visible or directly palpable on examination. Intermittent compression of the umbilical cord with each uterine contraction may be detected by the presence of variable decelerations of the fetal monitor (see Fig. 10.30). The new onset of variable decelerations should always prompt immediate cervical examination to rule out an overt cord prolapse. Severe persistent bradycardia may ensue if cord compression is sustained beyond the duration of the contraction, which is often the case in an overt prolapse.

Figure 10.42

Umbilical Cord Prolapse Prolapsed umbilical cord visible at the vaginal introitus in a patient with twin gestations. (Courtesy of Kevin J. Knoop, MD, MS.)

Figure 10.43

Umbilical Cord Prolapse Schematic drawing of an overt prolapse of the umbilical cord through a partially dilated cervical os. (Courtesy of Judy Christensen.)

Differential Diagnosis

Rarely, an inexperienced examiner may mistake a presenting hand or foot for a prolapsed cord. This may be clarified by careful digital or speculum examination.

Emergency Department Treatment and Disposition

Prolapse of the umbilical cord presents an immediate threat to the fetal circulation and constitutes an obstetric emergency. If an overt prolapse is detected in the ED, the patient should immediately be placed in a knee-chest position and continuous upward pressure applied by the examining hand to relieve the pressure of the presenting part on the lower uterine segment. An obstetrician should be summoned immediately and the patient taken directly to the operating room for cesarean delivery. Continuous upward pressure should be applied to the presenting part of the fetus at all times during transport. Occasionally, precipitous vaginal delivery may ensue in the ED shortly after a cord prolapse is detected. Resuscitative equipment should be available in anticipation of a physiologically compromised infant. If a funic prolapse is appreciated in the ED, an obstetrician should be notified and the patient prepared for cesarean delivery. Under no circumstance should the membranes be broken. Occult prolapse is rarely appreciated in the ED.

Clinical Pearl

1. Pelvic examination to exclude umbilical cord prolapse should be performed immediately following rupture of membranes, the appearance of variable decelerations, or the detection of bradycardia.

Breech Delivery

Associated Clinical Features

The incidence of singleton breech presentation is approximately 3% but rises to higher than 20% in preterm infants weighing less than 2000 g. In a frank breech, both hips are flexed and both knees extended. In a complete breech, both hips and knees are flexed, whereas a footling breech has one or both legs extended below the buttocks. Frank breech is most common in full-term deliveries, whereas footling presentation can be found in up to half of all preterm deliveries. Breech deliveries carry a much higher mortality rate than cephalic deliveries. Complications of breech delivery include umbilical cord prolapse, nuchal arm obstruction, and difficulty in delivery of the following head (Fig. 10.44).

Figure 10.44

Breech Delivery Footling breech vaginal delivery of the following head. (Courtesy of John O. Boyle, MD.)

Emergency Department Treatment and Disposition

The specific maneuvers for breech extraction are beyond the scope of this text. If breech delivery appears imminent, support and gentle traction should be applied as the various parts spontaneously pass through the vaginal outlet, keeping in mind that the biparietal diameter is greater than either the bitrochanteric or bisacromial diameter.

Clinical Pearl

1. Immediate obstetric consultation should be obtained in all breech deliveries.

Nuchal Cord in Emergency Delivery

Associated Clinical Features

The circumferential wrapping of the umbilical cord around the child's neck occurs in about 20% of all deliveries (Fig. 10.45). Tight approximation of the cord around the infant's neck can lead to transient disruption of uterine blood flow during contractions, leading to variable decelerations noted on the fetal heart rate monitor (Fig. 10.30); it may also impede delivery once the head passes through the introitus.

Figure 10.45

Nuchal Cord A loose nuchal cord is seen around the neck. (Courtesy of William Leninger, MD.)

Emergency Department Treatment and Disposition

Once a cord is identified around the neck, it should be slipped over the head using the index and middle fingers. Occasionally two coils are identified.

Clinical Pearl

1. A loosely applied cord should be pulled over the child's head. If the cord is wrapped too tightly, it can be clamped and ligated on the perineum, followed by the immediate delivery of the shoulders and body.

Shoulder Dystocia in Emergency Delivery

Associated Clinical Features

Shoulder dystocia is defined as failure to deliver the shoulders, following delivery of the head, because of impaction of the fetal shoulders against the pelvic outlet (Fig. 10.46). Risk factors include gestational diabetes, prior delivery of large infants, and postterm delivery.

Figure 10.46

Shoulder Dystocia Firm approximation of the fetal head against the vaginal outlet consistent with shoulder dystocia. (Courtesy of William Leninger, MD.)

Emergency Department Treatment and Disposition

Shoulder dystocia is an acute obstetric emergency, with the immediate life threat being asphyxia from prolonged delivery. An obstetrician should be summoned immediately. Equipment for neonatal resuscitation should be set up and, ideally, a pediatric consultant should be summoned. In the absence of an obstetric consultant, a wide episiotomy should be performed. The least invasive maneuver is to forcefully flex the mother's knees toward her chest (McRobert's maneuver). This extreme dorsal lithotomy position occasionally allows for the appropriate engagement of the fetal shoulders. If this is unsuccessful, a Wood's maneuver can be attempted by hooking two fingers behind the infant's posterior scapula and rotating the entire body in a screwlike manner. As the posterior shoulder rotates upward, it can generally be delivered past the symphysis pubis. If the Wood's maneuver fails to deliver the anterior shoulder, delivery of the posterior arm may be attempted by inserting two fingers into the sacral fossa and bringing down the entire posterior arm by flexing it at the elbow. The remaining anterior shoulder should then deliver, either spontaneously or else following rotation into the oblique position to facilitate its delivery.

Clinical Pearls

1. Shoulder dystocia is an acute obstetric emergency that requires quick action:

Call for help.

Cut a wide episiotomy.

Perform McRobert's maneuver.

Rotate the posterior shoulder.

2. After delivery, look for fracture of the clavicles or humerus and possible brachial plexus injury.

Postpartum Perineal Lacerations

Associated Clinical Features

Lacerations to the perineum occur commonly following a rapid, uncontrolled expulsion of the fetal head. Postpartum perineal lacerations range from minor to severe.

Differential Diagnosis

Perineal lacerations due to birth trauma are categorized into four groups. First-degree lacerations are limited to the mucosa, skin, and superficial subcutaneous and submucosal tissues (Fig. 10.47). Second-degree lacerations penetrate deeper into the superficial fascia and transverse perineal musculature (Fig. 10.48). In addition to these structures, a third-degree laceration disrupts the anal sphincter, whereas a fourth-degree laceration extends into the rectal lumen (Fig. 10.49).

Figure 10.47

First-Degree Laceration First-degree laceration limited to the mucosa, skin, and superficial subcutaneous and submucosal tissues. There is no involvement of the underlying fascia and muscle. (Courtesy of Jerry Van Houdt, MD.)

Figure 10.48

Second-Degree Laceration There is disruption of the hymenal ring and the deep perineal musculature, extending into the vaginal mucosa and transversalis fascia, but no involvement of the anal sphincter or mucosa. (Courtesy of Pamela Ambroz, MD.)

Figure 10.49

Fourth-Degree Laceration Fourth-degree perineal laceration revealing wide separation of the perineal fascia and anal sphincter. The examiner's small finger is in the rectal lumen, showing extension of the tear proximally. (Courtesy of Timothy Jahn, MD.)

Emergency Department Treatment and Disposition

In precipitous ED deliveries, the repair of the episiotomy and/or perineal lacerations can often be performed by the obstetric consultant, the details of repair being beyond the scope of this book.

Clinical Pearl

1. Perineal laceration repair fundamentally involves the sequential anatomic reapproximation, using absorbable suture material, of the rectal mucosa, anal sphincter, transverse perineal musculature, vaginal mucosa, and skin.