Grand Rounds - June 1, 2016

Grand Rounds June 1st:

• Intern Board Review with Marie-Eve
• Sepsis Update with Alex
• Nausea & Vomiting in Pregnancy by Jared
• Evidence-Based Updates by Dr. Pourmand
• The Pelvic Exam by Annabel
• Specialty Conference: Ob/Gyn - by Michelle and Dr. Anna BuAbbud, chief Ob/Gyn resident
  

Board Review: Ob/Gyn by Marie-Eve

HELLP Syndrome

• increased risk of intracranial bleeding
• criteria for Preeclampsia: BP >140/90 beyond 20weeks gestation, severe preeclampsia BP >160/110
• tx: Mg and antihypertensives

Endometritis

• sx: fever, abd pain, foul-smelling, profuse blody d/x, uterine and adneal tenderness
• cesarean (70%)

Tubo-ovarian Abscess

• polymicrobial: chlamydia, gonorrhea, gram neg orgs, anaerobes
• mgmt: IV abx (amp, gent, clinda)
• • if >10cm -> drain

Post-Partum Cardiomyopathy/Pericarditis

• rare, but mortality as high as 30%
• clinical presentation similar to CHF
• mgmt: inotropes, after load reduction (hydralazine and labetalol), rest
• on echo, all 4 chambes enlarged with decreased systolic LV dysfunction
• RF: maternal age, multi-parity, twin pregnancies

Spontaneous Abortion

• up to 80% of women with first trimester SAB complete the abortion without intervention
• threatened AB should avoid anything in the vagina temporarily
• Rhogam - anytime RH - pt exposed to fetal bleeding (if father Rh + or unkown)
• • 50 ug in first trimester
  • 300 ug after first trimester (counteracts up to 15mL RBCs or 30mL whole blood)

Kleihaur-Betke Test (KBT)

• detects fetal cells in maternal circulation
• not sensitive - requires 5mL of fetal cells (as little as 0.1mL can sensitize the mother)
• KBT not useful in most pregnancies, but can help if >30mL

Fetal Heart Monitoring

• VEAL
• CHOP
• • Variable decels - Cord compression
  • Early decels - Head compression
  • Accelerations - (normal)
  • Late decels - Placental/uteroplacental insufficiency

Ulcerative STDs

• HSV 2
• • multiple small grouped vesicles, shallow ulcers, recurr, painful
  • can have lymphnode involvement
  • dx by cx of PCR
  • mgmt: first episode - Acyclovir 400mg PO TID 7-10 days
  • • can also take suppressive therapy
• Syphilis
• • treponema pallidum
  • indurated, sharply demarcated with red smooth base, not painful
  • firm, rubbery lymph nodes
  • dx: dark field exam (scrap lesion or use fluid)
  • • serology for screening: RPR, then confirm with MHA-TP or FTA-ABS
  • tx: Penicillin G, one time does of 2.4 mil units IM (must be long-acting!)
• Chancroid
• • hemophilus ducreyi
  • irregular, sharply demarcated, painful
  • tx: ...
• Lymphogranuloma Venerum
• • chlamydia
  • usually single lesion, papule, or ulcer, transient, frequently not noticed, not painful. lymph nodes unilateral, firm, tender, fized, may form fistulas
  • tx: Doxy or erythromycin x 21 days
• Granuloma Inguinale
• • Klebsiella, chronic, hard, irrgular, clea-based granulomatous ulcer, highly vascular and bleed easily, not painful. no lymph node involvement. 

Vulvovaginitis

• Bacterial Vaginosis: tx: Metronidazole x 7 days
• Trichomonas: dx on wet mount, Metronidazole
• Candida: white, curdy discharge, budding and hyphae. Fluconazole 150mg PO x 1 or intravginal agents. oral -azoles contraindicated in pregnancy

Bartholin's Gland Cyst

• typically polymicrobial
• tx: Word catheter should be placed for 6-8 weeks (2-4 weeks in other sources?)
• • drainage by fistulization or marsupializataion
  • local anesthesia, scapel incision, break up septations with hemostat, place cathether (fill with 2-3mL of saline)
  • once, drained, abx not of value unless surrounding cellulitis
• located at 5 and 7 o'clock, normally NOT palpable
• older women should have elective excision b/c more likely to be adenocarcinoma

Shoulder Dystocia

• tx:
• • can be relieved by extreme lithotomy position (McRobert maneuver)
  • apply moderate suprapubic traction and apply moderate traction to fetal head
  • can drain bladder with foley to create more room
  • episiotomy
• RFs: fetal macrosomia, GD
• fetal complicationsL brachiala plexus injuries, clavicle fxs, cord compression

Earliest Sign of Pregnancy

• gestational sac
• • can be seen at level of BhCG 1,500 for TVUS and 6,500 for TAUS
• double decidual sign is gestational sack with ecogenic outer...
• yolk sac - first structure seen WITHIN gestational sac
• • first definitive evidence of IUP
• fetal pole - seen after yolk sac. once reaches 0.5cm, cardiac activity should be seen

Sepsis Update by Alex

Mortality from sepsis has decreased to 5%, which is the 5th percentile nationally. In pts with septic shock, studies show that each hour of delay of abx was a/q decrease in survival of 7.6%. 80% survival if abx w'in first hour

• Algorithm
• • triage nurse identifies 2 SIRS and possible source
  • calls Senior Resident of Attending, who evaluates
  • bundle to be initiated in 15 minutes
• UHS 3+ SIRS criteria, no organ dysfunction = sepsis
• Improved time to abx, but still avg 160 mins
• 22% of pts who fire sepsis sun have final dx of sepsis (picks up all severe sepsis and septic shock)
• time from abx order to admin ~60 mins
• • reasons for delay: most have delay in IV access, 1 with delay in blood culture, 1 with vancomycin given first

Sepsis 3.0 (Third International Consensus Definitions for Sepsis and Septic Shock)

• • sepsis - organ dysfunction caused by dysregulated host response to infection
  • • organ dysfunction = SOFA >=2 (many variables, better for ICU, made to be mortality predictor)
    • in-hospital mortality 10%
  • septic shock...
  • screening with q-SOFA
  • • resp >= 22
    • AMS
    • SBP <= 100

Nausea and Vomiting during Pregnancy

DDx:

• • NVP usually manifest <9 weeks GA
  • if >9 weeks, consider appy, choley, pyelo, DKA< preeclampsia
  • ROS: abd pain, fever, hepatitis, goiter
• Hyperemesis Gravidarum
• • prevalence 0.3-3% of all pregnancy
  • no criteria, look for electrolyte abnormalities
• maternal complications:
• • Wernicke's, splenic avulsion, esophageal rupture, PTX, ATN, psyclsocial impact

Treatment

• • assess for dehydration, IVF PRN
  • treat pt's view of condition
  • first line: B-6: 10-25mg Q8H
  • • plus doxylamine
    • combined pill previously accused of birth defects, but subequently exonerated
    • • now reissued as Diclegis (10mg/10mg)
      • reduced sx from 49% to 33% - clinically significant
    • very expensive: can try combining OTC B6 and doxylamine (anecdotally, another resident's wife had bad NVP and OTC didn't help but Diclegis did)
  • Zofran 4-8mg ODT Q6H
  • • watch for prolonged QTc
    • serotonin syndrome - use cautiously in pts taking SSRIs
    • HA, weakness, drowsiness (less than others)
    • one study showed increased risk of fetal cardiac septal defect
    • ACOG says it is category B
  • Phenergan (promethezine)
  • • 12.5-25mg PO or IM Q4-6H (do not given IV, a/w tissue necrosis)
    • SEs: dry mouth, sedation
    • category C
  • Reglan
  • • 10mg IM or PO Q6H
    • SEs: tardive dyskinesia
    • • avoid high doses or treatment for >12 weeks
    • category B
  • Other
  • • Benadryl
    • Tigan
    • Dramamine
    • Mecliine
    • NO SCOPALAMINE - a/w teratogenicity
    • Steroids last resort b/c can cause increased rate of cleft palate
  • Non-pharma options
  • • multivitamins 3 months prior to preg, a/w decreased incidence
    • ginger capsules shown to reduce N but not V
    • dietary modifications
    • • small meals
      • avoid spicy fatty foods
      • eating more protein
    • avoid sensory stimuli
    • psychotherapy does not help
    • accupuncture :(
• Dispo:  admit if AMS, can't tolerate liquids, ketonuria, unstable VS

Evidence-Based Update

"Does This Patient With Chest Pain Have Acute Coronary Syndrome?" systematic review in JAMA Nov, 2015

• 10% of pts with CP in ED have ACS
• Accuracy of clinical exam in dx of ACS
• • radiation to both arms - 96% specificity; LR 2.6
  • pain similar to prior ischemnia - 79% specificity, LR 2.2
  • RFs: hx of abnl prior stress test and PAD most important (fam hx, tobacco use not as significant)
  • PE: HTN, rales, tachypnea, tachycardia most important
  • EKG findings: STD, ischemic EKG, TWI
  • decision rules: HEART misses 2.9%, TIMI misses 4.4% of ACS

"Postural modification to the standard Valsalva maneuver in SVT" Lancet 2015

• cardioversion in clinical practice 5-20% (ACLS Guideline 2010 says 25%)
• pts blew at 40mmHG for 15 seconds, then laid supine with leg elevation
• 43% using modified maneuver converted
• CEs: unstable c-spine, hip dislocation
• no reported serious SEs

"A Randomized Controlled Noniferiority Trial of Single Dose Oral Dexamethazone vs 5 Days of Oral Prenisone for Acute Adult Asthma" Annals of EM 2015

• 12mg dex vs 5 days of 60mg pred
• similar or slightly inferior to dex

The Pelvic Exam

Undifferentiated Abdominal Pain (not pregnant)

• Torsion
• • 29% had NO tenderness on pelvic exam
  • 53% had NO palpable mass on pelvic exam
• PID
• • tenderness on bimanual exam
  • • sensitivity 91-99%
    • low specificity - max 20%
  • CDC recs empiric tx for sexually active woman w pelvic/abd pain and pelvic tenderness (CMT, adnexal, or uterine) and no other explanation
  • cultures?
  • • self-collected vaginal swabs are equal in sensitivity and specificity to clinician collected

First Trimester Abdominal Pain/Bleeding

• DDx:
• • Ectopic
  • • pelvic exam is not that sensitive:
    • • CMT - OR 3.3 (45% had this)
      • lateral or bilateral adnexal tenderness - OR 2.4 (61% had this)
      • adnexal mass - OR 2.2 (14% had this)
    • still need U/S
  • Abortion
  • Normal IUP
  • Abnormal IUP
  • Trauma/Cervical lesion
• Can you skip the pelvic if pt is getting U/S?
• • No change in mgmt when U/S shows IUP
  • • TVUS can predict cervical length and open/closed os (put in comments, "Please assess cervix")
    • consider self-collected specimen for STD testing
    • still need to r/o active/massive hemorrhage
  • If TVUS indeterminate, need pelvic exam for tenderness and open/closed os
  • • tenderness keeps ectopic on ddx
  • Study at GW Brown et al in Western Journal of Emergency Medicine 2011
  • • 6% of pts with findings on pelvic exam that changed mgmt
• On study in Western Journal of Medicine 2001 showed that "The findings of bimanual pelvis examinations performed by emergency physicians are unreliable." Previous studies show the ob/gyn practitioners have similar degree of unreliability

Specialty Conference

Specialty Conference: Ob/Gyn - by Michelle and Dr. Anna BuAbbud, chief Ob/Gyn resident
First Trimester Vaginal Bleeding/Pain

• exam: abdominal exam for peritoneal signs
• pelvic exam: os opened or closed? clots? POC?
• TVUS - should see something if beta >3000 (upper discriminatory zone)
• indeterminate: non-specific fluid collection, gestational sac with no yolk sac, echogenic material, enlarged cul-de-sac
• Patient counseling:
• • worsening pain, bleeding, fever
  • "pelvic rest" to reduce risk of infection to reduce risk of infection (and guilt)
  • emotional support (not their fault, would have happened anyway, usually genetic problem with baby, 1 in 3 early pregnancies result in miscarriage)
• ACEP guidelines:
• • even if beta is below discriminatory zone, get pelvic U/S (can have ectopic even if beta is low)
  • if TVUS is indeterminate, DO NOT use beta value to EXCLUDE ectopic
  • • obtain specialty consultation or close outpatient f/u for all pts with indeterminate U/S

Consulting Ob/GYN

• Useful information before calling:
• • Age, G's and P's
  • Where they are seen?
  • How many pads filling with blood?
  • LMP
  • VS
  • blood type
  • beta level
  • pelvic exam
  • U/S results
• Should we do a pelvic if you're likely going to?
• • highly variable, ok to ask
  • make sure to do it if brisk bleeding - removal of POC from OS can stop bleeding
  • • use ring forceps and keep for pathology
• What happens when we call to put someone in the "beta book"?
• • new policy that ob/gyn resident needs to come down and see pt
• What triggers surgical tx of ectopic?
• • unstable/abnl vitals
  • low Hct
  • possibly for unreliable pt
  • heart beat in tube
• Ob/Gyn clinic does take Medicaid but does not take uninsured pts (they can go to Unity or Planned Parenthood)

Pregnancy Induced Hypertension

• gestational HTN (after 20 weeks): >140/90, resolves postpartum
• preeclampsia
• • vasospastic disease
  • gestational HTN +proteinuria (or AMS, signs of end-organ damage: elevated LFTs, RUQ TTP, thrombocytopenia, headaches, visual changes)
  • spot urine protein to creatinine ratio (24 hour protein collection no longer needed)
  • • cutoff 0.3
  • cure is delivery of placenta
• HELLP
• • hemolysis
  • elevated liver enzymes
  • low platelets (<100,000)
  • Pt/Ptt/fibrinogen - normal
• Eclampsia
• • preeclampsia + seizure
  • don't forget to feel for fundus if unknown PMH and pt unable to provide
  • increased total leukocyte count, creatinine, or AST - a/w increased morbidity
  • can happen up to 6 weeks postpartum
  • MC sx is headache - remember to ask if they have new infant at home if BP is >140/90
  • testing:
  • • fetal monitoring
    • CBC, BMP, LFT, coags, Mg, (UA, U Cr, U prot), [LDH, uric acid - can be added on to CMP]
    • if seizures, check blood glucose
    • if no hx of preeclampsia or refractory seizures -> CT head
  • Mgmt:
  • • Mild/Moderate
    • • close f/u
      • accurate gestational age on U/S
      • bed rest to reduce BP, allow pregression of pregnancy
      • hospitalization if BP >140/90
    • Severe (BP >160/110)
    • • control seizures -> Mg sulfate (6g over 10-15 minutes, then 1-2g/hr)
      • • watch for hypotension, but expect it - it's one of hte goals
      • control BP if DBP >105
      • • hydralazine or labetalol
        • DO NOT USE ACEI
      • maintain UOP <25mL/hr
      • limit IVF
      • avoid diuretics, hyperosmotic agents
      • CT head if AMS, persistent seizures, lateralization
      • delivery baby
    • Imaging as needed
    • • give pts ACR handout on radiation in pregnancy and lactation

Fetal Monitoring

• blunt body trauma
• • preg >24 weeks -> send for 4hrs of fetal monitoring if no other treatment needed
  • preg <20 weeks -> fetus not viable, no monitoring indicated as no obstetric intervention will alter outcome

Medications

• NSAIDs - increase risk of spontaneous abortions, birth defects, neonatal pHTN, fetal death
• opiates ok until nearing delivery
• usual RSI meds ok or unknown
• • just do it if needed
  • previously considered avoiding propofol for possibly fetal hypotension
• no fluoroquinolones, tetracyclines
• cephalosporins, penicillins ok
• nitrofurantoin CI'd in 3rd trimester (theoretic risk if fetus has G^PD)
• metronidazole contraindicated in 1st T
• cardiac and neuro meds are often class C or D
• Phenylephrine is vasopressor of choice

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