Category: Obstetrics and Gynecology

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All breast complaints are cancer until proven otherwise!!!

History

• Increased risk of breast cancer
  • Family history of breast cancer (especially 1st degree)
  • Delayed childbearing (no children until after 30)
  • Age >50
• Associated with menstrual cycle

Exam

• Asymmetric appearance of breasts
• Palpable mass
  • Red Flags
    • Non-mobile
    • Overlying skin changes
    • Lymphadenopathy
    • Located in upper/outer quadrant of breast

Differential Diagnoses

• Red/inflamed/painful breast
  • Postpartum engorgement
    • Treat with warm compresses, continue breastfeeding/pumping, massage
  • Infection (“Mastitis”)
    • Treat with antibiotics and continue breastfeeding
  • Abscess
    • Treat with needle aspiration
    • Refer to breast surgeon
• Non-inflamed breast pain
  • Fibrocystic changes
    • Associated with menses
    • Treat with supportive bra
• Breast mass
  • Fibroadenoma
    • Slippery/mobile
  • Fibrocystic changes
• Nipple discharge
  • Red flags
    • Unilateral discharge
    • Bloody discharge

Additional Reading

• Breast Cancer Screening Guidelines (CDC)

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Common Causes

• Structural
  • Cancer
  • Post-menopausal bleeding is cancer until proven otherwise
  • Fibroids
  • Adenomyosis
  • Polyps
• Coagulopathy
  • Present in approximately 20% of non-pregnant vaginal bleeding
  • Most common = Von Willebrand Disease
• Hormonal causes
  • Dysfunctional uterine bleeding

Basic Approach to Non-Pregnant Vaginal Bleeding

• Step 1: Pelvic exam
  • The utility of this is debated
  • It is best to sound thorough on your clerkship
  • Have a chaperone present and document this (include the chaperones name)
• Step 2: Obtain Labs
  • CBC
    • Anemia?
    • Thrombocytopenia?
  • Coags
    • aPTT is prolonged in 50% of patients with Von Willebrand Disease!
  • Thyroid (TSH)
    • Can be obtained outpatient
    • Common cause of hormonal related vaginal bleeding
• Step 3: Pelvic ultrasound
  • Evaluates for ANATOMIC causes of vaginal bleeding
• Step 4: NSAIDS
  • This treats both abdominal pain/cramping
  • Also improves bleeding
• Step 5: Oral contraceptive pills
  • Can be started on an outpatient basis
  • Useful in patients with hormonal/dysfunctional uterine bleeding
    • Stabilizes endometrial lining

Additional Reading

• NBME Shelf Review: OBGYN (EM Clerkship)
• Non-Pregnant Vaginal Bleeding (WikiEM)

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The pregnancy test is the most important test in females of reproductive age!

Five Important Tests in 1st Trimester Vaginal Bleeding

• CBC
  • Hemoglobin/Hematocrit
    • Mild anemia in pregnancy is physiologic and normal
  • Thrombocytopenia
• Type and Screen
  • Required for blood transfusion
  • Determines if patient needs RhoGAM
    • Rho(D) immune globulin
      • Binds fetal Rh antigens from a fetus so that mother doesn’t develop antibodies against future Rh positive children
      • Prevents hemolytic disease of the newborn
      • Give to Rh negative mothers to protect future Rh positive children
• Quantitative hCG
  • hCG >1500
    • “Cutoff” where definitive pregnancy should be seen on ultrasound
    • If no pregnancy is seen, highly concerning for ectopic pregnancy
  • hCG <1500
    • Ectopic pregnancy still possible
    • Common for healthy early pregnancies to not be visualized below this level
• Urinalysis (UA)
  • Treat asymptomatic bacteriuria in pregnant patients
    • One of the only times UTI should be treated in asymptomatic patients
    • Theoretical increased risk of miscarriage
• Pelvic ultrasound
  • Evaluates for ectopic pregnancy
  • Subchorionic hemorrhage
  • Miscarriage

Additional Reading

• Ectopic Pregnancy (EM Clerkship)

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Never ignore a pregnant woman’s blood pressure.

Introduction

• Pre-Eclampsia
  • Pathophysiology unknown
  • Pregnancy induced multi-organ dysfunction
  • Definition
    • Pregnancy
      • PLUS
    • BP 135/85
      • PLUS
    • Proteinuria
• Eclampsia
  • Preeclampsia
  • PLUS
  • Seizures
• HELLP Syndrome
  • Preeclampsia
  • PLUS
  • Hemolysis
  • PLUS
  • Elevated liver enzymes
  • PLUS
  • Low platelets

Step 1: Evaluate For Four Big Symptoms

• Swelling/edema
• Headache
• Visual changes
• Abdominal pain

Step 2: Testing

• Urinalysis
  • Proteinuria
• CBC
  • Hemolysis
  • Thrombocytopenia
• Electrolytes
• Liver function tests

Step 3: Start Magnesium

• Hypomagnesemia = Hyporeflexia

Step 4: Control the Blood Pressure

• Hydralazine
• Labetalol

Step 5: Admit

• OB emergency
• All patients need fetal monitoring

Additional Reading

• Round 2 – Seizure (EM Clerkship)
• Preeclampsia and High Blood Pressure During Pregnancy (ACOG)