Obstetrical/Gynecology ER

presentations
KHMH Strengthening Emergency Care in Belize
December 2022

With special thanks to:

Dr Brighid Cassidy, BSc(Kin), MD, CCFP-EM
Clinical Assistant Professor, Emergency Medicine,
University of British Columbia
Emergency Physician, Lions Gate Hospital
 ER Gynecolgy
Vaginitis

Cervicitis

Pelvic Inflammatory Disease

Genital Ulcers

Genital Warts

Bartholin Cysts and Abscesses

Pelvic Pain

Vaginal Bleeding

Sexual Assault
 Vaginitis

definition: vaginal disorders caused by infection,

inflammation or changes in vaginal flora.

symptoms: itching, discharge, odor discomfort

most common causes: bacterial vaginosis,

trichomonas, candida
 Vaginitis
Bacterial vaginosis: polymicrobial, overgrowth of normal
vaginal flora

not specifically sexually transmitted

in preg, increased risk of PROM, PTL, Postpartum

endometritis

sx: ++ watery d/c, + odor, not purulent usually

dx: spec exam - greyish + odorous (amine) d/c, clue cells,

pH > 4.5

rx: metronidazole (PV*/PO), clindamycin, recurrence rates

high, not need to treat partners
 Vaginitis
Trichomonas: anareobic flagellated protozoan. Is
sexually transmitted

asymptomatic in men, often cervicitis in women,

co-infection with GC up to 50%

in preg: PTL, PROM, post-partum endometritis

dx: frothy d/c (not always), “strawberry cervix”,

slides - motile trichomonads, KOH prep - amine
odor, also send CT/GC

Rx - metronidazole (PO/PV*), in preg Rx

symptomatic woman only, treat partners
 Vaginitis
Candida albicans: fungal infection

predisposing: preg, immunosuppression, abx, OCP,

steroids, DM, Luteal phase, clothing, not STI

presentation: itchy, burning sensation, thicker

whitish d/c, min odour

Dx: spec - white thick d/c, vulvar erythema, no

abdo/adnexal pain, KOH - pseudohyphae

rx: antifungals topical or PO (diflucan 150mg po x

1 dose), preg treat topically.
 Cervicitis
Definition: cervix inflammation (infectious or
noninfectious)

Worrisome pathogens are Chlamydia and

Gonorrhea

Can progress to Pelvic Inflammatory Disease

 Cervicitis
Neisseria Gonorrhea (GC): gram-neg intracellular
diplococci

5 patterns:

asymptomatic

cervicitis

PID

Disseminated disease – Gonococemia

Opthalmitis
 Cervicitis - GC

presentation: purulent endocervical discharge,

lower abdo pain, usually symptoms soon after
menses start

dx: clinical suspicion, cultures, PCR more sensitive

rx : ceftriaxone, cefixime ?, azithromycin, avoid

quinolones, co-treat for chlamydia

test of cure, partner test/treat, investigate for other

STI
 Cervicitis - CT
Chlamydia Trachomatis: obligate intracellular
parasite

most common STI

5 patterns:
asymptomatic
urethral syndrome (pyuria without bacteria)
cervicitis
PID
Lymphogranuloma Venereum: small painless
vesicles, which ulcerate, tender ulcerated
inguinal LA
 Cervicitis - CT
dx: Culture, PCR

rx:

urethritis/cervitis - doxy or azithromycin

preg - azithromycin or amoxicillin

LGV - doxy for 21d

treat partner, test of cure, investigate other STI

 PID
Pelvic Inflammatory Disease: syndrome due to
ascent of microorganism from vagina and cvx
to:

endometrium - endometritis

fallopian tubes - salpingitis/abscess

ovaries - oophoritis/abscess

can progress to sepsis

usually GC/CT, often polymicrobial

 PID
Risk Factors

prev hx PID

mult partners/sex trade

IUD

adolescence, majority cases 15-25yo

instrumentation of uterus
 PID
SYMPTOMS

lower abdo pain - often bilateral

purulent vaginal d/c

abnormal vaginal bleeding

fever and malaise, nx, anorexia

often shortly after menses

dysuria w/o frequency or urgency

 PID
physical findings:

lower abdo/adnexal tenderness

Cervical motion tenderness (CMT) - chandelier

sign

adnexal mass possible if tubo-ovarian abscess

purulent cervical discharge often

fever
 PID
CDC minimum criteria:

CMT

OR adnexal/uterine tenderness

pt with lower abdo/pelvic pain, at risk for STI and NO other cause identified

Other supporting criteria:

abnormal d/c

leukocytosis in vaginal secretions

fever

elevated inflammatory markers

pus seen on laparoscopy

 PID
Testing:

gram stain

c and S

PCR - more sensitive

urine (first catch) or swabs

assess for pregnancy - preferable serum beta-

hcg

CBC - leukocytosis - not sens or spec

Pelvic US
 PID
Complications:

chronic pelvic pain

dyspaerunia

infertility

ectopic pregnancy

tubo-ovarian abscess

fitz hugh curtis syndrome

 PID
Treatment:
high rate of co-infection - treat for GC and CT

indications for admx:

? tubo-ovarian abscess
sepsis / toxic
? pregnancy
unable to take po fluids
Fitz hugh curtis syndrome
failed outpt therapy, unreliable for followup, unsafe home enviro,
minor.
 PID
Inpatient management:

ceftriaxone or cefoxitin or cefotetan IV

treat with doxy po

alternative clindamycin IV AND gentamycin

IV, or

ampicillin/sulbactam IV AND po doxy

 PID
Outpatient Management:

ceftriaxone 250mg IM x1 + doxycycline 100mg po bid x

14d +/- flagyl 500mg po bid

cefoxitin 2gm IM + 1gm po probenicid + doxy 100mg po

bid x 14d +/- flagyl 500mg po bid

d/c info:

no sexual activity until all partners are treated and test

of cure, ensure contact info for followup, ? refer to
public health
 Genital Ulcers
Herpes Simplex

high prevalence of HSV-1 and -2

spread primarily through sexual contact

after 1st attack, virus stays dormant in dorsal

nerve root ganglia of affected site

viral disease then reactivated in up to 50% by

emotional and physical stress
 Genital Ulcers
Presentation:

Primary: within 3-7 d of contact with virus

pain at site, fever, malaise, myalgias, sore throat

tender, nonfluctuant, bilateral inguinal LA

2-4mm clear fluid vesicles, rupture then form small

ulceration.

lasts 2-6 weeks

 Genital Ulcers
Presentation cont’d

Recurrence:

up to 50%

tingling or pruritis at site before rash

usually LESS painful and lesser systemic

illness, less lymphadenopathy

duration is usually SHORTER than primary

infection
 Genital Ulcers
Diagnosis:

classic lesions

viral cultures and PCR

Treatment:

symptomatic

Primary: acyclovir, famcyclovir, or valcyclovir

Recurrence: same - shorter duration

Counselling, safer sexual practices and partner

discussion.
 Genital Ulcers
Chancre:

smooth, painless ulcer at site of innoculation of primary

syphilis

primary: 3 week incubation period

secondary: 4-10wks post primary chancre, macular pink

rash on trunk, extremities, palms/sores, condylomata
lata at intertrig areas, fever/malaise, LA, mucous
patches

latent: + labs, asymptomatic

tertiary: 10yr after initial chancre, neurosyphilis, CV,

auditory, ophthalmic and gummatous disease
 Genital Ulcers
Syphilis cont’d

Diagnosis:

WEAR gloves

non-treponemal serology (RPR, VDRL)

treponemal test ( ANTIBODY TEST)

 Genital Ulcers
Syphilis cont:

Diagnosis:

1*, 2* or latent (<1yr)- PCN G 2.4million U IM

PCN allergy - doxy/tetracycline po x 14 days

3* or latent (>1yr) - PCN ^ 2.4 million U IM q wk x 3

weeks.

PCN allergy - doxy/tetracycine po x 28 days

Neurosyphilis - PCN G 3-4 million U IVq4h x 10-14d

 Genital Ulcers

Chancroid (H. Ducreyi)

painFUL genital ulcers, ing LA

r/o HSV and syphilis

Azithromycin 1g po x 1 or ceftriaxone 250mg

IM x 1 or erythromycin 500mg po tid x 7d or
cipro 500mg po bid x 3 days
 Genital Warts
Condyloma Acuminata

HPV, painless, STI

associated with cervical neoplasia,

dx: biopsy, check for co-infxn

Rx: cryo, laser, imiquimod,

Condyloma Lata

warty lesion caused by syphilis, smoother,

wetter
 Bartholin Abscess
++ Painful

I and D in dept, consideration Word catheter