_OHFP.indb 491 _OHFP.indb 491 30/05/2014 16:18 30/05/2014 16:18 492 CHAPTER 15 Emergency department Overdose emergency Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEAM If GCS \211 8 \200\223 CALL anesthetist Airway Breathing Circulation Disability Drug overdoses are often deliberate but can happen accidentally at home or in a hospital. T he emergency management is the same. 3Call for senior help early if patient unwell or deter iorating. \200 Lie patient down ask a colleague to observe for vomiting and be ready to turn them onto their side Assess respiration RR, O2 sats, O2 requirement, consider blood gas: \200 call anesthetist if poor respiratory eff ort, it will only get worse Assess CVS HR, BP, consider fl uid resuscitation (b p381) \200 Venous access, take bloods : FBC, U+E, LFT, salicylate, paracetamol, glucose, PT/APTT \200 Monitor pulse oximeter, BP cuff , defi brillator ECG leads if unwell \200 Take brief history to establish the medica tion(s), quantity and timing \200 Consult the Toxbase/Poisons service (b p493) for info o n the specifi c overdose Consider gastric lavage if <1h since overdose \200 Examine patient condensed CVS, resp, a bdo and neuro exam \200 Repeat set of observations and ECG \200 Consider: urine toxicology \200 urinary catheter \200 ABG Follow management plan from Toxbase/Poisons service (b p493) If patient deteriorating: \200 call for senior help \200 reassess starting with A, B, C \200 Life-threatening causes Paracetamol \200 Other overdoses b p495 Check Toxbase/Poisons service (b p493) OHFP.indb 492 OHFP.indb 492 30/05/2014 16:18 30/05/2014 16:18 493 OVERDOSE AND DELIBERATE SELF-HARM Overdose and deliberate self-harm 1 Worrying features violent method, intention to die, ongoing wish to die, previous attempts, preparation, concealment. Think about emergency psychosis, acute suicidal intent; common depression, grief, stressful situations, relationship breakdown. Ask about medical medications taken, dose, number of t ablets, time- frame, ingestion of alcohol, symptoms (vomiting, tinnitus, dizziness, abdo pa in), mechanism of injuries; psychiatric events leading to overdose, expected outcome, inten t (eg call for help, to kill themselves), suicide note, extent of planning/preparation (eg spontaneous), circumstances of seeking help, expectation of being found, current intent (eg still suicidal), alcohol intoxication prior to events, recent stresses (relationships, wor k, money, family, legal); PMH previous suicide attempts and methods, psychiatric care, chro nic illness; risk factors for paracetamol toxicity (if paracetamol over- dose, b p495); DH regular medications, alternative medicines (eg St John \200\231s wort), tetanus status, all ergies, alcohol intake, substance abuse; SH who do they live with? Who is at home? Relation ships, family, friends, employment. Obs temp, HR, BP, RR, GCS, glucose. Look for1 medical o rientation, conscious level, pupil size, refl exes, tone, tremor, sweating, agitated, abdo tenderness, sweating, nutritional state; psy- chiatric (mental state examination once medic ally stable and not intoxicated, see b p160) neglect, scars on wrist/forearms, eye contact, withdrawn, abnormal posture or movements, anxiety, paranoia, fl at aff ect, speech form an d content, thought form and content including delusions, percep- tion including hallucinati ons, concentration, memory, insight into actions. See Table 15.19. Investigations2 paraceta mol and salicylate levels in all overdoses (ideally 4h post-overdose); consider blds glucos e, FBC, U+E, LFT, PT/ APTT ECG; ABG. Management2 Severe overdose stabilize the patient acco rding to b p492 and get senior help early. Severe trauma call the trauma team and see b p23 2. Paracetamol see b p495. Other trauma see b p434. Risk assessment (b p494) this determine s the psychiatric management of the patient. Once medical problems are resolved the patient must be discussed with the on-call liaison psychiatrist. They will recommend further in-pa tient psychiatric assessment or discharge home with appro- priate psychiatric follow-up. Ac utely suicidal patients must not leave the hospital without psychiatric assessment. If nece ssary they can be restrained or sedated (b p364) under the Mental Health Act (1983); always seek senior advice and help. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/C G16 2 Guidance on specifi c overdoses can be obtained from the UK National Poisons Informat ion Service at (cid:27)www.toxbase.org (all UK NHS emergency departments should have a logi n). _OHFP.indb 493 _OHFP.indb 493 30/05/2014 16:18 30/05/2014 16:18 494 CHAPTER 15 Emergency department Table 15.19 Features of common overdoses Symptoms and signs Vomiting, iRR, tinnitus, vertigo, sweating Investigations Salicylates (aspirin) Respiratory alkalosis then metabolic acidosis; idglucose, isalicylate levels Acidosis, prol onged PR, QRS and QTc heart block, ventricular dysrhythmias Dysrhythmias, ST depression ( \200\230reverse tick \200\231 shaped, b p259); eff ects more severe if dK+ Respiratory acid osis, opioids on urine toxicology Respiratory acidosis (mixed acidosis if excess alcohol); blood and urine toxicology Urine toxicology; ECG abnormalities (dysrhythmia, ischaemia) Tricyclic antidepressants (TCAs) Digoxin Dilated pupils, blurred vision, seizures, dGCS, dysrhythmia, tachycardia Nausea, confusion, hallucinations, yellow haloes around lights, anorexia Pinpoint pupils, dRR, dGCS dGCS, dBP , dtone, drefl exes Opioids Benzodiazepines, barbiturates, alcohol Ecstasy, amphetamines, cocaine Thirst, confusion, agitation, tremor, dilated pupils iHR, iBP, itemp Assessing risk after suicide attempts This is a diffi cult judgment that requires experienc e; making the wrong decision could result in a preventable death. All cases should be discu ssed with the on-call psychia- trist.The mnemonic \200\230SAD PERSONS \200\231 was origina lly developed to teach medical stu- dents to assess suicide risk; this has been modifi ed i nto a validated scoring system for use in the emergency department setting (Table 15.20).1 It is by no means foolproof; trust your instinct and ask for help if you are in any doubt Table 15.20 Modi \201 ed \200\230SAD PERSONS \200\231 score Sex: Male Age <19yr or >45yr Depressed or hopeless Previous suicide attempts or psychiatric care Excessive alcohol or drug use Rational thinking loss: psychotic or organic illness Se parated, widowed or divorced Organized or serious attempt at suicide No social support Stat ed future intent (determined to repeat or ambivalent) Score +1 Score +1 Score +2 Score +1 Score +1 Score +2 Score +1 Score +2 Score +1 Score +2 Interpreting the score Score <6 Score 6 \200\2238 May be safe to discharge, depending upon circumstances Probably requires psychiatric assess ment Score >8 Likely to need admission and urgent psychiatric assessment Other important risk factors include stressful life-events, unemployment or retire- ment, i dentifying with others who have committed suicide, chronic illness (medical or psychiatric) and availability of lethal weapons or drugs (eg farmers or vets). 1 Hockberger et al. J Emerg Med. 1988 6:99 (subscription required). OHFP.indb 494 OHFP.indb 494 30/05/2014 16:18 30/05/2014 16:18 495 OVERDOSE AND DELIBERATE SELF-HARM Paracetamol overdose Paracetamol is the most widely used analgesic in the UK and the world. It is con- tained in a large number of preparations available over the counter, leading to the potential for both accidental and deliberate overdose. In the UK, paracetamol is the c ommonest drug overdose, and the commonest cause of acute liver failure, but only rarely lea ds to death (approximately 130 deaths and 15 \200\22320 liver transplants a year). Symptoms and signs occur in 3 phases; initially patients may have no specifi c symp- toms, or mild nausea and vomiting; after 24h, RUQ pain evidence of liver failure (iPT iALT iAST); after 3 \200\2235d recovery may begin, or fulminant hepatic failure will develop with coagulopat hy, dblood glucose, encephalopathy and acute kidney injury (hepatorenal syndrome). Investig ations Paracetamol and salicylate levels 4h after overdose or as soon as pos- sible if >4h; less reliable in staggered overdose (tablets taken over >1h) \200\223 begin acetylcystein e regardless; LFT (iALT), U+E, clotting, blood glucose; ABG (pH<7.3 despite adequate fl uid resuscitation predicts mortality). Treatment activated charcoal PO given within 1h if inge stion of >150mg/kg. Acetylcysteine helps replace the substrates necessary to eliminate the toxic prod- ucts formed when normal hepatic metabolism of paracetamol is overwhelmed, and s hould be given to all those with a staggered overdose or a blood paracetamol level above th e treatment threshold on the nomogram in Fig. 15.6. Fig. 15.6 Paracetamol overdose treatment nomogram. Reproduced from Drug Safety Update Septe mber 2012, vol 6, issue 2: A1 MHRA. In adults three doses of acetylcysteine are given: \200 150mg/kg IV infusion in 200ml 5% glucose or 0.9% saline over 1h \200 50mg/kg IV infusion in 500ml 5% glucose or 0.9% salin e over 4h \200 100mg/kg IV infusion in 1000ml 5% glucose or 0.9% saline over 16h. Start t reatment within 8h of ingestion \200\223 do not wait for level if patient presents close t o or after this time. Discontinue treatment if the plasma concentration is later reported a s below the treatment line and patient is asymptomatic with normal LFTs, creatinine and PT. Discuss patients with acidosis, encephalopathy, worsening renal function or PT prolongatio n with hepatologist on call (or at nearest liver center if not available locally) Side eff ects Flushing, rash, pruritus, urticaria, nausea and vomiting are all relatively common dur ing treatment. More severe anaphylactoid reactions (dBP, iHR, bron- chospasm) should be man aged as per b p470 with infusion slowed or stopped. _OHFP.indb 495 _OHFP.indb 495 30/05/2014 16:18 30/05/2014 16:18 496 CHAPTER 15 Emergency department g Vaginal bleeding Worrying features iHR, dBP, weight loss, anemia, abdominal pain, +ve pre gnancy test. g Think about emergency massive bleed, ectopic pregnancy, miscar- riage; common menstruation, dysfunctional uterine bleeding, trauma, ectropion, contraceptive-related, infection, cervi cal or endometrial polyps, malignancy (cervix, uterus, ovaries), foreign body, miscarriage, fi broids, pelvic infl amm atory disease; rare clotting abnormalities, hypo- thyroid. See box and Table 15.20. y Causes of vaginal bleeding Menorrhagia Dysfunctional uterine bleeding, fi broids, endometriosis, polyps, pelvic infl ammatory dise ase, endometrial cancer, IUCD/foreign body, clotting disorder, hypothyroid Ectropion, polyp s, infection, cancer (cervix, uterus), trauma Polyps, ectropion, infection, IUCD/foreign bo dy, pregnancy, hormonal contraception, cancer (cervix, uterus) Postcoital Intermenstrual Postmenopausal 3Endometrial cancer until proven otherwise, other cancer (cervix, ovarian), atrophic vaginitis, infection, polyps Ask about possibility of pregnancy, timing of bleeding (between periods, during periods, af ter intercourse), duration of bleeding, amount of bleeding (pads, tampons, clots, fl ooding ), menstrual pain, eff ect on lifestyle, other vaginal discharge, weight loss, abdo pain, t rauma, dyspareunia (pain during intercourse), lumps; PMH anemia, clot- ting problems, thyro id problems; DH contraceptive pills or injections, IUCD, anticoagulants, aspirin; SH sexual activity; O+GH usual cycle and bleeding, pregnancies, miscarriages, terminations, last sme ar test and result, STIs, date of last menstrual period (LMP). Obs HR, BP, postural BP, RR, temp, pregnancy test. Look for abdo tenderness/guarding, pelvic masses, inguinal lymphad- enopathy, exclude PR bleeding; internal examination (b p156) vulval lesions, size of uterus , uterine masses, adnexal tenderness or masses, presence of blood/discharge; speculum exam (b p157) ulceration, ectropion, bleeding, lumps, prolapse, triple swab if infection is susp ected. Investigations pregnancy test by urinary B-hCG is absolutely essential; consider bld s serum B-hCG, FBC, CRP, clotting, U+E, LFT, TFT; USS pelvis (trans-vaginal). May need diag nostic laparoscopy or hysteroscopy. Treatment \200 Signs of shock call for senior help; resuscitate as for other causes of blood loss (b p478) Positive pregnancy test and abdominal tenderness: assume an ectopic pregnancy (b p498); sec ure two sites of good IV access (gray or bigger), X-match 4 units and contact a gynecologis t immediately Postmenopausal bleeding refer urgently to rule out cancer \200 Otherwise consider likely diagnoses and rule out serious conditions. See Table 15.20. OHFP.indb 496 OHFP.indb 496 30/05/2014 16:18 30/05/2014 16:18 497 VAGINAL BLEEDING Table 15.20 Common causes of vaginal bleeding History Examination Investigations +ve B-hCG; dHb; empty uterus may be seen on USS B-hCG +ve, fetus or empty uterus on USS Ectopic Abdo pain; LMP >4wk, PV bleeding Abdo tenderness peritonism, shock Miscarriage PV bleeding, crampy pain Open/closed os, products of conception Dysfunctional uterine bleeding Menorrhagia Normal Normal Fibroids Menorrhagia Bulky uterus Visible on USS Endometrial cancer Postmenopausal bleeding, abdo pain Usually normal; inguinal lymphadenopathy Thickened endometrium on USS; mass on hysteroscopy Pelvic infl ammatory disease Abdominal pain, vaginal discharge, dyspareunia Abdominal tenderness, foul- smelling discharge +ve cultures Infection Vaginal discharge, itching, foul odor Erythema, swelling, discharge +ve cultures Ectropion/ erosion Intermenstrual or postcoital bleeding; use of OCP or pregnant Red ring or fl are around external os Normal Polyps Intermenstrual or postcoital bleeding Polyp may be visible on speculum examination Polyp on hysteroscopy Cervical cancer Postcoital bleeding, dyspareunia, discharge Mass, ulcer or bleeding cervix Colposcopy and biopsy iCA-125; mass on USS or CT dT4, iTSH Ovarian cancer Lower abdo pain, Adnexal mass, abdominal distension weight loss, bleeding Hypothyroid Constipation, cold intolerance, tiredness, menorrhagia Dry skin, goiter, bradycardia, slow relaxing refl exes Clotting abnormality Family history, bleeding, bruising, joint swelling Bruises, joint swelling or deformity Abnormal clotting or bleeding time Causes of vaginal bleeding covered elsewhere b p500 b p405 b p503 Miscarriage Hypothyroid b p334 Pelvic infl ammatory disease Clotting abnormalities Infection (cervicitis, vaginitis) Infection with candida or STIs (b p465); similar symptoms can be caused by a lack of estrogen (atrophic vaginitis), allergy or foreign body. Symptom s itching, vaginal discharge, dysuria, superfi cial dyspareunia, abnormal odor, small amoun ts of bleeding. Signs vaginal or cervical erythema, swelling, exudates, discharge. Investig ation high vaginal, endocervical and chlamydial swabs. Treatment treat the cause eg antibio tics, antifungals, oestrogens. _OHFP.indb 497 _OHFP.indb 497 30/05/2014 16:18 30/05/2014 16:18 498 CHAPTER 15 Emergency department 3Ectopic pregnancy1 (OHCS8 b p262) A gynecological emergency, usually presenting at 6 \200 \2239wk gestation. Consider this in every woman of child-bearing age presenting with collap se, acute abdominal pain PV bleeding. Symptoms abdominal pain, shoulder tip/back pain, PV bleeding, recent amenorrhoea, dizziness; ruptured ectopic collapse, shock, peritonism. Ris k factors imaternal age, previous ectopic, tubal surgery, previous STIs/PID, IUCD, assisted conception techniques, smoking. Signs abdo unilateral iliac fossa pain (75%) mass (50%); if rupture guarding; iHR dBP; PV bleeding (50%), extreme cervical pain. Investigations b lds B-hCG (serum and urine), FBC, G+S/X-match; trans- vaginal USS fetal sac/pole in the adn exae, free fl uid. Diff erentials miscarriage, appendicitis, pelvic infection, ovarian cyst . Management IV access (14 \200\22316G), IV fl uids and urgent referral to gynae; medical m ethotrexate increasingly used for small (<3.5cm) early ectopics in stable patients surgical laparoscopic/open salpingectomy/ salpingostomy or oophorectomy; send sample for histology. Dysfunctional uterine bleeding Menorrhagia without any detectable abnormality. Symptoms hea vy bleeding during periods only, interfering with daily activ- ities, otherwise well. Signs normal systemic and gynecological exam. Investigations blds may have mild iron defi ciency anemia, otherwise normal. Management tranexamic acid 1g/6h PO or mefenamic acid 500mg/8h P O (both started on the fi rst day of periods and whilst fl ow is heavy), cyclical progester one, combined OCP, Mirena coil; in severe cases endometrial ablation/resection or hystere ctomy may be considered. Cervical ectropion/erosion Temporary extension of the uterine epithelium through the cervic al os into the vagina in response to estrogen eg combined OCP or pregnancy. Symptoms often asymptomatic; intermenstrual bleeding, postcoital bleeding, menorrhagia. Signs red fl are o r ring around the external os on speculum examination. Investigations none required but mus t have usual smear test screens. Treatment usually none, change of contraceptive, cautery/c ryosurgery. Cervical and endometrial polyps Uterine growths that may pass through the external os into the vagina. Symptoms often asymptomatic, menorrhagia, intermenstrual, postcoital or postmen opausal bleeding. Signs may be visible on speculum examination. Investigations hysteroscopy endometrial polyps may be seen; if removed they should be sent for histology, but 99% are benign. Treatment surgical removal with cautery of the base with silver nitrate via speculu m or hysteroscopy. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG154 OHFP.indb 498 OHFP.indb 498 30/05/2014 16:18 30/05/2014 16:18 499 VAGINAL BLEEDING Fibroids (uterine leiomyoma) Benign tumors of the uterine smooth muscle. Symptoms may be as ymptomatic, menorrhagia, prolonged periods, pelvic pain, urinary frequency or incontinence, infertility, abdominal mass. Signs palpable mass on abdominal or vaginal examination, bulk y uterus. Investigations blds may have anemia; visible on pelvic USS. Treatment symptoms im prove after menopause so treatment is often conservative; medical GnRH agonists (eg goserel in, leuprorelin) cause a temporary menopause to shrink the tumor; radiology uterine artery ablation; surgery myomectomy, hysterectomy. Endometrial (uterine) cancer This is common and presents early, so all postmenopausal or ir regular perimenopausal bleeding must be referred to gynecologists. Risk factors age, overwe ight, high fat diet, polycystic ovaries, late menopause, no pregnancies, family history, ta moxifen; OCP is protective. Symptoms postmenopausal or intermenstrual bleeding, menorrhagia , watery vaginal discharge, lower abdo pain, dyspareunia. Signs usually normal unless advan ced. Investigations transvaginal USS to assess endometrial thickness; biopsy via aspiration sampling; hysteroscopy dilation and curettage (D+C). Treatment total abdominal hysterec tomy and bilateral salpingo-oophrectomy radiotherapy or palliative treatment with radioth erapy. Prognosis overall 5yr survival 80%. Cervical cancer Risk factors human papillomavirus, early fi rst intercourse, multiple partn ers, smoking, others STIs, lack of screening. Vaccination against HPV types 16 and 18 is ro utinely off ered to all 12yr-old girls in UK (Cevarix ); predicted to lead to d70% cervica l cancer incidence. Screening all women aged 25 \200\22364yr are off ered screening by cerv ical smear (3yrly from 25 \200\22349yr; 5yrly from 50 \200\22364). Symptoms asymptomatic (a bnormal smear tests); postcoital, intermenstrual or postmenopausal bleeding, dyspareunia, v aginal discharge. Signs ulceration, mass or bleeding on cervix. Investigations colposcopy biopsy; CT/MRI. Treatment low stage (1a) hysterectomy and radiotherapy; high stage (>1b) chemotherapy and radiotherapy. Prognosis overall 5yr survival 65%. Ovarian cancer1 Risk fac tors family history, age, early menarche, late menopause, no pregnancies, infertility, over weight; OCP is protective. Symptoms lower abdo pain (similar to ovarian torsion b p500), we ight loss, bloating, irregular periods, postmenopausal bleeding, urinary fre- quency, const ipation, pain on intercourse. Signs adnexal mass, abdominal distension/mass, ascites, leg o edema, DVT. Investigations blds iCA-125, A-FP, B-hCG; USS or CT abdomen/pelvis. Treatment s urgical removal of all visible tissues (uterus, ovaries, omentum) and chemotherapy. Prognos is usually poor due to late presentation; overall 5yr survival 30%. 1 NICE guidelines avail able at guidance.nice.org.uk/CG122 _OHFP.indb 499 _OHFP.indb 499 30/05/2014 16:18 30/05/2014 16:18 500 CHAPTER 15 Emergency department Gynecological causes of pain 3Consider ectopic pregnancy in every woman of child-bearing ag e pre- senting with collapse, acute abdominal pain and PV bleeding (b p498). Pelvic in \202 ammatory disease (PID) Infection and infl ammation of the upper genital tract commonly with STIs (b p465) eg Chlamydia trachomatis or Neisseria gonorrhoeae. Symptoms lower abdom inal pain (90%), vaginal discharge (75%, may be foul-smelling), intermenstrual/postcoital b leeding (40%), pyrexia (30%), dysuria, dyspareunia, nausea, vomiting, infertility, general malaise. Signs abdomen tenderness; PV adnexal tenderness, cervical excitation. Risk factors young age at fi rst intercourse, multiple sexual partners, no barrier contraception, smoki ng. Diff erential diagnosis appendicitis, endometriosis, ovarian cysts, ectopic pregnancy, other STIs, HIV, urinary tract infection. Investigations MSU; genital swabs (high vaginal, endocervical, Chlamydia) for M,C+S; blds FBC, CRP, cultures; USS (to exclude ovarian cyst). Management IV access for fl uids, analgesia; remove IUCD; antibiotics (eg ceftriaxone 250m g IM STAT, then metronidazole 400mg/12h PO and doxycycline 100mg/12h PO for 14d); refer to GUM for contact tracing. Complications untreated may lead to chronic pelvic pain and infert ility; tubo-ovarian abscess, septicaemia, 2 infertility, ectopic pregnancy. Ovarian cyst/torsion Torsion most commonly occurs with fi bromas and dermoid cysts. Symptom s severe, sudden onset lower abdominal pain, iliac fossa pain radiating to the fl ank, naus ea, vomiting, fever. Signs abdomen tenderness; PV adnexal tenderness. Risk factors developm ental abnormalities, early pregnancy, women under going hormonal stimulation for IVF. Diff erential diagnosis appendicitis, diverticulitis, ectopic pregnancy, urinary tract infection . Investigations urine dipstick MSU; urine and serum B-hCG (to exclude pregnancy/ectopic) ; USS. Management IV access for fl uids, analgesia; laparoscopy if not settling. Complicati ons infection, peritonitis, adhesions, infertility (rare). Endometriosis Endometrial tissue found outside the endometrial cavity that bleeds with the menstrual period; called adenomyosis if in the uterine muscle wall. Symptoms often asymptom atic; painful periods, pelvic pain before/with periods or constantly (adhesions), deep dysp areunia, infertility, rectal pain. Signs generalized pelvic tenderness, fi xed (retroverted ) uterus, palpable nodule on uterosacral ligaments; large uterus in adenomyosis. Investigat ions laparoscopy (though it is a common incidental fi nding). Management medical preventing cyclical hormone changes can shrink ectopic tissue: continuous combined OCP; GnRH agonists (eg goserelin, leuprorelin); surgery laparoscopic laser ablation of ectopic tissue and div ision of adhesions, bilateral salpingo-oopherectomy hysterectomy. OHFP.indb 500 OHFP.indb 500 30/05/2014 16:18 30/05/2014 16:18 501 CONTRACEPTION Contraception Contraception (OHGP3 b p748) Ideally, this should be discussed with both part ners; options include: \200 Barrier methods condoms, caps, diaphragm, femidoms, sponges; condoms reduce transmission of STIs (no other contraceptives have this eff ect) \200 IUCD local progesterone-releasing (Mirena ) or copper-containing plastic device; side eff ects bleeding, pain, pelvic infection, ectopic pregnancies, expulsion Oral contraceptive pill either estrogen and progesterone (combined, COC) or progesterone only (POP); side eff ects acne, bleeding, breast tenderness, bloating, weight gain, mood changes, nausea, DVT/PE \200 Hormones by other routes eg implants (3yr ) and injections (3mth) \200 Sterilization for couples who have completed families; NB ma le sterilization is 10 times more eff ective than female sterilization. Eff ectiveness is usually quoted as the percentage of typical users who would avoid pregnan cy if having regular unprotected intercourse for 1 year. Male sterilization >99.9%, female sterilization 99.7%, Mirena 99.9%, COC 99.7%, POP 99.5%, Depo 99.5%, Implants 99.9%, IUCD 99%, barrier methods 85 \200\22398%, coitus interruptus 70%. Pill checks (OHGP3 b p752) Wo men on the COC or POP need reviews every 3 \200\2236mth: Problems headaches, weight gain, b loating, breakthrough bleeding, depression, acne, breast tenderness, hypertension (check BP ). Education stop smoking, DVT risks (reattend immediately if painful ) swollen leg), mis sed pill rules (see box). g) p ( Advice for missed pills COC if <12h since missed dose, take the pill immediately then at th e usual time; no extra precautions. If >12h take next pill at normal time; alternative cont raception for next 7d, start another pack without a break if due to fi nish pack within 7d. POP if >3h since missed dose, take pill immediately and then take the next dose at the nor mal time; alternative contraception for 7d. If patient develops vomiting or diarrhea whilst on either pill, advise her to use barrier contraception until 7d after resolution of sympt oms. Emergency contraception (OHGP3 b p748) Discuss timings, LMP, risk of PE/migraine, future co ntraception, STI testing. Levonorgestrel available over the counter as a single 1500microgr am tablet within 72h then barrier contraception until next period. Copper IUCD inserted wit hin 5d; more eff ective but infection is a risk so needs STI screen (b p465) and consider p rophylactic antibiotics. Menopause and HRT (OHGP3 b p708) HRT helps alleviate menopausal sy mptoms, including hot fl ushes and vaginal atrophy. Much attention has focused on the irisk of PE/DVT, stroke, breast, ovarian and endometrial cancers associated with HRT usage. In g eneral, HRT should only be prescribed after a discussion of these risks with the patient, a nd then at the lowest eff ective dose for the shortest necessary period of time, with regul ar review. The risks of HRT are summarized in section 6.4.1 of the BNF. _OHFP.indb 501 _OHFP.indb 501 30/05/2014 16:18 30/05/2014 16:18 502 CHAPTER 15 Emergency department Early pregnancy (1st trimester) Diagnosing pregnancy Symptoms missed period, urinary freque ncy, nausea, vomiting, malaise, nipple tingling/itching, breast enlargement. Signs enlarged uterus, cervix looks bluish (venous engorgement). Investigations Urine B-hCG usually posit ive from the fi rst day of the missed period; Serum B-hCG only measure if urine B-hCG is +v e; useful for assessing 1st trimester complications (should increase by >66% every 2d) USS transvaginal yolk sac should be detectable within the endometrium from about 5/40 gestation . Management give the news sensitively, consider who is present (eg relatives), off er cong ratulations if appropriate; start folic acid 0.4mg/24h PO (more if on anticonvulsants); ask GP to refer to antenatal clinic. Health promotion exercise, no smoking or alcohol, no vita min supplements (vitamin A is teratogenic), avoid unpasteurised cheese, shellfi sh and raw eggs (listeria), and cat feces (toxoplasmosis). When to give Anti-D in rhesus (D) \210\222ve women <20/40: Anti-D 250units IM (deltoid) within 72h of the following situations: \200 Ectopic pregnancy \200 Spontaneous miscarriage <12/40 with instrumentation eg EPRC \200 Sponta neous miscarriage >12/40 \200 Threatened miscarriage >12/40 if bleeding persists this is repeated every 6wk until delivery Surgical or medical terminations <20/40 \200 Amniocentesis/chorionic villus sampling (CVS ) \200 Abdominal trauma. >20/40: Anti-D 500units IM (deltoid) within 72h of the following situations: \200 Routinely at 28/40 and 34/40 gestation \200 Antepartum hemorrhage \200 External cephalic version (ECV) attempts \200 Abdominal trauma \200 Delivery of r hesus-positive baby (none if baby rhesus-negative). Table 15.21 Selected NICE obstetric guidelines Topic Web reference Routine antenatal care (cid:27)guidance.nice.org.uk/CG62 Hypertension in pregnancy (cid:27)guidance.nice.org.uk/CG107 Diabetes in pregnancy (cid:27)guidance.nice.org.uk/CG63 Multiple pregnancy (cid:27)guidance.nice.org.uk/CG129 Mental health (cid:27)guidance.nice.org.uk/CG45 Intrapartum care (cid:27)guidance.nice.org.uk/CG55 Caesarian section (cid:27)guidance.nice.org.uk/CG132 Postnatal care (cid:27)guidance.nice.org.uk/CG37 Ectopic pregnancy and miscarriage in early pregnancy (cid:27)guidance.nice.org.uk/CG154 OHFP.indb 502 OHFP.indb 502 30/05/2014 16:18 30/05/2014 16:18 503 EARLY PREGNANCY (1ST TRIMESTER) Miscarriage (Table 15.22) Loss of pregnancy <24/40 gestation. Diff erentials ectopic pregna ncy (b p498), ectropion, infection, polyp. Symptoms vaginal bleeding (may see products of c onception), crampy lower abdominal pain, nausea, vomiting, dizziness. Table 15.22 Types of miscarriage Miscarriage PV \201 ndings USS \201 ndings Threatened Inevitable Missed Incomplete Complete Bleeding, closed os Bleeding, open os None/bleeding Bleeding, open os Bleeding settling Intrauterine pregnancy with heart beat Intrauterine pregnancy with heart beat Intrauterine pregnancy, no heart beat Retained products of conception Empty uterus Signs may be shocked (iHR, dBP); abdominal tenderness suggests ectopic; PV check size of ut erus, exclude adnexal tenderness; speculum open/closed cervical os, clots, products of conc eption. Investigations blds FBC, G+S, B-hCG urine B-hCG USS transvaginal. Management if the re is marked abdo/cervical tenderness exclude an ectopic (b p498) by USS and serial serum B hCG. If shocked insert a gray cannula, fl uid resuscitate (b p472) and remove products of conception from the os (can cause vasovagal); ergometrine 0.5mg IM is given for severe blee ding. Off er all patients analgesia (b p86). \200 Threatened no treatment has demonstrate d any benefi t; bed rest is often suggested but does not aff ect outcome; 25 \200\22350% wi ll abort Inevitable/incomplete the products of conception usually pass without intervention or with mifepristone; surgical removal by ERPC may be considered for pain, bleeding or large quanti ties of tissue in the uterus Missed evacuation of products of conception medically eg mifepristone or surgically by EPRC. ERPC Evacuation of Retained Products of Conception is performed under spinal or general ane sthetic; send evacuated material for karyo- typing and histology. Counseling Off er those a ff ected a chance to ask questions and provide written material for them to take away. Up t o 40% of pregnancies end in miscarriage and of these 80% are due to a fetal abnormality eg chromosomal; it should be stressed that miscarriage is almost never due to the actions of t he mother. Recurrence \211 2 unexplained consecutive miscarriages should prompt investigat ion eg parental karyotypes, karyotype of the products of con- ception, maternal antiphospho lipid antibodies, maternal pelvic USS. Termination of pregnancy (TOP) Patients are referred by GPs or family planning centers. Fut ure contraception should be discussed. Methods medical (<9wk) mifepristone 600mg PO, then 1 mg gemeprost PV 36 \200\22348h later; surgical dilatation and evacuation or vacuum aspirati on. Complications hemorrhage, infection, retained products of conception, uterine perforati on, feelings of guilt, depression. _OHFP.indb 503 _OHFP.indb 503 30/05/2014 16:18 30/05/2014 16:18 504 CHAPTER 15 Emergency department Later pregnancy (2nd/3rd trimester) Table 15.23 Normal ranges in later pregnancy Parameter Range Parameter Range Haematocrit Hemoglobin WCC Platelets ESR Fibrinogen No change 95 \200\223150g/L 5 \200\22316 x 109/l 150 \200\223400 x 109/l 44 \200\223114mm/h 3000 \200\2236200mg/L Albumin Urea Creatinine PaO2 PaCO2 HCO \200\223 3 25 \200\22340g/l 1.6 \200\2236mmol/l 35 \200\22375 mol/l 11.0 \200\22314.0kPa 3.6 \200\223 4.2kPa 18 \200\22323mmol/l Hypertension in pregnancy1 (BP >140/90mmHg) Hypertension occurs in up to 20% of pregnancies ; 90% will be associated with known chronic hypertension, but some women will develop newly iBP, typi- cally after 20/40 gestation (pregnancy-induced or gestational). Pre-eclampsia i s hypertension with development of proteinuria (>0.3g/24h) and may develop from \211 20/40 gestation until 6wk post-partum. Risk factors for pre-eclampsia <18yr or >35yr, fi rst pre gnancy, BMI >30, chronic iBP, DM, SLE, thrombophilia, PMH or FH pre-eclampsia. Symptoms usu ally asymptomatic, headache, vomiting, visual disturbance. Signs evaluate for signs of 2 causes of iBP (b p263) or end-organ damage (b p265); pre-eclampsia: RUQ tenderness, oedema, papilloedema, hyper refl exia, clonus. Investigations urine M,C+S, 24h collection for prot ein (essential if dipstick \211 2+ protein); blds in chronic hypertension ensure secondary causes of hypertension excluded (b p263) and recent screening for baseline evidence of end -organ damage (b p265); if suspect pre-eclampsia: FBC (plts <100 109/l suggests pre-ecla mpsia, ITP or HELLP), U+E, iurate (sensitive but not specifi c for renal damage), LFT, clot ting (for DIC, b p405), G+S. See Table 15.23. Assess the fetus USS (fetus growth, size, pre sentation, liquor volume, fetal movements), umbilical artery Doppler, CTG. Management hyper tension stop any existing treatment with ACEi, ARB or chlorothiazide and refer to antenatal medical clinic for monitoring antihy- pertensive therapy; options include labetalol or Ca2+-channel antagonists; if suspect pre-eclampsia admit treat with IV hydralazine or lab etalol and MgSO4; consider expediting delivery. 3Eclampsia New onset tonic-clonic seizures or unexplained coma during pregnancy or postpartum; usually develops on background of pre-e clampsia. Signs and symptoms headache, hyperrefl exia, clonus, oedema, seizures Management 3Obstetric crash call move into left lateral position, protect airway, 15l/min O2, IV acces s (FBC, U+E, LFT, clotting, G+S), check BP, check glucose; MgSO4 4g over 20min IV, then mai ntenance dose of 2g/h IV; if diastolic >110mmHg give hydralazine or labetalol IV (b p266). Once stabilized, establish close fetal monitoring and consider urgent delivery. After deliv ery treat BP >160/110mmHg (b p266), strict fl uid balance, monitor FBC, U+E, LFT, observe f or \211 5d. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG107 OHFP.indb 504 OHFP.indb 504 30/05/2014 16:18 30/05/2014 16:18 505 LATER PREGNANCY (2ND/3RD TRIMESTER) 3HELLP (Haemolysis, Elevated liver enzymes, Low Platelets) Develops in 10% of cases of seve re pre-eclampsia. Symptoms upper abdominal pain, headache, malaise, vomiting. Signs RUQ ten derness, oedema, iBP. Results dHb, ibilirubin, iALT, dplts, proteinuria. Management resusci tate, FFP/plts/blood transfusion, urgent delivery. Complications DIC, hemorrhage (brain, li ver), eclampsia. Gestational diabetes mellitus (see also b p328) Any degree of glucose into lerance fi rst detected during pregnancy. Screening although some advocate universal screen ing, current NICE guid- ance1,2 is to off er a 2h 75g oral glucose tolerance test (OGTT) at booking to women with: previous gestational DM or baby >4.5kg, BMI >30, 1st-degree relativ e with DM, South Asian, black Caribbean or Middle Eastern ethnicity. Symptoms often asympto matic, glucose on urine dipstick. Signs large for dates, polyhydramnios. Investigations bld s plasma glucose \211 7.8mmol/l after OGTT (b p328); self- monitoring of capillary blood g lucose; regular USS to assess fetal growth. Treatment diet changes and exercise will achiev e good glycaemic control in 80%; start insulin or oral hypoglycaemics after 1 \200\2232wk i f this fails; stop treat- ment after birth and repeat OGTT at 6wk. Complications congenital abnormalities, stillbirth, pre-eclampsia, poly- hydramnios, large baby, traumatic delivery ; neonate birth injury (eg shoulder dystocia, brachial plexus trauma), respiratory distress syndrome, poly- cythaemia, hypoglycaemia, jaundice. 3Antepartum hemorrhage Vaginal bleedin g after 24/40 gestation. Causes placenta praevia, placental abruption; gynae causes see b p 486. Severe bleeding call senior help; lay fl at and elevate legs; O2 (15l/min); secure 2 l arge bore IV cannulae (take blood for FBC, clotting, G+S), 1l 0.9% saline STAT; urgent bloo d (O-negative, type specifi c, or full X-match, b p400); consider urgent delivery. Mild ble eding admit, IV access (FBC, clotting, G+S), monitor HR and BP, PV only if placental site k nown; USS; consider anti-D (b p502). Anemia in pregnancy Screening checked FBC at 12, 28 an d 36wk, treat if Hb <110g/L. Treatment ferrous sulfate 200mg/24h PO and folic acid 0.4mg/24 h PO. Breech presentation Should be noted from antenatal examination and scans. External ce phalic version can be attempted at 37/40 gestation (Rhesus \200\223ve mothers will need an ti-D b p502). Elective Cesarean section is often performed. Gestation >41/40 The risk of st illbirth increases after 42/40 gestation. If the baby has not been delivered by 41/40 then the mother should be seen in antenatal clinic to discuss induction. Induction methods inclu de: \200 Prostaglandin vaginal gel to \200\230ripen \200\231 the cervix \200 Artifi ci al rupture of membranes (AROM, amniotomy) \200 Oxytocin infusion. 1 NICE antenatal care guidelines available at (cid:27)guidance.nice.org.uk/CG62 2. NICE dia betes in pregnancy guidelines available at (cid:27)guidance.nice.org.uk/CG63 _OHFP.indb 505 _OHFP.indb 505 30/05/2014 16:18 30/05/2014 16:18 506 CHAPTER 15 Emergency department Delivery 1 See b p554 for the procedure for normal vaginal delivery. Prematurity Birth <37/ 40 gestation can have serious eff ects on the baby \200\231s survival and risk of disabilit y, especially <32/40. Key components of management of a woman in preterm labor include earl y and close liaison with obstetrics and pediatrics, maternal steroids (beclometasone 12mg/1 2h IM) if 24 \200\22334/40, consideration of tocolytics, consideration of transfer to a hos pital with neo- natal intensive care. Premature rupture of membranes (PROM) Rupture of membranes prior to onset of labor. Beyond 37/40 gestation, delivery should occur within 24h to reduce the risk of maternal/fetal infe ction; consider use of IV oxytocin or vaginal prostaglandin gel to induce labor. If <37/40 gestation, admit for IV antibiotics, close monitoring and specialist consideration of the u se of steroids, and induction of labor. Fetal monitoring \200 Doppler probe listen for decelerations at the end of a contraction \200 CTG (see box) \200 Fetal blood sampling (through a dilated cervix from the fetal s calp) to check for acidosis, representing hypoxia (normal pH >7.25). 3Fetal distress (worrying CTG, abnormal fetal blood sample) may indicate need for urgent de livery.