Genitourinary and Obstetric/Gynecologic Emergencies
What to know
Obstetric emergencies require knowledge of normal pregnancy physiology: plasma volume rises, blood pressure is lower, heart rate is higher, and dilutional anemia is expected. Ectopic pregnancy is the leading cause of first-trimester maternal death; a positive quantitative hCG with an empty uterus and an adnexal mass is concerning. Preeclampsia is new hypertension after 20 weeks with proteinuria or end-organ dysfunction; magnesium sulfate prevents and treats seizures, while labetalol, hydralazine, or nifedipine control blood pressure. Placenta previa causes painless vaginal bleeding - no digital examination. Abruption causes painful bleeding with a rigid uterus. Postpartum hemorrhage is usually uterine atony; treat with fundal massage and oxytocin. Cord prolapse requires relieving pressure and emergent delivery. Also know testicular and ovarian torsion as surgical emergencies.
Traps
Magnesium toxicity shows loss of deep tendon reflexes, respiratory depression, and oliguria; the antidote is calcium gluconate. Place the pregnant patient in a left lateral tilt to relieve inferior vena cava compression. Do not exclude ectopic pregnancy with a urine test alone. A blood pressure in the normal range may still be elevated for that patient.
Worked example
A 34-week pregnant patient has painless vaginal bleeding and a soft uterus. Do not perform a digital examination; obtain ultrasound, place IV access, and prepare for possible delivery. Rule of thumb: painless bleeding means previa until imaging says otherwise.