Flipping EM: Obstetrics and Gynecology

Welcome to Flipping EM, our flipped classroom case-based learning conference activity! Each conference module we will post clinical cases for your consideration and each learner level (PGY1, 2, 3) will be asked to answer a question about the cases. In order to aid your response, links to journal articles will accompany each question. You will be responsible for reading the articles for your level’s assigned questions and developing an answer to the questions (feel free to seek out other resources as well!). During our scheduled conference time, we will break up into small groups of 6-9 residents (2-3 residents per level in each group) with a faculty facilitator. Each level of learner will discuss their question and corresponding articles and teach the rest of the small group what they learned with the other group members adding their input. Below you will find the cases for this edition which focuses on Obstetrics and Gynecology. Please be prepared to discuss your articles and questions by conference on 10/27/16!

Case #1

18 F c/o lower abdominal pain for several hours. The pain is sharp and waxing and waning in intensity. The patient notes some associated nausea. She denies any vomiting, diarrhea, vaginal discharge, dysuria. The patient is sexually active with one male partner and occasionally uses condoms and denies previous sexually transmitted infection. She admits to having an irregular menses and her LMP was 2 months ago. She has one prior SAb. VS: T= 37C BP=110/65, HR=95, R=18, O2=98%. 

PGY 1: The patient exhibits tenderness to palpation of the lower abdomen without guarding/rebound. Would you perform a pelvic exam on this patient? What is the clinical utility of pelvic exams in the ED? How might findings on the pelvic exam change your management of this patient?

• Does pelvic exam in the emergency department add useful information?

PGY 2: The urine HCG is negative as well as the POC urinalysis. You decide to perform a pelvic exam that shows bilateral adnexal tenderness  as well as cervical motion tenderness without any palpable masses. What is your differential diagnosis at this point? Tubo-ovarian abscess (TOA) is on your differential, what is the best imaging modality to evaluate for a possible TOA?

• Sensitivity of ultrasound for the diagnosis of tubo-ovarian abscess: a case report and literature review. (requires library login)

PGY 3: In addition to considering TOA, you are also concerned about the possibility of ovarian torsion (OT). In general, what factors from the history, physical, and ancillary tests help to identify patients with OT? What aspects of this case increase or decrease your suspicion for OT? What is the management for OT?

• Ovarian torsion: a fifteen-year review. (requires library login)
• Is It Ovarian Torsion? A Systematic Literature Review and Evaluation of Prediction Signs.

Case #2

30 F c/o nausea and vomiting for 5-6 days. She reports more than 10 episodes per day of non-bilious and non-bloody vomitus and is unable to tolerate anything by mouth. The patient denies any fever, diarrhea, dysuria. Her last menstrual period was 2 months ago. She does note some vaginal bleeding that began yesterday associated with some pelvic pain. The patient appears dehydrated; her lower abdomen is non-tender to palpation without any guarding/rebound. Her urine HCG is positive.

VS: T: 37C, BP: 120/80, HR: 100, RR: 18, O2: 100%

PGY 1: What factors differentiate hyperemesis gravidarum from simple vomiting in pregnancy? How would you manage this patient’s nausea and vomiting? Describe your management strategy for vomiting in pregnancy.

• Management of nausea and vomiting in pregnancy. (requires library login)

PGY 2: Remembering the old adage that a pregnant patient should be considered to have an ectopic pregnancy until proven otherwise, you perform a pelvic exam that demonstrates mild to moderate blood in the vault, a closed internal cervical os, and no significant adnexal tenderness to palpation. You grab your trusty ultrasound machine and perform a bedside pelvic ultrasound but are unable to identify a definitive IUP. What is your next step in your workup? Should you check a quantitative HCG level? How would it affect your management?

PGY 3: You decide to discharge the patient with return for repeat evaluation in 48 hours. Should this patient receive anti-D immunoglobulin prior to discharge? What are the indications for anti-D immunoglobulin administration in early pregnancy?

• Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy
• Ectopic pregnancy and miscarriage: diagnosis and initial management

Feel free to utilize additional resources to support your responses and further the discussion of the topics raised in the cases! Please leave any questions or comments below. Thanks!