Paula C. Brady1 and Michelle R. Davis2
(1)
Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, MA, USA
(2)
Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, MA, USA
Paula C. Brady (Corresponding author)
Email: Pbrady2@partners.org
Michelle R. Davis
Email: mdavis31@partners.org
Keywords
Vaginal hemorrhageChest painAltered mental statusPostoperative complicationsPostoperative infectionPelvic painEmergency contraception
Patient calls to a gynecologist—including subspecialists in minimally invasive surgery, gynecologic oncology, urogynecology, family planning, and reproductive endocrinology—include but are not limited to the following issues. Whenever a patient’s complaints are difficult to parse over the phone but are concerning for any reason, urgent assessment is recommended in the emergency department, urgent care clinic, or outpatient setting as available and appropriate.
When to Ask the Patient to Call an Ambulance
1. 1.
Vaginal hemorrhage . A report of completely soaking two pads or more per hour for 2 h is a rough estimate of excessive bleeding. Excessive bleeding resulting in symptoms of anemia, including palpitations, pre-syncope or syncope, or bleeding through a patient’s pad or tampon and clothes—particularly in the setting of pregnancy or known bleeding diathesis—require emergent assessment, and may warrant activation of emergency medical services. Please see Chap. 2, Vaginal Hemorrhage, for more information.
2. 2.
Chest pain . Reported symptoms most suggestive of an acute coronary syndrome are exertional chest pain with radiation to one or both arms [1]. Chest pressure, nausea, and diaphoresis are moderately predictive, while pleuritic, positional, sharp, and reproducible pain is least consistent with an acute coronary syndrome. Risk factors include age greater than 65 years in women, prior coronary artery disease, current smoking, diabetes, hypertension, hyperlipidemia, obesity, and family history of coronary artery disease [2]. Please see Chap. 15, High Acuity Postoperative and Inpatient Issues, for more information on the diagnosis and management of acute chest pain.
3. 3.
Altered mental status or somnolence . Patients’ family members or caregivers may call reporting these symptoms; acute changes to mental status require emergent assessment. Please see Chap. 15, High Acuity Postoperative and Inpatient Issues, for more information regarding the diagnosis and management of altered mental status.
When to Ask the Patient to Present to the Emergency Room the Same Night for Assessment
1. 1.
Fever greater than 100.4 F. Fevers require urgent assessment, particularly in postoperative, pregnant, and neutropenic patients. More information on these subjects can be found in Chap. 16, Complications of Minimally Invasive Gynecologic Surgery; Chap. 17, Induced Abortion; and Chap. 18, Gynecologic Oncology.
2. 2.
Intractable nausea and vomiting . Patients with severe nausea and vomiting, associated with inability to tolerate any oral intake and/or the absence of stools and flatus, are suggestive of a bowel obstruction or other complications requiring assessment, particularly in a postoperative or gynecologic oncology patient. Please see Chap. 16, Complications of Minimally Invasive Gynecologic Surgery, for more information.
3. 3.
Dyspnea and/or pleuritic chest pain . Patients calling to report these symptoms—particularly patients who are postoperative, pregnant (or recently pregnant), or being treated for gynecologic malignancy—should be assessed urgently for possible pulmonary embolism. Postoperative, pregnant, or oncology patients calling with unilateral, painful lower extremity edema should also be assessed urgently, given their increased risk for deep vein thrombosis; consider the patient’s symptoms and risk factors for thromboembolism when determining the appropriate timeframe for evaluation, either overnight or the following day. Please refer to Chap. 15, High Acuity Postoperative and Inpatient Issues, and Chap. 16, Complications of Minimally Invasive Gynecologic Surgery, for more information on the diagnosis and management of pulmonary embolism.
Patients undergoing in vitro fertilization (IVF), particularly after oocyte retrieval or in very early pregnancy, may also call with dyspnea potentially attributable to ovarian hyperstimulation syndrome (OHSS). Attempt to clarify the severity of the patient’s symptoms over the phone and consider her risk factors for OHSS to determine whether the patient must be seen immediately. Please see Chap. 20, Reproductive Endocrinology and Infertility , for more information regarding the diagnosis and management of OHSS.
4. 4.
Worsening pain after surgery: Patients reporting significant pain not improved with pain medication as prescribed, including narcotic pain medications, acetaminophen, and ibuprofen—particularly when associated with fever, nausea and vomiting, or other concerning symptoms—require urgent assessment. Patients undergoing laparoscopic surgery should have continual improvement in pain post-operatively, and any patient with increased pain after laparoscopy while taking adequate pain medication should be evaluated urgently to rule out a serious post-operative complication such as port-site herniation or an occult bowel injury. Please see Chap. 16, Complications of Minimally Invasive Gynecologic Surgery, for more information.
5. 5.
New or worsening abdominal or pelvic pain . Patients reporting severe pain that does not improve with acetaminophen and ibuprofen or the patients’ standard pain medications (such as narcotics in patients with chronic pain syndromes) require urgent assessment, particularly when associated with emesis or fever. A patient with a known or suspected ectopic pregnancy requires immediate assessment; please refer to Chap. 3, Pregnancy of Unknown Location and Ectopic Pregnancy, for more information.
Patients undergoing IVF frequently develop abdominal discomfort due to ovarian enlargement ; these patients are also, however, at risk for ovarian torsion and OHSS. Assessment of the severity of a patient’s pain over the phone can be helpful in determining whether she needs to be seen immediately or within 24 h. Of note, ibuprofen and heating pads on the abdomen should be avoided in pregnancy (including after an embryo transfer). More information on ovarian torsion and OHSS can be found in Chap. 5, Adnexal Torsion, and Chap. 20, Reproductive Endocrinology and Infertility, respectively.
Finally, patients with endometriosis or chronic pain managed with hormonal medications may have pain in the setting of recently missing doses of their medications; most often, resumption of these medications and reassurance is sufficient. Assessment of patients with chronic pain by phone can be challenging; however, any new or different symptoms, particularly emesis or fever, warrant evaluation.
When to Refer Patients to the Outpatient Setting the Next Day
1. 1.
Spotting and/or mild cramping in early pregnancy. Patients can be given the reassurance that spotting in early pregnancy occurs in 27 % percent of first trimester pregnancies; spotting may not increase the risk of miscarriage, though heavy vaginal bleeding (like a menstrual period), which is less common, increases the risk of miscarriage [3]. Administration of anti-D immune globulin before 12 weeks of gestation age is debated, as alloimmunization at this gestational age is very rare, though most providers do provide this prophylaxis regardless of gestational age [4, 5]. In general, patients who are rhesus-D antigen (Rh) negative should be seen within 72 h for the administration of Rho(D) immune globulin after reporting any vaginal bleeding in early pregnancy.
2. 2.
Incisional erythema. Patients calling to report incisional erythema , particularly in the first 2 days after surgery, may be mistaking ecchymosis for infection. Patients reporting fever or associated symptoms—including copious and/or purulent wound drainage, acutely worsened abdominal pain, nausea, or vomiting—should be seen urgently to rule out wound complications. In the absence of these symptoms, patients can be assessed in the outpatient setting. To avoid antibiotic resistance, any wound should be evaluated prior to prescribing antibiotics; thus, referral to the outpatient clinic for evaluation within 48 h is the preferred management. Please see Chap. 16, Complications of Minimally Invasive Gynecology, for more information on the diagnosis and management of wound complications.
3. 3.
Bloating and abdominal discomfort . Patients undergoing IVF often develop these symptoms, but those who are tolerating oral intake, voiding, without shortness of breath or acutely worsened abdominal distention, and with pain adequately controlled can be followed closely as outpatients [6]. Postoperative patients who call with these symptoms should be assessed for return of bowel function and constipation. Patients who are able to tolerate oral intake and are passing flatus may be monitored as outpatients, and adherence to a bowel regimen (including stool softeners such as docusate and laxatives as needed) should be encouraged [7]. Patients receiving chemotherapy may experience nausea, vomiting, constipation, or diarrhea as a result of their chemotherapy. Patients who are passing flatus and able to hydrate with liquids may be managed with antiemetics and seen as outpatients within 48 h for evaluation of chemotherapy toxicity and hydration as needed. Please refer to Chap. 16, Complications of Minimally Invasive Gynecologic Surgery, for more information on postoperative bowel complications, Chap. 18, Gynecologic Oncology, for a discussion of chemotherapy and nausea, and Chap. 20, Reproductive Endocrinology and Infertility, for more information on the diagnosis and management of OHSS.
4. 4.
Dysuria or suprapubic pain . In the absence of fever or pregnancy, patients without a history of frequent urinary tract infections or those who are recently postoperative should be seen in the office for a urine dipstick for confirmation of infection [8]. Those with frequent urinary tract infections who are aware of their urinary tract infection symptoms can be offered presumptive treatment with antibiotics. Those who are pregnant and/or febrile should be seen urgently for assessment of pyelonephritis. Please see Chap. 16, Complications of Minimally Invasive Gynecology, for more information on urinary tract infections.
Issues Managed Over the Phone
1. 1.
Vaginitis : Patients calling with symptoms of vaginal discharge or irritation can be seen in the outpatient setting, as these issues are generally nonurgent. Patients may call requesting treatment for vaginal candidiasis, with symptoms that can include itching, burning, dysuria, and thick white vaginal discharge. Studies have shown that patients’ ability to self-diagnose yeast infections is poor [9]. However, patients can be offered a short course of presumptive treatment, with counseling to follow up as outpatients if their symptoms do not improve [10]. Please refer to Chap. 7, Vulvovaginal Dermatoses, Lesions, and Masses, for more information on the diagnosis and treatment of vulvovaginal candidiasis.
2. 2.
Risk of pregnancy: Patients may call following unprotected intercourse or contraceptive failure. Review whether the sexual encounter was consensual; if it was not, the patient can present to the emergency room for full assessment. Please see Chap. 9, Sexual Assault, for more information. Patients should be counseled regarding their options, which are listed in Table 21.1. Patients do not require physical examination or laboratory assessment before receiving emergency contraception, unless preexisting pregnancy is suspected by the patient’s history or missed menses. Patients should be counseled regarding risk of sexually transmitted infection and can be seen in the outpatient setting for testing for these as needed.
Table 21.1
Summary of options for emergency contraception (EC ) in the United States
|
Method |
Mechanism of action |
Considerations |
Dose |
Efficacy |
Contraindications |
|
Ulipristal acetate |
Delays or prevents ovulation |
30 mg PO once, within 120 h of exposure |
Failure rate <2 % |
Confirmed pregnancy |
|
|
Levonorgestrel (progesterone-only pill) |
Delays or prevents ovulation |
Provide antiemetics for side effects of nausea and vomiting Retake dose if vomiting within 2–3 h of administration |
1.5 mg PO once, within 120 h of exposure Alternatively, 0.75 mg PO every 12 h for 2 doses, associated with more nausea |
Failure rate <2.5 % |
Confirmed pregnancy Contraindications to progesterone contraception likely do not apply given short treatment duration. See CDC Medical Eligibility Criteria for Contraceptive Use, Appendix D |
|
Combined estrogen–progesterone |
Delays or prevents ovulation |
Provide antiemetics for side effects of nausea and vomiting Retake dose if vomiting within 2–3 h of administration |
Each dose should contain 100 micrograms of ethinyl estradiol and 0.5 mg levonorgestrel, given 12 h apart for 2 doses. The first dose is given within 72 h of exposure |
Failure rate of 3.2 % Less effective than levonorgestrel and should be considered only if other options are unavailable |
Confirmed pregnancy Contraindications to estrogen-containing contraception likely do not apply given short treatment duration. See CDC Medical Eligibility Criteria for Contraceptive Use, Appendix D |
|
Copper intrauterine device (IUD) |
Oocyte toxicity, inhibition of sperm function, endometrial inflammation |
Ideal for women also seeking long-term contraception Recommend testing for Chlamydia trachomatisand Neisseria gonorrhoeaeat time of insertion Significantly higher cost compared to other forms of EC |
Intrauterine device, within 120 h of exposure Effective for up to 10 years |
Most effective form of emergency contraception, with failure rate of 0.09 % |
Confirmed pregnancy Cancer of genital tract Uterine malformation Copper allergy Mucopurulent cervicitis |
From Li et al. [11], Glasier et al. [12], Centers for Disease Control and Prevention (CDC) [13]
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13.
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