CONSULTS
OB/GYN ISSUES
VAGINAL BLEEDING
Abnormal bleeding from lower (vulva, vagina, cervix) or upper genital tract (uterus)
Etiologies
• Premenopausal
Not pregnant: menses, dysfunctional uterine bleeding (menorrhagia), leiomyoma, polyp, trauma, cervical dysplasia/cancer (rare), endometrial hyperplasia/cancer (rare)
Pregnant
1st trimester: threatened abortion, spont. abortion (missed, incomplete or complete), ectopic pregnancy, molar pregnancy (partial or complete hydatidiform mole)
2nd or 3rd trimester: preterm labor, placenta previa, placental abruption
• Postmenopausal: atrophy, polyp, leiomyoma, endometrial hyperplasia/cancer, cervical dysplasia/cancer
History & exam
• Age, menopausal status, gestational age if preg.; volume & duration of current bleeding
• If premenopausal: menstrual hx including age of onset, interval between & duration of menses, any assoc. sx and LMP to assess timing of menstrual cycle
• Past Ob/Gyn hx (any structural abnl, STD and contraception)
• Health maint. (Pap smear, HPV screening); domestic violence; anticoag or antiplt meds
• General physical & abdominal exam (incl. tenderness, masses)
• Pelvic exam: external (quantity of bleeding seen on vulva, any lesions, any trauma); also, w/ assistance from Ob/Gyn, speculum exam (quantity of bleeding; cervical os open or close and if open, dilation; any polyps) & bimanual exam (uterine size and tenderness, adnexal mass and tenderness)
Laboratory evaluation & imaging
• Urine (rapid test) & serum pregnancy test (bhCG); Hct/hemoglobin
• Pelvic U/S: visualize intrauterine preg to r/o ectopic; if preg., intrauterine not seen, & bHCG > discrim. zone → concern for ectopic; if bHCG < discrim. zone → follow bHCG; nl placental position to r/o placenta previa and likely severe abruption
• Ectopic pregnancy is life-threatening diagnosis, ∴ must rule out if Pt pregnant
VAGINAL DISCHARGE
Fluid or mucus from vagina, cervix or uterus
Etiologies
• Infectious: bacterial vaginosis, candida vulvovaginitis, trichomoniasis
• Noninfectious: physiologic (in preg. or non-preg.), rupture of membranes, foreign-body rxn
Initial evaluation
• Age, LMP, gestational age if preg. or menopausal status
• Discharge quantity, color, consistency, odor, assoc. sx (itchiness, redness, abd/pelvic pain)
• Past gyn hx incl STD and contraception usage (condoms ↓ STD risk)
• Tampon or condom use as risk factors for retained foreign body
• Pelvic exam: external (quantity & quality of discharge on vulva, any lesions); speculum (discharge, appearance of cervix), bimanual (cervical motion tenderness)
• Laboratory: pH of discharge; microscopy (saline & KOH wet mounts); urine pregnancy test
Treatment
• Bacterial vaginosis: oral or vaginal metronidazole or clindamycin
• Candida vulvovaginitis: oral or topical antimycotic medications
• Trichomoniasis: oral metronidazole
ADNEXAL MASS IN NON-PREGNANT WOMAN
Mass arising from ovary, fallopian tube or surrounding connective tissue
Etiologies
• Ovarian: functional (follicular and corpus luteum) or hemorrhagic cyst, endometriomas, ovarian torsion, tubo-ovarian abscess, benign & malignant ovarian tumors
• Fallopian tube: paratubal cyst, hydrosalpinx, ovarian torsion, tubo-ovarian abscess
Initial evaluation
• LMP / menopausal status; associated sx of abd/pelvic pain, FHx of gyn cancers
• Abd exam (distension, tenderness, masses); bimanual (uterine or adnexal masses)
• Preg. test if premenopausal (if 
, then mass likely pregnancy); CA-125 if postmenopausal
• Pelvic U/S (even if mass first identified on CT as U/S is best modality); U/S appearance of mass most important factor used to determine risk of malignancy