CASE SCENARIO

32 yo female pregnant patient who is 18 weeks pregnant presents to the emergency department for OBGYN consult after a motor vehicle accident incident. Patient breaked abruptly due to the incoming of a speeding car and made impact with the steering wheel and experienced tension with the seat belt. Patient experienced sharp abdominal pain rated a 7/10 that radiates to the lower back.

SEARCH QUESTION :

Should pregnant patients be advised to avoid driving to reduce the likelihood of pregnancy complications due to motor vehicle accidents?

QUESTION TYPE : 

Prevalence Screening Diagnosis

Prognosis Treatment Harms

Assuming that the highest level of evidence to answer your question will be meta-analysis or systematic review, what other types of study might you include if these are not available (or if there is a much more current study of another type)? Please explain your choices. 

If meta-analysis or systematic review are not available, I would look for retrospective cohort studies. Although the next best study would be a randomized control trial, this study would not be feasible to expose pregnant mothers to motor vehicle accidents. Retrospective cohort studies would be able to shed light on incidents that have already occurred and to evaluate for any patterns to the findings. Furthermore, retrospective cohort studies may be able to encompass a larger number of participants over a wide geographic area to provide diverse data. Retrospective studies may also provide insight on long-term consequences of motor vehicle accidents that may not be immediately observable right after an accident. For example, accidents may carry consequences into childhood development or maternal complications to conceive in the future. 

PICO SEARCH TERMS :

P	I	C	O
Pregnant Mothers	No driving	Driving	No pregnancy complications
Expectant Mothers	Abstain from driving	Motor vehicle use	Fetal safety
Pregnant Patient	Avoid motor vehicle use	Behind the wheel	No fetal complications

SEARCH TOOLS & STRATEGIES USED :

Please indicate what databases/tools you used, provide a list of the terms you searched together in each tool, and how many articles were returned using those terms and filters. 

Database	Filter	Terms Searched	Articles Returned
PubMed	Meta- AnalysisSystematic ReviewCohort Studies2010 – 2021	Pregnant women driving	64
Pregnant women motor accident	5
JAMA	Research Review2010-2021	Pregnant women motor accident	14
Cochrane	Review2010- 2021	Pregnant driving	2

My first priority was to ensure that high-level journal articles were searched for. This would ensure that the quality of content was sufficient to make a definitive clinical bottom line. For this reason, my first step was to include meta-analysis and systematic review. However, as stated above, I did not include a randomized control trial as subjecting mothers to motor vehicle accidents would be unethical. Instead, I chose to include cohort studies as this could include evaluations from past incidences to draw a conclusion as to whether motor vehicle accidents had an impact on pregnancy. For all of the above mentioned filters, I also included the most recent ten years for the most relevant data as changes in automobile design, driving laws, and hospital protocol can influence outcomes. 

RESULTS FOUND :

Article 1

Citation: Miller N, Biron-Shental T, Peleg K, Fishman A, Olsha O, Givon A, Kessel B. Are pregnant women safer in motor vehicle accidents? J Perinat Med. 2016 Apr;44(3):329-32. doi: 10.1515/jpm-2015-0163. PMID: 26356252.

Type of Study: Retrospective Cohort Study

Abstract: As motor vehicle accidents are a major cause of pregnancy-related maternal deaths in the U.S., this study was performed to see if there was any association between MVA’s and poor outcomes for the fetus in mother. This study also evaluated whether seat location had an impact on fetal and maternal injury and risks.

Methods :This study was performed by looking at data collected from the Israeli National Trauma Registry from 2006 – 2013 of 2794 pregnant  female patients and 3,441 non-pregnant patients aged 18 – 40 years old who were involved in a MVA. 67% of the participants were drivers and 33% were non-drivers.

Results :Pregnant patients had a lower injury severity core than non-pregnant patients (p < 0.001). 38% of the pregnant patients had adverse-maternal-fetal outcomes. To further break this down, 0.1% experienced placental abruptions and 0.2% experienced micarriage. 0.03% of patients experienced mortality as compared to 0.93% mortality rate in  non-pregnant patients. There was a negative correlation found between gestational age and spontaneous abortion (p < 0.009).

Reason for Selection: This article was selected as it contained a large database of pregnant patients who were involved in a motor vehicle accident within the last 15 years. This provided a broad overview to identify any patterns between motor vehicle accidents and pregnant patients. Furthermore, MVAs involving non-pregnant patients were also included. This constructs a type of control to see how MVAs specifically impact pregnant patients. The study also provided a unqiue perspective as to whether passenger seating influenced risks in pregnant patients.

Conclusion :This study found that the rate of MVA injury and mortality was lower in pregnant patients compared to non-pregnant patients. Furthermore, pregnant patients had a lower severity of trauma than non-pregnant patients.

Key Points:MVAs inrease the risk of placental abruptions, miscarriage, and mortality in pregnant patientsThe lower the gestational age, the greater the risk of spontaneous abortionPregnant patients present with a lower risk of injury and mortality compared to non-pregnant patientsPregnant drivers presented with lower severity of MVA trauma than non-pregnant patients

Article 2

Citation: Amezcua-Prieto C, Ross J, Rogozińska E, Mighiu P, Martínez-Ruiz V, Brohi K, Bueno-Cavanillas A, Khan KS, Thangaratinam S. Maternal trauma due to motor vehicle crashes and pregnancy outcomes: a systematic review and meta-analysis. BMJ Open. 2020 Oct 5;10(10):e035562. doi: 10.1136/bmjopen-2019-035562. PMID: 33020077; PMCID: PMC7537450.

Type of Study: Meta Analysis

Abstract: This study reviewed the effects of motor vehicle crashes on pregnant patients and fetal outcomes.

Methods :A meta-analysis was conducted using data from Medline, Embase, Web of Science, Scopus, Latin-American and Caribbean System on Health Sciences Information, Scientific ELectronic Library Online, TRANSPORT, International Road Research Documentation, European Conference of Ministers of Transportation Databases, Cochrane Database of Systematic Reviews, and Cochrane Central Register. Follow-up with participants was conducted in secondary care, collision and emergency, and inpatient care. Data was then evaluated by estimated per 1,000 women. Quality of studies was then assessed with the Newcastle-Ottawa Scale. No language or date restrictions were applied to electronic searches. Terms searched were “motor vehicle collision”, “road traffic collision”, “crash”, “collision” and “pregnant women”, “gravid women”, “childbearing women”, or “maternal”.

Results : 19 studies that included 3, 222, 066 women showed that maternal death occurred in 3.5/1000 (95%, Cl 0.25-10.42) and fetal death or stillbirth occurred in 6.6/1000 (95%, Cl 0.25, 10.42). 276.43/1000 of patients had induction of labor (95% Cl 262.54-290.54), 191.90/1000 needed preterm delivery (95%, Cl 47.34 – 339.00), 42.44/1000 for PROM, 17.09/1000 required hospital admission, 16.14/1000 had placental abruption, and 15.19/1000 experienced neonatal respiratory distress.

Reason for Selection: This article was selected as it was a meta-analysis of female pregnant patients involved in a motor vehicle accident. This ensured that data was pooled from a variety of sources and put through a rigorous selection process. Furthermore, the study was performed in 2020 and included the most relevant information.

Conclusion : The findings concluded that motor vehicle accidents increased the risk of maternal death and complications in both pregnant women and fetuses. The greatest flaw in the study, however, was that none of the 19 studies had a prospective design. This meant that data was chosen by random method of sampling and increased the risk of bias. Furthermore, the outcomes were not reported by trimester, did not assess for seatbelt-use, and the majority of the studies were conducted in the United States.

Key Points:MVAs increased the risk of maternal and fetal birthMVAs increased induction of labor, preterm delivery, and premature rupture of membranesMVAs increased hospital admission, placental abruption, and neonatal respiratory distress

Article 3

Citation: Chang YH, Cheng YY, Hou WH, Chien YW, Chang CH, Chen PL, Lu TH, Yovita Hendrati L, Li CY, Foo NP. Risk of Mortality in Association with Pregnancy in Women Following Motor Vehicle Crashes: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2022 Jan 14;19(2):911. doi: 10.3390/ijerph19020911. PMID: 35055738; PMCID: PMC8775890.

Type of Study: Meta-Analysis

Abstract: This study was performed to examine the association between motor vehicle crashes and mortality risk between pregnant women versus non-pregnant women. Pregnant women are at a greater risk of experiencing soft-tissue edema, difficult surgery interventions, and poor adverse outcomes if exposed to trauma. As motor vehicle crashes account for the largest number of reported trauma during pregnancies, this study aimed to find a correlation between the two.

Methods :Data was collected through PubMed, Embase, and MEDLINE databases. The Newcastle-Ottawa Scale (NOS) was used for quality assessment. There were two inclusion criteria for the study : (1) Studies examined the mortality rate associated with motor vehicle crashes. (2) Studies were conducted in both pregnant and non-pregnant women. Additionally there were two exclusion criteria : (1) case reports, qualitative reports, comments, simulation studies, reviews (2) studies that did not report information relevant for key clinical questions (ex. Reports that did not provide adequate information about death following motor vehicle crash).

Results :251 of 297 articles were reviewed. In the end, only 8 observational studies that evaluated retrospective cohort studies proved eligible. The studies investigated 14,120 pregnant women and 207, 935 non-pregnant women who were involved in a motor vehicle accident. It was found that pregnant patients experienced a moderate but insignificant association with in-hospital mortality than non-pregnant patients (95%, Cl = 0.38-1.22) Pregnant women were also found to experience less severe injuries in age-matched analyses. However, if the severity of trauma increased, the likelihood of mortality increased in pregnant patients compared to non-pregnant patients.

Reason for Selection: This article was selected as it was a meta-analysis that pertained to the demographic and incident presented in the PICO question. It also contained specific parameters for studies that were included, Furthermore, the study compared pregnant patients and non-pregnant patients in terms of severity of trauma. This ensured that there was some type of control to evaluate the outcomes of pregnant patients in motor vehicle collisions as creating such a design would be unethical.

Conclusion : The study demonstrated how pregnant women injured in a motor vehicle crash experienced moderate but insignificant association with lower risk in-hospital mortality than non-pregnant women (OR = 0.68, 95% Cl = 0.38 – 1.22). However, if the injury increased in severity, pregnant women experienced a higher risk of mortality than non-pregnant women. This is likely due to the shunting of blood away from uteroplacental circulation to the site of trauma that may result in fetal decline. Altered anatomical states during pregnancy could present an additional layer of challenge for trauma surgeons and complicate rescue treatments. However, the study acknowledges that the studies may present with surveillance bias as they were based on reports from clinical institutions.

Key Points:Moderate to low risk of mortality in pregnant patients compared to non-pregnant patientsHowever, there is a direct relationship between the severity of injury and risk of mortality in pregnant womenPhysiological and anatomical changes present with complications for surgeons, fluid care, and blood loss in pregnant patients who experience traumaLimitations in study include surveillance bias as data was collected based on clinical reportings rather than a structured research design

Weight of Evidence:

When weighing evidence, I believed Article 3 was the strongest. Article 3 was a meta-analysis with a large number of participants. Furthermore, it was conducted on a global scale through multiple reputable databases to allow for a diverse collection of information. Article 2 was the next strongest study. Although it presented with the largest number of participants, the study was conducted in the United States alone. This presents with the issue of a lack of diverse settings that could skew results. For example, the United States demonstrates different driving regulations and hospital protocol that could influence the data outcomes. Lastly, I would argue that Article 1 presents with the weakest evidence. As it is a retrospective cohort study, it does not provide the same breadth of material as the meta-analyses. Furthermore, data was limited to the United States and presents with similar drawbacks as discussed about Article 2. 

What is the clinical “bottom line” derived from these articles in answer to your question?

The clinical bottom line is that there is no strong evidence to advise pregnant women to stop driving. Although motor vehicle accidents present with undeniable risks in loss of fetus, maternal mortality, preterm delivery, and other labor complications, they were found to generate only a low to moderate risk of negative outcomes compared to non-pregnant patients. Instead, patient education may be implemented instead. For example, pregnant patients may be advised to drive in a safer vehicle, at slower speed limits, right lane of highways, avoid abrupt braking, and be more vigilant of surrounding drivers. On the other end, hospitals can work to develop and improve a universal and rapid response to pregnant patients involved in a motor vehicle accident. This would include fluid resuscitation, blood transfusion, readily available imaging tools, and a prepared surgical team. Unfortunately, accidents do occur due to chance encounters. Pregnant mothers should not be discouraged from driving, but instead take necessary precautions and understand the risks involved. 

Identifying Data :

Full Name: Ms. SS

Address: Brooklyn, NY

Date of Birth: 8/6/1984

Age: 37 yo

Date & Time: February 23, 2022 2:00 PM

Location: Woodhull Hospital, Brooklyn NY

Religion: None
Source of Information: Self

Reliability: Good
Source of Referral: Self – admitted with husband to emergency room

Chief Complaint : “Bleeding and hurting so bad after abortion.” x1 day

History of Present Illness

37 yo female patient G2P1011 with PMHx of D&C abortion, spontaneous abortion, anemia, gestational hypertension, and pre-diabetes presents to the Emergency Room complaining of heavy vaginal bleeding and lower abdominal pain after an elective dilation and curretage abortion procedure performed on 2/19/2022. She was discharged home and took Acetaminophen (Tylenol) every 8 hours and Ibuprofen (Mortin) every 6 hours. However, she continued to bleed bright red blood with passage of large clots. Patient says she changes her pads 3 – 4 times a day for the bleeding. The abdominal pain is sharp, constant, and rated an 11/10 that causes her to lie in the fetal position at all times. She describes that the pain intensifies several times a day with an intense throbbing and pulsating sensation. Patient experiences fever and diaphoresis and has to pause several times to deep breathe while accounting symptoms. Denies chest pain, palpitations, shortness of breath, dizziness, headache nausea, vomiting, constipation, diarrhea, or urinary symptoms. Denies recent travels.

Past Medical History

• Anemia
• Gestational Hypertension
• Pre-Diabetic
  

Past Surgical History

•  Dilation & Curettage – 2/19/22
•  3 other termination of pregnancies – Date Unspecified
• Myomectomy for Uterine Fibroids – Date Unknown Medications Currently On :

•  Acetaminophen (Tylenol) 650 mg PO q8 hrs
• Ibuprofen (Motrin) 600 mg PO q6 hrs

Allergies

• No allergies to foods or medications

Family History

• Mother – Aged 60 yo, alive
• Father – Aged 62 yo, alive
• Husband – Aged 38, alive
• Sister – Aged 33, alive
• Daughter, alive
• Son, alive
• Son, alive
• Family history of hypertension and diabetes
• Denies family medical history of cancer or respiratory complications
  

Social History

Patient is a married English & Spanishing speaking 41 yo female who lives with her husband and three children in an apartment in Brooklyn, NY. Patient is currently unemployed and a homemaker. Habits : Patient denies drinking, smoking, and use of drugs.
Travel : Denies recent travel.
Diet : Patient eats a balanced diet of carbs, protein, fruits and vegetables.

Exercise : Patient maintains a sedentary lifestyle. She states that she does not work out and that her physical activity comes from daily steps around the house.

Sexual History : Heterosexual, married, monogomaous, and sexually active. Not currently on birth control and uses condoms occasionally. Denies history of sexually transmitted diseases.

Review of Systems

General – Female patient appears in acute distress and the fetal position due to extraordinary lower abdominal pain. Patient is sweating and moaning with poor pallor. Expresses that she feels very weak. Denies loss of appetite, fever, and chills.

Skin, hair, nails – Presents with sweating. Denies excessive dryness, discolorations, pigmentations, moles, rashes, or pruritus.

Head – Denies headaches, vertigo, head trauma, coma, or fractures.
Eyes – Denies other visual disturbances, use of glasses, lacrimation, photophobia, or pruritus.

Last eye exam – unknown.

Ears – Denies deafness, pain, discharge, tinnitus, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction, or epistaxis.

Mouth/throat – Denies bleeding gums, use of dentures, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown.

Neck – Denies localized swelling/lumps. Denies stiffness or decreased range of motion. Breast – Denies lumps, pain, or discharge.

Pulmonary System – Denies shortness of breath that is alleviated with a daily inhaler. Denies dyspnea, dyspnea on exertion, dry cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System – Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope.

Gastrointestinal System – Denies nausea, vomiting, diarrhea, or constipation. Denies intolerance to specific foods, dysphagia, pyrosis, abdominal pain, diarrhea, hemorrhoids, constipation, rectal bleeding.

Genitourinary System – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, awakening at night to urinate or flank pain.

Menstrual and Obstetrical — Menarche age 14. Last menstrual cycle – unknown. Presents with heavy bright red vaginal bleeding with passage of clots from incomplete D&C abortion. Denies abnormal vaginal odor or itching.

G6P1051

Nervous System– Denies seizures, headache, loss of consciousness, or change in mental status / memory.

Musculoskeletal System – Presents with constant sharp lower abdominal pain. Denies muscle weakness, slowness, aching, swelling, erythema, and stiffness.

Peripheral Vascular System – Denies coldness or trophic changes, peripheral edema, or color changes.

Hematological System – History of anemia. Denies ecchymosis, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine System – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, hypothyroidism, excessive sweating or goiter.

Psychiatric – Denies depression and anxiety. Denies history of speaking with a therapist and psychiatrist. Denies current suicidal ideation. Denies homicidal thoughts.

Physical Exam

General: Female patient appears in acute distress and the fetal position due to extraordinary lower abdominal pain. Patient is sweating and moaning with poor pallor. Expresses that she feels very weak. Appears well developed and nourished, but poorly hydrated. Appears stated age.

Skin: Poor pallor. Warm, dry, and poor turgor. Non-icteric, no lesions, masses, scars, tattoos, or bruising.

Nails: Clean cut. Capillary refill is normal and <2 seconds throughout. No clubbing, splinter hemorrhages, beta lines, koilonychia, or paronychia.

Head: Skull is normocephalic and non-tender to palpation. Hair is full, good texture, and good luster.

Eyes: Sclera is white and conjunctiva is a pale pink. Pupils are equal, round, reactive to light. EOMs are full with no nystagmus or strabismus.

Visual Acuity : Uncorrected – 20/20 OS, 20/20 OD, 20/20 OU

Fundoscopy : Red reflex is present. Cup:Disk <0.5 OU. No AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears: External auditory canals are non-tender to touch. Presence of yellow cerumen. Tympanic membranes are intact with good cone of light. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

Nose: Nose and sinuses were non-tender to palpation. No signs of nasal swelling or deviation. Lips: Dry, pale. No cyanosis, masses, lesions, swelling, or fissures.

Mucosa: Pink, dry. No masses lesions noted. No leukoplakia. No thrush.
Palate: Pink, dry. No lesions, masses, scars.
Teeth: Teeth intact, no dentures. White and no cavities.
Gingivae: Pink, moist. No hyperplasia, recession, masses, lesions, erythema or discharge. Tongue: Pink, well papillated. No masses, lesions, or deviation.

Oropharynx: Well hydrated. No exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate, Grade 0. Uvula pink, no edema.

Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Good range of motion. No cervical adenopathy noted. Lymph nodes are mobile, discrete, and non-tender to palpation.

Thyroid – Non-tender to palpation. No palpable masses or thyromegaly.

Chest: Symmetrical. No deformities or trauma. Respirations are unlabored. No paradoxic respirations or use of accessory muscles. Lateral to AP diameter 2:1. Non-tender to palpation throughout.

Respiratory: Clear to auscultation and percussion bilateral. Chest expansion and diaphragmatic excursion symmetrical. Tactile remits are symmetric throughout. No adventitious sounds.

Cardiovascular: JVP is 2 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Abdominal: Unable to palpate lower abdomen due to acute distress and severe abdominal pain. Abdomen is round with no striae or pulsations. Bowel sounds normoactive in all four quadrants. No CVA tenderness.

Genitalia : Heavy vaginal bleeding with passage of clots. External genitalia without erythema or lesions. Vaginal mucosa pink without inflammation, or erythema. Cervix multiparous, pink, and without lesions or discharge. No cervical motion tenderness. Uterus anterior, midline, smooth, non-tender and not enlarged. No adnexal tenderness or masses noted. Pap smear scheduled for next annual GYN exam. No inguinal adenopathy.

Rectal : Rectovaginal wall intact. No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative.

Neurologic:
Mental Status: The patient is alert, attentive, and oriented. Speech is clear and fluent with good

repetition, comprehension, and naming. Recalls 3/3 objects in 5 minutes.

Cranial Nerves :

CN I : Olfaction is intact by identifying the smell of coffee grounds and vanilla extract.

CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 3-5 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally.

CN III, IV, VI: At primary gaze, there is no eye deviation. When the patient is looking to the left, the right eye does not adduct. When the patient is looking up, the right eye does not move up as well as the left. Negative for diplopia and ptosis. Convergence is intact.

CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact.

CN VII: Face is symmetric with normal eye closure and smile. Taste of salty & sweet is present in anterior 2/3 of the tongue.

CN VIII: Hearing is intact. Whisper test presents diminished hearing bilaterally. Weber test heard midline with no materialization. Rinne test showed AC>BC bilaterally.

CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact.
CN XII: Tongue is midline with normal movements and no atrophy.

Motor/Cerebellar :

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia. Tandem walking and hopping show balance intact. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory :

Intact to light touch, sharp/dull, and vibratory sense throughout. Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally.

Reflexes :

Brachioradialis Triceps
Biceps Abdominal

Meningeal Signs :

RL RL

2+ 2+ 2+ 2+ 2+ 2+ 2+/2+ 2+/2+

Patellar
Achilles
Babinski
Clonus negative

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

Muscoloskeletal : Unable to palpate lower abdomen due to patient’s acute distress and severe abdominal pain. No erythema, ecchymosis, atrophy, or deformities in bilateral upper and lower extremities. Full active range of motion with no crepitus in all upper extremities and left lower extremities. Full spinal range of motion with no deformities.

Vitals

Blood Pressure – 124/75
Temp – 99.4 °F

SpO2 – 97%

RR – 18

Height – 5’ 7”

Weight – 175 lbs

BMI – 27.4

Assessment & Plan

37 yo female patientwith PMHx of D&C abortion, spontaneous abortion, anemia, gestational hypertension, and pre-diabetes presents to the Emergency Room complaining of heavy vaginal bleeding and lower abdominal pain after an elective dilation and curretage abortion procedure performed on 2/19/2022. Exam is positive for heavy vaginal bleeding and lower abdominal pain and cramping.

Problem List :

• Heavy vaginal bleeding
• Lower abdominal Cramp
• Weakness
• Fever
• Sweating

D/Dx :

1. Incomplete Abortion – The patient is most likely to have an incomplete abortion as she had a D&C 4 days prior to admission to the ED. If there are still products of conception retained in the uterus, they may become infected and lead to fever, sweating, abdominal pain, and continual vaginal bleeding.
2. Endometritis – Endometritis refers to infection of the decidua and is a common cause of postpartum fever and uterine tenderness. The infection may also extend to the peritoneal cavity, causing severe abdominal pain. It is possible that the D&C procedure was not sterile or exposed the uterus and led to infection.
3. Uterine Perforation – There is always a risk of perforation during intrauterine procedures that injures the uterine tissue and blood supply. Complications are likely if the perforation becomes infected. Pelvic
4. Leiomyoma– The patient may also have myomas that can lead to vaginal bleeding and abdominal pain. However, this is lower on the D/Dx list as it would not account for the signs of infection such as fever and sweating. The more likely scenario would be the presence of infection with myomas contributing to vaginal bleeding.
5. Pelvic Inflammatory Disease – There is a possibility that the patient has a history of undiagnosed pelvic inflammatory disease. PID is rare during pregnancy, but can occur in the first 12 weeks of gestation. As a result, there is a possibility that the patient experienced an upper reproductive tract infection that was exacerbated by D&C.

Plan :

Admit the patient for continuous monitoring. Initiate daily blood tests and labs to trend her H/H and ensure that she is hemodynamically stable. Administer IV fluids and consider transfusion. Consult the surgical team for dilation & curettage for incomplete aboration.

1. Transvaginal Sonogram

1. Order sonogram to visualize any remnants of product of conception (POC)

2. Urine Test, EKG, & Labs

1. Rule out urinary tract infection
2. Rule out cardiac complications for surgery
3. Assess for CBC and H/H status for transfusion and IV fluid administration

3. Medications

1. Initiate Medroxyprogesterone (Provera) to minimize bleeding
2. Consider Gentamicin (Garamycin) 5 mg/kg every 24 hours for infection and fever
3. Prepare Packed Red Blood Cell transfusion if Hemoglobin falls < 7 g/dL or presents with unstable signs and symptoms at 7 – 8 g/dL

4. Surgery Consultation

1. Consult surgical team for dilation & curettage if sonogram shows remnants of product of consumption and patient continues to bleed

The OBGYN rotation experience was truly a profound one. The greatest challenge I learned was that to work in OBGYN, a medical provider should embody both intellectual and emotional intelligence. The maternal patient is especially vulnerable during this time as both her mind, body, and emotions are on the line. As a provider ensures the medically safe delivery of the baby, he should also be mindful of the patient needs at this time. 

For example, the patients seen at the OBGYN rotation ranged from miscarriage to labor & delivery to elderly women with fibromas. Each of these scenarios requires a separate set of treatment guidelines as well as empathetic skills to manage the patient. In a patient experiencing miscarriage, I found that the simple act holding her hand greatly impacted the difficult process. The patient is typically alone, in a sterile clinic environment, and experiencing significant loss and bodily pains. It can be especially invasive and foreign to have a transvaginal ultrasound in this time and the act of touch will provide her a sense of comfort and reassurance. Furthermore, the patient often needed longer time after the diagnostic procedure to process her emotions and make any necessary phone calls to family members and friends.

In contrast, patients in labor & delivery required both empathy yet firm guidance. It was important that the patient felt she was cared for. At the same time, she needed encouragement and strength to continue pushing during a long and painful process. Her vitals also had to be monitored regularly to ensure both her and the fetus were stable. Medications such as Butorphanol, Oxytocin, Misoprostol, and Magnesium Sulfate could be administered in order to effectively manage her pain, contractions, cervical ripening, or signs and symptoms of pre-eclampsia. 

For a patient with fibromas, patience and reassurance was necessary in order to explain the condition to her. These patients were typically terrified as fibromas could present with excessive vaginal bleeding for long periods of time.  As a medical professional, we must explain that bleeding is typical complication of fibromas. However, treatment may not be immediate as medications take time to take effect and surgical interventions need to be cleared.

Another aspect I enjoyed immensely about the OBGYN rotation was the hands on approach. I felt very lucky that our rotation site trusted students to be involved in the process such as performing transvaginal ultrasounds, venipunctures, pap smears, STD cultures, and placental removals. I felt that this rotation allowed me to take what I learned through a textbook, apply it hands on, and thoroughly engrain it in my memory for future practice. 

This study looked at women of reproductive age with diabetes mellitus and their responses to different types of contraceptives including combined contraceptive pills, progestogen-only contraceptive pills, transdermal contraceptive patches, combined vaginal rings, combined injectable contraception, intrauterine devices, progestogen-only injectable contraceptives,  and progestogen-only subnormal implants. The results showed that 35 ug of combination contraceptive pills had no effect on glucose concentrations and insulin secretions. Progestogen-only contraceptive pills were found to produce no complications in women with diabetes mellitus of any age. Across the board, long-active reversible contraceptives (IUD, IUS, progestogen-only injectables, subdermal implants, & vaginal ring) were all found to be safe for use in women with diabetes mellitus. The only complication found was an effect on lipid metabolism. However, the benefits of family planning outweighed the impact on lipid metabolism. Overall, the study found that contraceptives of all types were safe to use in women with diabetes mellitus. The main concern was limiting the dosage value of oral combined contraceptive pills to 35 ug and to consider the needs of each patient in determining which type of contraceptive was most suitable.