One or more of the following additional criteria can

be used to enhance the specificity and s upport a diagnosis

of PID: oral temperature >101°F, abnormal cervical or

mucopurulent discharge, presence of abundant WBCs on

microscopy of vaginal fluid, elevated ESR, elevated CRP,

or laboratory documentation of cervical infection with

N. gonorrhoeae or C. trachomatis.

TREATMENT

The treatment of vaginitis, cervicitis, and PID is outlined

in Tables 44-1, 44-2, and 44-3. All regimens used to treat

cervicitis and PID should be effective against N. gonorrhoeae

and C. trachomatis. The need to treat anaerobes has not

been completely studied. Gardnerella (BV) has been

present in many patients with PID, so many recommend

treatment regimens that include anaerobic coverage (ie,

metronidazole). For women with mild to moderate severity PID, parenteral and oral regimens appear to have

similar efficacy.

DISPOSITION

.... Admission

In women with mild or moderate PID, outpatient therapy

yields similar short and long-term outcomes.

Hospitalization is recommended when the patient meets

any of the following criteria: surgical emergencies cannot

Table 44-3. Treatment of PID.

Option 1 Option 2

Outpatient Ceftriaxone 250 mg IM Cefoxitin 2 g IM WITH

treatment PLUS Probenecid 1 g PO

Doxycycline 1 00 mg PO PLUS

BID X 14 days Doxycycline 1 00 mg PO

± BID X 14 days

Metronidazole 500 mg ±

PO BID x 14 days Metronidazole PO BID x

14 days

Inpatient Cefotetan 2 g IV q12hrs Clindamycin 900 mg IV

treatment OR q8hrs

Cefoxitin 2 g IV q6hrs PLUS

PLUS Gentamicin 2 mg/kg IV

Doxycycline 1 00 mg PO followed by 1 .5 mg/

or IV q12 hrs kg q8hrs

be ruled out (eg, appendicitis, tubo-ovarian abscess), pregnancy, nonresponse to oral antimicrobial therapy, unable

to tolerate oral regimen.

.... Discharge

Patient with vaginitis and cervicitis can be safely discharged. When an STI is suspected, patients should be

instructed to notify their partners. For PID, outpatient

therapy is initiated in patients who do not have any of the

criteria listed previously, appear nontoxic, and have reliable follow-up.

SUGGESTED READING

Buckley RG, Knoop KJ. Gynecologic and obstetric conditions.

In: Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas

of Emergency Medicine. 3rd ed. New York, NY: McGrawHill, 20 10.

Centers for Disease Control and Prevention. Sexually

Transmitted Diseases Treatment Guidelines, 20 10. http:// www.cdc.gov/std/treatrnent/20 10/toc.htm

Kuhn, JK, Wahl RP. Vulvovaginitis. In: Tintinalli JE, Stapczynski JS,

Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 20 11, pp. 71 1-16.

Shepherd SM, Shoff WH, Behrman AJ. Pelvic inflammatory

disease. ln: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM,

Cydulka RK, Meckler GD. Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawHill, 20 1 1, pp. 716-720.

Sweet RL. Treatment of acute pelvic inflammatory disease. Infect

Dis Obstet Gyneco/ 20 1 1;56 1-909.

Preeclampsia

and Eclampsia

Kathleen A. Wittels, MD

Key Points

• Gestational hypertension, preeclampsia, and eclampsia

represent a spectrum of potentially life-threatening

diseases that must be diagnosed and treated aggressively.

• Consider preeclampsia in any pregnant patient with an

elevated blood pressure.

INTRODUCTION

Hypertension in pregnancy occurs in approximately 10%

of pregnancies and can be associated with significant

maternal and fetal morbidity and mortality. The spectrum

of disease is divided into 3 main categories: gestational

hypertension, preeclampsia, and eclampsia. Preeclampsia

affects 2-6% of pregnancies in the United States, with a

higher incidence globally. Eclampsia occurs in <1% of

patients with preeclampsia.

Gestational hypertension is defined as a blood pressure

> 140/90 mmHg in a pregnant patient without preexisting

hypertension. The hypertension will resolve within

12 weeks postpartum. When proteinuria is also present, it

is defined as preeclampsia. Preeclampsia typically occurs

after 20 weeks' gestation. A subset of patients will develop

severe preeclampsia, which is associated with one of more

of the following: severe hypertension (> 1 60/110 mmHg on

2 separate occasions >6 hours apart), large proteinuria,

neurologic symptoms, epigastric/right upper quadrant

(RUQ) pain, pulmonary edema, or thrombocytopenia.

Eclampsia is preeclampsia with seizures. HELLP syndrome

affects some patients with preeclampsia and eclampsia and

is associated with hemolysis, elevated liver enzymes, and

low platelets.

Although the exact etiology of preeclampsia is unknown,

there are several factors that are thought to contribute.

• The degree of hypertension does not correlate with the

severity of preeclampsia.

• Delivery of the fetus is the definitive treatment of

preeclampsia and eclampsia.

These include maternal immunologic intolerance, abnormal

placental implantation, endothelial dysfunction, and genetic

factors.

CLINICAL PRESENTATION

..... History

Patients with gestational hypertension and preeclampsia may

be asymptomatic. Some women will report facial or extremity

edema, epigastric or RUQ pain, headache, or visual disturbances. Seizures in a woman with preeclampsia is pathognomonic for eclampsia and may occur in the postpartum

period. Risk factors for preeclampsia that should be screened

for during the history include nulliparity, advanced maternal

age, a multiple gestation pregnancy, diabetes, obesity, and

previous preeclampsia.

..... Physical Examination

It is critical to pay careful attention to the vital signs,

particularly the blood pressure. Edema of the face or

extremities may be appreciated. Examination of the lungs

may reveal rales suggestive of pulmonary edema. The

abdominal exam is important to assess for tenderness as

well as to estimate the gestational age of the fetus

(Figure 45-1). Listen for fetal heart tones with a Doppler or

1 89

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30

--24'

�

.r---...

20

16

"12'

CHAPTER 45