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Emergency Medicine > OB-GYN emergencies > Flashcards

OB-GYN emergencies Flashcards

1
Q

What should be done if pt w/ vaginal bleeding isn’t hemodynamically stable when presenting to ER?

A
  • begin approp measures for fluid resuscitation and stabilization
  • immediately determine if pt is preg
  • emergently refer to OB/GYN for possible OR intervention
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2
Q

What should be done if pt w/ vaginal bleeding presents to ER and is hemodynamically stable?

A
  • determine if pt is pre
  • determine amt and length of time of bleeding
  • do complete pelvic exam UNLESS you suspect placenta previa (US first)
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3
Q

Hx ?s to ask pt that presents w/ vaginal bleeding?

A
  • assess amt of bleeding: number of pads/tampons used, any clots, size?
  • pattern of periods: LMP, regularity, missed/late periods - possibility of preg
  • sexual hx: number of partners, use of condoms to assess risk of STI/PID
  • if pain, where? quality and radiation?
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4
Q

PE of pt w/ vaginal bleeding?

A
  • vital signs: low BP is late sign of hemodynamic instability
  • look for mucosal hemorrhage, petechiae (HELLP, DIC)
  • signs of PCOS: oligomenorrhea or amenorrhea, anovulation, acne, hirsutism, infertility
  • abdominal exam:
    pain, masses, rebound tenderness
  • pelvic exam:
    looking for source of bleding, signs of trauma, cervical motion tenderness, uterine size, contour, masses, and tenderness
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5
Q

Tests to order for pt w/ vaginal bleeding?

A
  • Qualitative and sometimes quantitative hCG test: sx pts w/ hCG less than 1000 mIU/ml 4x more likely to have ectopic preg
  • TVUS can determine a intruterine preg at hCG levels of 1500 mIU/nl
  • CBC
  • type and cross if sig bleeding
  • type and screen if not immediately needing transfusion
  • coag tests if suspected infection (PID)
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6
Q

DDx of vaginal bleeding in prepubertal pt?

A
  • vulvovaginitis: bloody vaginal d/c/pruritus
  • fb: bloody vaginal d/c, foul smelling
  • trauma: hx is impt
  • urethral prolapse: can visualize on exam
  • sexual abuse: blood from sexual trauma, may have bruising, c/o pain: must have careful approach and may involve collecting evidence
  • hormone secreting tumor
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7
Q

DDx for vaginal bleeding in a premenopausal nonpreg pt?

A
  • ruptured ovarian cyst
  • ovarian torsion
  • PID
  • dysfxnl uterine bleeding: may be caused by endometrial cancer in pt as young as 35, tx for DUB
  • uterine leiomyoma
  • uterine polyp
  • genital polyp
  • genital trauma secondary to sexual abuse
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8
Q

DDx for peri/post-menopausal pts w/ vaginal bleeding?

A
  • primary concern: endometrial cancer (don’t start on OCPs!!), refer for appropriate eval and dx
  • anticoag meds
  • hormonal therapy
  • other meds
  • coagulopathy
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9
Q

Bleeding etiology of 1st trimester?

A
  • bleeding from implantation
  • threatened, impending or incomplete miscarriage
  • ectopic pregnancy: abdominal pain, amenorrhea, vaginal bleeding
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10
Q

Bleeding etiology of 2nd and 3rd trimesters?

A
  • placenta previa
  • placental abruption
  • genital trauma secondary to abuse (goes up in preg)
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11
Q

Most likely bleeding etiology of early post-partum pt?

A
  • PPH: need surgery ASAP
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12
Q

Initial tx for unstable preg pt? Signs of hemodynamic compromise?

A
  • O2, fluids, lateral displacement of uterus
  • w/ vaginal bleed: early signs of compromise: tachycardia and tachypnea
  • late: hypotension, weak pulse and oliguria
  • women who are Rh neg need rhogam after any bleeding episode
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13
Q

Etiologies of bleeding in early preg?

A
  • ectopic preg
  • threatened, impending, incomplete miscarriage
  • physiologic (implantation of preg)
  • cervical, vaginal or uterine pathology
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14
Q

Eval of bleeding in early preg?

A
  • hx: amt of bleeding, passed clots or tissue, pain?
  • physical: hemodynamic status
  • US
  • labs: hCG, CBC, UA, cultures as indicated
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15
Q

Signs of threatened miscarriage?

A
  • no cramping
  • closed cervix
  • US: + fetal cardiac activity
  • 90-96% will go on to term
  • expectant management
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16
Q

Signs of inevitable miscarriage?

A
    • cramping
  • increased bleeding
  • US: cardiac activity or fetal demise
  • open cervical os
  • management: expectant or surgical
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17
Q

What is an incomplete miscarriage? Sxs? Exam findings?

A
  • fetus is passed but placental tissue is retained
  • sxs: moderate to severe cramping
  • bleeding: can be severe enough to cause hypovolemic shock
  • on exam: cervical os is open and gestational tissue may be present, uterus feels boggy on palpation
  • US shows tissue in uterus
  • surgery usually necessary to remove retained tissue
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18
Q

Hx an presentation of ectopic pregnancy?

A
  • 1/100 preg in US
  • hx: look for RFs -
    previous ectopic
    tubal surgery
    hx of PID
    women tx for infertility
  • presentation:
    abdominal pain (MC sx)
    vaginal bleeing
    amenorrhea
    hypovolemic shock
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19
Q

DDx for abdominal pain?

A
  • UTI or kidney stones
  • appendicitis, diverticulitis
  • ovarian torsion, neoplasm, ruptured cyst
  • endometriosis, PID, endometritis
  • implantation of preg
  • threatened, inevitable or incomplete m/c
  • cervical, vaginal or uterine pathology
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20
Q

PE findings of ectopic preg? What else should be done?

A

PE:

  • check hemodynamic status
  • may reveal abdomial or pelvic tenderness
  • may find adnexal mass
  • may be unremarkable

TVUS:

  • most helpful to determine if IUP is present
  • an IUP should be seen if serum hCG greater than 2000mIU/ml
  • if it’s an ectopic usually seen in fallopian tube (97%)
  • if TVUS is inconclusive and pt is stable serial quantitative hCGs are followed (will start to drop instead of increasing if ectopic)
21
Q

How common is a heterotopic preg?

A
  • IUP and extruterine gestation ar concomitant: occur 1/30,000 spontaneous conceptions, but in preg conceived w/ assisted reproductive technologies they can be 1%
22
Q

When does a pt w/ ectopic preg need immediate surgical intervention?

A
  • if pt (has + hCG) and is hemodynamically unstable she is considered to have ruptured ectopic pre and needs immediate surgical intervention
  • if pt is stable then tx w/ methotrexate and consder OB consult
23
Q

Lower genital tract tests, etiology?

A 
- tests (when indicated):
chlamydia, gonorrhea, HPV
vaginosis, yeast, trich
syphillis, HIV, herpes
- etiologies:
vaginal lacerations, cervicitis
growths, infections
genital wrts, cervical polyps
- if infection concern then test and tx partner
24
Q

Tx of cervicitis secondary to infection?

A
  • Rocephin 250 mg IM

- Azithro I gm

25
Q

23 YO F presents w/ lower abominal pain for last 3 days. Deep ache 6/10, fairly constant and has worsened in intensity. Hurts more w/ movement, nothing has made it better. Has had some spotting. LMP last week, 2 partners in last 9 months. + dyspareunia, no d/c. Has elevated temp (101.3) Exam and testing that should be done? Most likely dx?

A
  • pelvic exam: cervix erythematous
  • bimaual exam: cervix tender, no adnexal masses
  • NAT: for gonorrhea and chlamydia
  • CBC - will be high
  • Most likely dx: PID
  • if pt stable, not dehydrated (Not N/V), tx w/ rocephin and azithro
26
Q

How common is ruptured ovarian cyst? Presentation?

A
  • common in women in reproductive yrs
  • usually present w/ mild-moderate unilateral lower abdominal pain
  • sx intensity varies w/ type of fluid from cyst:
  • serous fluid - not very irritating, sxs mild
  • blood - more irritating, can be at risk for hemorrhage
  • sebaceous material (dermoid cyst)- quite irritating: can cause chemical peritonitis
27
Q

W/U of ruptured ovarian cyst?

A
  • thorough H and P
  • urine or serum hCG to r/o ectopic
  • CBC: look for decreased Hgb or platelets
  • UA
  • if indicated cultrues to r/o STIs
  • management and reassurance
28
Q

What is considered pre-term labor? Tx goal?

A
  • labor that begins b/f 37 wks
  • if it occurs b/f 28th wk: referred to as extreme preterm labor
  • goal is to stop pre-term labor w/ tocolytics to attempt to allow fetus more time to develop
  • if pre-term labor starts ante-natal steroids are given to mom to aid in maturing of lungs of fetus
29
Q

Mechanism of antenatal corticosteroids? What is used?

A
  • enhances maturational lung architecture and induces lung enzymes which results in biochemical maturation
  • studies show reduction of RDS by 50%, also decreases risk of IVH, NEC and systemic infection for 1st 48 hrs of life
  • betamethasone 12 mg IM 2 doses 24 hrs apart
  • dexamethasone 6 mg IM 4 doses 12 hrs apart
30
Q

What is placenta previa? What shouldn’t be done?

A
  • 4/100 preg over 20 wk gestation
  • classic: painless vaginal bleeding, although some women may have contractions
  • Don’t do a vaginal exam w/ fingers or speculum as long as pt is hemodyn. stable. Do a TVUS to dx previa and R/O placental abruption or other etiologies of bleeding
  • about 33% have initial bleeding episode less than 20 wks of gestation and are at greater risk of preterm birth
  • management: bed rest and monitoring until delivery
  • if complete previa - need C section
31
Q

Management of PP?

A
  • confirm dx
  • if acutely bleeding determine hemodynamic status:
    2 large bore IVs, foley for following output (30 cc/hr is goal), CBC, coag studies (can develop DIC), type and cross match 4 units of pRBCs
  • maintain maternal hgb over 10, if plt less than 100,000 give platelets
  • monitor fetal status, consult OB for possible emergent delivery
  • if pt has minimal bleedin or it stops, or hemodynamically stable monitor mom and baby
  • if baby less than 34 wks gestation consult w/ OB about giving antenatal steroids
  • if contracting consult about tocolysis prob mag sulfate
  • if not in facility where immediate c-section and neonnatal capabilities consider transfer
32
Q

Rfs, presentation and differential, tx for placental abruption?

A
  • RFs: HTN, trauma, polyhydramnios, mult gestation, smoking, cocaine use
  • presentation: uterine bleeding (concealed 20%), abdominal pain or contractions, fetal distress
  • diff: PP, uterine rupture, labor, cervical or vaginal trauma
  • tx: stabilize mom, monitor fetus, tocolysis w/ mag sulfate, consult w/ OB and neonatal services
33
Q

Normal fetal heart?

A
  • 120-160 beats/min
  • look for variability and accelerations
  • decelerations where HB drops ok to decrease slightly during a contraction and then return to normal (cord may be compressing O2 to baby temporarily - seen in late stage labor)
34
Q

bad fetal heart tracing findings?

A
  • lack of variability or prolonged (greater than 10 min), HR less than 120 indicates fetal distres
  • late decelerations indicate fetal distress
  • sinusoidal pattern indicates severe fetal distress - need to deliver ASAP
35
Q

Initial measures if baby is in fetal distress?

A

Try to increase O2 to fetus:

  • maternal admin of O2
  • change maternal position
  • bolus w/ NS
  • stop any utertonic drugs and if cont frequent contractions w/ continued fetal distress may consider tocolytic
  • if fetal distress continues for 15-20 min may try scalp stim to see if FHR will accelerate which is reassuring - if FHR doesnt’ accelerate - can indicate fetal acidosis - prompt delivery is indicated
36
Q

Definition of mild preeclampsia?

A
  • 2 BP measurements 6 hrs apart above 140/90

- + proteinurea of more than 0.1 g/L on urine dipstick or more than 300 mg protein 24 hrs

37
Q

DDx for mild preeclampsia?

A
  • DKA
  • gallbladder disease
  • glomerular nephritis
  • hepatic encephalopathy
  • TTP
  • PUD
  • viral hepatitis
  • nephrolithiasis
38
Q

Management of mild preeclampsia?

A
  • if pt 37 wks or greater: deliver
  • 34-36 wks - do expectant management
  • labs: CBC w/ platelets, CMP, 24 hr urine
  • assessment of fetus:
    US to assess size, amt of amniotic fluid
  • nonstress test
  • ana sign of severe preeclampsia –Deliver!!
39
Q

What is severe preeclampsia? Tx?

A
  • SBP over 160, DBP over 110
  • proteinurea = to or greater than 5 gm in 24 hrs
  • edema, signs of end organ damage (blurred vision)
  • indication for admission
  • start on mag sulfate to prevent seizures
  • tx BP w/ labetalol or hydralazine
  • delivery: induction initially may reqr c-section
  • if less than 30 wks best to go to a tertiary center for management w/ perinatologist
40
Q

Use of Mag sulfate? SEs? Monitoring?

A
  • maintenacnce phase given only after patellar reflex is present, loss of reflexes 1st sign of hypermagnesemia
  • get baseline DTRs b/f tx
  • respirations greater than 12/min and urine output greater than 100 cc/hr are signs that mag level is ok
  • SEs:
    w/ loading dose: diaphoresis, flushing b/c of vasodilation and decrease in BP, N/V, rare pulmonary edema, chest pain
  • Fetus: no sig SEs
  • Mag sulfate: acting as anticonvulsant
41
Q

Cure for preeclampsia? How long is pt at risk for complications of preeclampsia?

A
  • cure: delivery of placenta
  • pt still at risk for complications including seizures for 48-72 hrs postpartum so mag sulfate should be cont and pt monitored closely
42
Q

What is ecclampsia?

A
  • occurrence of 1 or more general tonic-clonic seizures or coma in preeclamptic woman
  • generally lasts no longer than 3-4 min (usually 60-75 sec)
43
Q

Management of preeclampsia?

A
  • protect maternal airway
  • lower BP if severely high:
    hydralazine
    labetalol
  • prevent further seizures by starting Mg sulfate
  • monitor fetus: often limited bradycardia
  • Can turn into HELLP - need to deliver immed
44
Q

Presentation of death in utero, what should be documented? What should be done?

A
  • presentation: usually mom comes in c/o decreased fetal movement
  • document: no fetal heart sounds, no cardiac activity on US
  • in 2nd and 3rd trimester generally best to induce labor except if prior C section then woman at higher risk for uterine rupture
  • mother at risk for coag the longer the fetus remains in uterus
  • great loss and should be tx as such - attend to emotional needs of parents
45
Q

Breech delivery and mangement?

A
  • usually fetal position is determined well b/f term and most breech babies are delivered C section, but there are times when there is no time for C section
  • ***cephalic flexion
  • bring out one leg at a time
  • delivering arms: once trunk delivered up to scapula, cord pulsation is checked and small loop is pulled down to prevent traction on cord
  • w/ next push shoulders should present, along w/ arms folded over chest, if shoulder fail to deliver then lift baby’s legs and trunk and flex elbow jt and deliver w/ arm across chest
  • suprapubic pressure and Mcroberts maneuver helps keep head flex and delivery of baby
  • if this doesn’t work - have mom get on all 4s
46
Q

Diff shoulder dystocia maneuvers?

A
  • drain distended bladder
  • McRoberts: 2 assistants sharply flex maternal thighs back against abdomen
  • apply suprapubic pressure w/ palm or fist
  • cut a generous episiotomy
  • rubin maneuver: clinicain places one hand in vagina behind posterior shoulder rotates it anterior towards fetal face
  • get mom on all 4s: gaskin all 4s - infant delivered by gentle downward traction on post shoulder
  • sympysiotomy: used as last resort when c section not available, anesthetize area, displace urethra w/ finger and cut through carilagenous portion of symphysis
  • can replace fetal head and do emergent c section
47
Q

What should be done if extremity is presenting?

A
  • may be vertical or breech presentation w/ extremity beside it:
    don’t use oxytocin, sometimes extremity will naturally be moves out of the way and vaginal delivery will occur
  • if extremity persists c section needed
  • may be a footling breech or leg first or arm generally these are delivered by c section unless spontaneously deliver
48
Q

Highest risk for newborn to acquire congenital herpes?

What should preg woman do if in labor who has hx of genital herpes?

A
  • is to mom who was infected w/ primary HSV-2 during pregnancy (if infected b/f - will have abs)
  • should have a c section if:
    she has active herpes lesions on or near the birth canal, any prodromal sxs on or near the birth canal

Emergency Medicine (22 decks)

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