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Flashcards in vaginal bleeding Deck (116):
1

2-3 mo pregnant women complaining of severe abdominal pain and bleeding
BP70/30
HR130
RR22
O298%
POC glu 80
ETA 4-6 mins

any woman that comes in with abdominal pain and bleeding need ectopic on ddx


belly full of blood on ULS with + pregnancy test

fluid collects in morrison's pouch any trauma pt or hypotensive pt will see this space

need type and cross need a surgeon and operating room

2

Most ectopics happen in the

ampulla
scarring form STDs cause the fetus to get stuck

3

blood work up in a pt with ectopic

not especially helpful

Blood  WBC 8K, Hgb 11.9; Urine  WBC 10-20 + LE

in a UA we are looking for undiagnosed UTI not helpful for ectopic

CBC +/- chemistry (if in case pt requires methotrexate later),
UA (check for infxn like undetected pyelo or STI – associated with preterm labor). A lot of preterm labor deliveries we see can be traced back to an infection

4

how does the cervix differ from the ULS

1. Cervix cant respond to active bleeding – if it is ripped in any way, you will bleed to death (like if you have a pregnancy there)

no hemostasis in the cevix

5

what are the ectopics we miss

The ectopics that we miss are in the cervical area

fimbriae in the ovary – they are hard to detect b/c on US they are sitting next to a lot of other structures

6

Ectopics hiding near the uterus will present with

More difficult to diagnose - both can appear intrauterine.

More likely to cause catastrophic bleeding.

iHigher rates in ART patients.

7

Cornual Ectopic

close to the insertion of the uterine artery

8

RF for cervical ectopic

prior instrumentation, fibroids, IUDs, IVF, uterine structural abnormalities (Asherman’s Syndrome, DES)

9

Heterotopic Pregnancy

one is in the uterus and one is not

i. 1 in 4,000 pregnancies
ii. 1 in 100 pregnancies in patients using assisted reproductive technology

10

endocaveterial ULS

always start with the transabdominal view


2 large bore IV
type and cross
OB on board

11

ULS pitfalls

i. Make sure you are oriented correctly!
ii. Find the uterine cavity.
iii. Find the endocervical canal.
iv. Always look in the adnexa and ovaries.

Always scan trans-abd AND trans vaginal

When in doubt, get a formal study!

12

Threatened miscarriage

just have bleeding
closed OS

13

pain, OS may or may not be closed, bleeding, some tissue left behind

Incomplete miscarriage

14

labs on pregnant ptds

CDC type and screen
STD

need to know if there is incompatibility
don't want mom to build a response

15

Quantitative beta hCG

Primarily used to trend an early pregnancy.ii. Indicates when we should see an IUP.

above 7500 -abd uLS
5000-transvaginal

if you have a completely early uterus with a Low HcG --> suspicious .

16

hcg for

iii. Ectopic pregnancies have been reported from 5-200,000 mIU.

with super high suspect molar pregnancies or multiple gestations

17

threatened miscarriage
workup

Address the possibility of ectopic pregnancy, and include the patient in this discussion.

Standard labs include CBC, CMP, UA, STI testing, Rh status, and quantitative hCG for trending purposes.

iii. Ultrasound.
iv. 48-hour follow-up either in the ED or with an OB provider.
v. Strict return precautions.

18

what can you assess in a patient coming 30+ weeks pregnant with blleding and pain

gestational age
abruption
looking a

anything outside a labor and delivery suite is precipitous delivery

19

two placental catastrophes

previa= over the cervix usually painless

abruption= part of the placenta has separated away from the uterine wall

20

classic abruption and sxs and dx tests

uterine cramping or pain with bleeding. Can occur from sheer forces as well

ULS not very sensitive for abruption
1. CBC, type/crossmatch
2. Coagulation profile
3. Renal function studies

maternal wellness and fetal variability on fetal heart rate strips

21

RF for abruption

1. MCC HTN
2. Maternal trauma
3. AMA
4. Multiparity
5. Smoking
6. Cocaine use
7. Previous abruptions



can go into DIC

22

what is the major problem with cord prolapse

deprieving oxygen and blood to the fetus

As uterus is contracting, there are decelerations which means the cord is being squeezed which means there are times baby is not getting O2 so there is a lack of circulation

need to elevate the presenting part

23

tx of cord prolapse

a. Elevate the foot off the cord and put pt in trendelenberg and take pt to the OR

Infusing the bladder with saline - although not as helpful if a presenting part is visible.

24

how do you know is the cord isn't in danger

success with pulsations in the cord

25

you do not want to pull the baby being delivered unitl

2. DO NOT PULL until the umbilicus is delivered.

26

should be delivered

Infant should deliver face down.

premi more likely to be breeched

27

presentation of shoulder dystocia


Buddha like faces – very plethoric, can appear purplish

“Turtle sign”

if the head comes out and back in

28

what could indicate a possible shoulder dystocia

Fetal macrosomia- is used to describe a newborn who's significantly larger than average.

Precipitous delivery
(less than 3 hours)

29

how to resolve should dystocia

NO fundal pressure/hold pushing until repositioned.

knees to chest in the mom

Want suprapubic pressure and turn the baby to dislodge the shoulder

c section preferred

a. McRobert’s Maneuver
b. Suprapubic pressure
c. Delivering the posterior shoulder
d. Rubin, Woods Corkscrew
e. Zavenelli Maneuver

30

what are we worried about in houlder dystocia

Worry about brachial plexus injury

31

Post-Partum Care

for devilry of the umbilical cord


Do not pull on the umbilical cord.

B/c it detaches and then the placenta stays up there. Can put you at risk for PPH

32

Postpartum Hemorrhage

atony of the uterus ( occurs when the uterus fails to contract after the delivery of the baby)

1. Greater than 500 cc blood.

2. Leading cause of obstetric death worldwide. In the US, second after VTE.

nipple stimulation will cause uterine contraction

33

Manual Interventions

Resuscitating PPH

Fundal massage (stimulates the uterus to contract down), explore for lacerations, manual uterine exploration for retained products

nipple stimulation will cause uterine contraction

34

medical interventions FOr PPH

Oxytocin, methylergonovine (ergot alkaloid), misoprostil ---> will cause vasoconstriction

Resuscitation with fluids and blood.


TXA (Tranexamic acid) now second-line.
1. Used for DUB and also used in PPH

makes you clot which isn't ideal

35

non pregnant cause of bleeding

i. Fibroids
vii. Infection
iii. Systemic disease
iv. Cancer
v. Dysfunctional uterine bleeding
vii. Look for symptomatic anemia.
viii. Consider evaluation for systemic illness.
perimenopause

36

fibroids

easy to detect on ULS

painful and heavy periods

37

contraception that can cause bleeding

a. Intrauterine device
i. Spotting and bleeding a known complication.
ii. Still check for pregnancy!

b. Hormonal therapies
i. Medroxyprogesterone
ii. Oral contraceptives
iii. Still check for pregnancy!

38

assessment needs to cover

a. Pregnancy status: negative
b. Hemoglobin level: not anemic
c. Status of the os: closed and no lesions
d. Size of the uterus: no fibroids
e. Skin: warm, dry, without bruising
f. Mucosa: no petechiae or bleeding
g. Discharge instructions: follow-up and return precautions.

39

Vaginal bleeding summary

Vaginal bleeding is an ectopic until you prove it is not!

Look for ABNORMAL VITAL SIGNS!
c. Screen for vaginal trauma and intimate partner violence.
d. Think about systemic disease.
e. Educate your patient to ensure safe follow-up.

40

screening for systemic disease in a female bleesing


CBC with smear, PT and PTT

Adolescents with menorrhagia: von Willebrand’s Disease

Secondary immune thrombocytopenias

SLE, antiphospholipid syndrome, thyroid disease

Viral associated thrombocytopenias:

HIV, Hep C, CMV

ITP: diagnosis of exclusion

41

when is estimating the gestational age inaccurate with fundal heigh and LMO

Multiple gestations

42

how else can you estimate gestation age?

ULS

43

how do you measure a BPD

Biparietal diameter

Measure perpendicular to the falx through that thalamus. Outer edge to inner edge of skull

44

pathogens in pyeo pregnancy

E.coli, Klebisiella, Group B strep.

increased risk in pregnancy

45

what diseases are we worried about in pregnancy

STI
PYELO
PNA

46

what does ALARA

ALARA: as low as reasonably achievable.

With respect to imaging

Risk highest in the first trimester and least in the third.

47

Higher rates of dissemination with this type of PNA in pregnancy

coccidyomycosis

48

Higher rates of morbidity and mortality; complications to the fetus with this type of pNA in pregnancy

varicella

49

High rates of respiratory failure with this type of PNA in pregnancyt

Influenza

50

what do you need to know about the increase risk of appy in pregnancy

Perforation rates increase with trimester.


risk of perf incraeases with trimester and increases risk to the fetus

imaginign ULS and MRI first

51

what test should be done to assess potential trauma to the fetus

Kleihauer–Betke

measures fetal hgb in mothers blood

52

new onset hypertension
excessive uterine size for dates
very elevated hCG levels
abnormal ULS
preeclampsia prior to 20 weeks

molar pregnancy

53

evaluation of a premature rupture of the membrane
PROM

iii. Nitrazine Paper: amniotic fluid has a pH of 6.5/7 or higher.

and ferning pattern on smear
Ferning: arborization of salt crystals in amniotic fluid.

54

when would a cervical exam be contraindicated

CONTRAINDICATED if you suspect placenta previa.

55

RF for Peripartum Cardiomyopathy

hypertension
preeclampsia
multiple gestations, advanced maternal age, African descent
use of prolonged tocolytics

56

sxs of preipartum cardiomyopathy

Peripartum Cardiomyopathy

57

causes of

preipartum cardiomyopathy

Causes include autimiimune, virally mediated
cytokine inflammatry repsonse
stress of pregnancy, genetics, nutrition, myocite apoptosis, elevated prolactin levels

58

approach to pregnant pt with dyspnea

Scrutinize the blood pressure, heart rate, and O2 sat.
Look for DVT.
Scan for PE if indicated.
Look for signs of heart failure.

59

Three medication for managing preeclampsia

: labetalol, nifedipine, hydralazine.

60

management of preterm labor

Tocolytics: Still given but not proven!

Calcium channel blockers now popular.
***Do not use more than one agent***
Corticosteroids: Proven! Give them!

Dexamethasone or betamethasone.
Fetal lung maturity.

Antibiotics: Proven, but only with ruptured membranes.
Increase the latency period in PPROM.

61

pelvic pain in female ddx

PID, ovarian cysts, torsion, endometriosis
Renal stones, renal infections
Appendicitis, diverticulitis, hernia

62

RF for ectopic pregnancy (6)

1. Current intrauterine contraception (IUD)

2. Hx of ectopic pregnancy, utero exposure to diethylstilbestrol

3. Hx genital infxn, including PID, chlamydia, gonorrhea

4. Hx of tubal surgery i.e. tubal ligation

5. IVF, infertility

6. Smoking

63

ddx of ectopic pregnancy

1. Acute appendicitis
2. Miscarriage
3. Ovarian torsion
4. PID
5. Ruptured corpus luteum cyst or follicle
6. Tubo-ovarian abscess
7. Urinary calculi

64

presentation of ectopic

1. Vaginal bleeding (only in 2/3 of pts!)
2. Abdominal pain
3. Normal or slightly enlarges uterus
4. Cervical motion tenderness
5. Hypotension/syncope
6. Palpable adnexal mass

65

mngmt of ectopic

1. No evidence of tubal rupture
2. Minimal pain or bleeding
3. Starting B-hCG <1,000 and falling
4. Ectopic or adnexal mass less than 3cm or not detected
5. No embryonic heartbeat
6. Then:
a. Admit or discharge & follow serial hCGs
b. Diagnostic laparoscopy
c. Presumptive methotrexate

66

Painless, bright red bleeding in 2nd or 3rd semester

what are you worried about

Placenta Previa

DON'T do a digital or speculum exam
iv. STAT abdominal U/S
v. Call OB stat for possible C/S

67

pt comes in with chief complain of pain in 2nd or 3rd trimester and vaginal bleeding

on PE she has a Tender uterus
and Hypertonic, hyperactive uterine contractions

Premature separation of a normally implanted placenta from the uterine wall
ii. Often misdiagnosed at preterm labor

68

Placental Abruption ddx

placenta previa
preterm labor

69

complication of placental abruption


1. Maternal death from hemorrhage or DIC
2. Fetal death, fetal distress
3. Fetomaternal transfusion
4. Amniotic fluid embolism
5. Hypotension

70

rf for placenta abruption

1. MCC HTN
2. Maternal trauma
3. AMA
4. Multiparity
5. Smoking
6. Cocaine use
7. Previous abruptions

71

management of placental abruption

1. Crystalloids to maintain volume status & FFP for coagulopathy
2. Emergency OB consult whenever suspected!
3. Stat U/S for fetal viability  emergency delivery
4. Rhogam, tetanus

72

Management of 1st trimester bleeding

Quantitative B-hcg >1800-2000
no sac on ULS
ectopic or SAB


U/S shows a gestational sac

a. Follow for threatened abortion
b. Consider subchorionic hemorrhage 
hematoma b/w chorion & uterine wall

73

Bright endometrial stripe suggests on evaluation of 1st trimester bleeding

SAB

74

Gestation sac >2cm should have a

embryo

75

Embryo > 5mm crown rump should have a

Heart beat

76

if fetal heart beat present in mother with 1st trimester bleeding

1. <35yo mother  2% risk of miscarriage
2. >35yo mother  16% risk of miscarriage

pt stable
Follow serial quantitative B-hcg q 48hrs
Confirm quant B-hcg double in 48hrs
Confirm IUP when B-hcg >1800-2000

77

CC of SAB

i. MCC chromosomal abnormalities (50-60%)
ii. AMA
iii. Prior poor OB hx  SABS, fetal demise, multiple gestations, uterine s/x
iv. Concurrent medical d/o  thyroid, DM, HTN, coagulopathies, P4 deficiency, SLE
v. Maternal infxn  HIV, syphilis, TORCH, GC/CT, UTI, vaginitis
vi. Exposures-> heavy metals, chemicals, tobacco, EToH, caffeine (>200mg/d)
vii. Meds antidepressants: paroxetine, venlafaxine

78

MCC of bleeding during 1st trimester

SAB

79

HELLP syndrome

1. Hemolysis
2. Elevated Liver Enzymes
3. Low Platelet count

(Often no HTN +/- proteinuria )

80

diagnoses of HELLP

CLINICAL

get
CBC, CMP, LFTs

81

presentation of HELLP

N/V, viral like, generalized malaise

Epigastric pain, HA

** any pregnant woman who presents w/ malaise or viral type illness in 3rd trimester should be eval w/ labs asap!

82

pe of HELLP

RUQ pain & tenderness  rupture of liver capsule= hematoma

83

TX of HELLPO

1. Prompt delivery of baby!
2. Magnesium sulfate --> decrease risk of seizures
3. Blood transfusions --> anemia
4. DIC --> fresh frozen plasma
5. Anti-HTN --> i.e. labetalol, hydralazine, nifedipine

84

Causes of PID

i. Salpingitis, endometriosis, tubo-ovarian abscess, pelvic peritonitis
ii. Neisseria gonorrhea, chlamydia trachomatis (may have been asymptomatic)
iii. Untreated cervicitis

85

RF of PID

i. Multiple sex partners
ii. Unprotected intercourse
iii. Hx of STIs
iv. Frequent vaginal douching
v. Younger age

86

clinical findings with PID

i. Lower abdominal pain
ii. abnml vaginal discharge
iii. vaginal bleeding
iv. post-coital bleeding
v. dyspareunia
vi. irritative voiding sxs
vii. malaise, N/V

87

PID PE

i. Lower abd TTP, abd guarding/rebound (peritonitis)
ii. CMT, uterine/adnexal TTP, adnexal mass or fullness (TOA)
iii. RUQ tenderness and jaundice

88

labs for suspected PID


i. hcG-->ectopic, SAB
ii. saline/KOH wet mounts--> trich
iii. endocervical swabs --> GC/CT, HIV, HEP
iv. CBC, ESR, CRP, liver panel

89

parenteral tx for PID


cefotetan or cefoxitin + doxycycline

Clindamycin or gentamycin

Ofloxacin or levofloxacin w/wo metronidazole

90

Oral/outpt

cefotetan or cefoxitin + probenecid + doxycycline w/wo metronidazole

91

alternative to doxy for PID

a. Azithromycin alternative to doxy

92

viollin strings is a classic appearance for

fitz hugh curtis syndrome

93

MC cystic growth in vagina

Bartholin Gland Cyst/Abscess

94

tx for Bartholin Gland Cyst/Abscess

depends on size, pain, infxn
i. Home tx
ii. I&D, word catheter placement
iii. Abx if cellulitis is present
iv. Marsupialization if recurrent

95

PID vs appy

PID: pain is NOT migratory
PID: pain is bilateral
PID: NOT associated with nausea and vomiting

96

Sudden onset of severe unilateral pelvic pain or dull aching pain w/ sharp exacerbations

and vomiting

torsion

get formal U/S to look at flow

ii. Pt w/ ovarian mass
iii. Pt w/ pelvic adhesions

97

tx of torsin

Adnexal torsion is a SURGICAL EMERGENCY
OR immedeatly

98

Superficial cellulitis of breast tissue that results in breast pain, swelling warmth, erythema, malaise, fever, chills

Mastitis/Breast Abscess

99

which populations do we usually see mastitis with

Often in first few wks of breastfeeding
Usually affects lactating women

100

Caused by a blocked milk duct that didn't empty during nursing

Stap aureus infxn

101

RF for mastitis

i. Breast feeding
ii. Sore or cracked nipples
iii. Breastfeeding only one position
iv. Wearing tight fitting bra
v. Fatigue
vi. Previous hx of mastitis

102

tx for mastitis if no response to anbxs

U/S if no response to supportive care or abx (mastitis vs abscess)

systemic emptying, anti-inflammatories, abx
Continue breast feeding!!

103

what should be on your tray for ED delivery

2 large hemostats
scissors
cord clamp
towels

syringe for cord gas

104

association between hypothermia and mortality

acidosis, respiratory distress, NEC, intraventricular hemorrhage

The smaller you are, the faster you lose heat. BIG problem less than 30 weeks

105

A ruptured cyst can causes abnormal vital signs and an acute abdomen in sudden unilateral pain think

e. A ruptured cyst can causes abnormal vital signs and an acute abdomen.

Cysts that are >8 cm, multiloculated, or solid are concerning for malignancy

106

chronic hypertension in pregnancy defined as

Defined HTN present before 20th wk of pregnancy or present before pregnancy


ii. Mild HTN: > 140-180/90-100
iii. Severe HTN: >180/100
iv. Major risk factor: development of preeclampsia or eclampsia later in pregnancy

107

preeclampsia

Preeclampsia is characterized by hypertension, greater than 140/90 mmHg, on two occasions at least 4 hours apart and proteinuria ≥300 mg in 24 hours in patients
at 20 weeks’ gestation until 4 to 6 weeks after delivery.

108

in the absence of proteinuria in a otherwise preeclampsic woman what can indicate this dx

In the absence of proteinuria, thrombocytopenia with platelet count less than 100,000,

elevation of liver enzymes twice normal,

new renal insufficiency with a creatinine of 1.1 or a doubling of serum creatinine,

pulmonary edema,

or new-onset mental status disturbances or visual disturbances can be used to make the diagnosis of preeclampsia.

109

what are some sxs of Preeclampsia

1. Facial edema, pulmonary edema, Ascites
a. Unresponsive to rest in supine position
2. BP > 160/110
3. Progressive renal insufficiency (Cr >1.1)
4. Cerebral or visual disturbances --> HA, scotomata
5. Epigastric or RUQ pain
6. Evidence of hepatic dysfunction-->transaminases doubled
7. Thrombocytopenia
8. Rapid weight gain (2lbs/wk)
9. Hyperreflexia or clonus at ankle -->worrisome!

110

Risks for preeclampsia

1. Placental abruption
2. ARF
3. Cerebral hemorrhage
4. Hepatic failure or rupture
5. Pulmonary edema
6. DIC
7. Progression to eclampsia (one of four leading causes of maternal death)

111

labs with preeclampsia

1. CBC
2. Platelets --> thrombocytopenia
3. PT, PTT--> coagulopathy
4. LFTS --> hepatocellular dysfunction
5. Serum Cr/ CrCl -->decreased renal function
6. 24hr urine -->protein

112

in a CBC if you see increased HCT on a pt with preeclampsia what are you worried about

increased Hct signals indicate worsening vasoconstriction & intravascular volume

113

what is eclampsia

i. Presence of convulsions/ grand mal seizures in a woman w/ preeclampsia NOT explained by a neuro d/o

114

when is eclampsia most commonly seen

ii. Most cases occur w/I 24hrs of delivery

115

what are the complications with eclampsia

1. Musculoskeletal injury
2. Hypoxia
3. Aspiration

116

tx of eclampsia

1. Urgent OBGYN consult!
2. Usually self-limited
a. Not dangerous unless >20min
b. Avoid delivery of baby
3. Tongue blade, gentle restraints, airway, IV access, foley catheter, EKG
4. Tx directed to initiation of Mg sulfate to prevent further studies