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Emergency Medicine - BT > Ch 11. Obstetrics Gynecology > Flashcards

Ch 11. Obstetrics Gynecology Flashcards

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1
Q

Most common coagulation disorder in women with heavy uterine bleeding (1)


A
  1. Von Willebrand’s disease


* 20% of women with HUB have a coagulation disorder


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2
Q

DDx of uterine bleeding (non-pregnant) (9)


A

PALM-COEIN

1. Polyp - benign

2. Adenomyosis – endometrial tissue within the myometrium. Painful, heavy periods. 

3. Leiomyoma (fibroids) – pelvic pain and bleeding, especially if they degenerate

4. Malignancy – Cervical, Endometrial, Uterine. 

5. Coagulopathy – von willebrand disease, factor VIII, ITP, hemophilia carrier

6. Ovulatory dysfunction - hypothyroid

7. Endometrial – endometrial hyperplasisa

8. Iatrogenic - OCP

9. NYD – PID, trauma, foreign body


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3
Q

Treatment of severe vaginal bleeding (4)


A
  • Check B-HCG, CBC, type+screen, call for 2 units pRBC
    
1. Transfuse pRBC

    2. IV conjugated estrogen (premarin 25mg IV)

    3. Tranexamic acid

    4. Local hemostasis

    5. Vaginal packing (last resort)

    6. Consult OB-GYN for surgery

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4
Q

PCOS triad (3)


A
  1. Hirsutism

  2. Obesity

  3. Oligomenorrhea
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5
Q

Classic symptoms of ovarian torsion (2).

Diagnostic study and sensitivity (1)


A
  1. Sudden onset severe lower abdo pain, +/- N+V.
* Often a large cyst or tumor is present on the ovary. 

  2. Ultrasound. 75% are right sided (right sided tube is longer) and US is only 75% sensitive.

    * Consult OB-GYN if clinical suspicion is high even if the US is negative

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6
Q

Estimated beta-HCG level at 1-4-8-12 weeks (4)


How often does beta-HCG double? (1)


A
  1. 1 week = 100

  2. 4 weeks = 1000

  3. 8 weeks=10,000

  4. 12 weeks=100,000

  5. Beta-HCG should double every 2 days in early pregnancy (but can increase 50%-200%)
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7
Q

When is a urine B-HCG unreliable (2)


A
  1. Needs to be at least 20mIU/mL

  2. Urine needs to be specific gravity > 1.015
    
Always use a serum B-HCG to exclude ectopic. Urine is 95% Sn and Sp.

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8
Q

Risk factors for ectopic pregnancy (5)


A 
* The MAJORITY of ectopics occur in those with ZERO risk factors. 

1. PID (Hx of STI infection)

2. Previous tubal surgery

3. Previous ectopic

4. Advanced maternal age (>35)

5. Assisted reproductive technology/IVF

6. Cigarette smoking

7. Previous D+C

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9
Q

Rate of heterotopic pregnancy in normal and IVF populations (1)


A
  1. Heterotopic pregnancy normally less than 1:3,000.


In IVF populations can be up to 5%


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10
Q

Beta-HCG discriminatory zone to visualize an IUP (2)


A
  1. Transvaginal=1500


2. Transabdominal=3000-6000 (differs depending on source)


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11
Q

Treatment of ectopic pregnancy (3)


A
  1. Surgery (salpingectomy)

  2. Methotrexate – small ectopic, stable patient, good FU
    
3. Rhogam for Rh- (50mcg if <12 weeks, or 300mcg ok too)

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12
Q

DDx for bleeding in first trimester pregnancy (4)


A
  1. Ectopic/heterotopic

  2. Abortion/miscarriage
  3. implantation bleeding
  4. Gestational trophoblastic neoplasm

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13
Q

Define threatened abortion, inevitable, incomplete, complete, missed, septic (6)


A
  1. Threatened=small bleed, Inevitable=bleeding+cervical dilatation, Incomplete=passage of some products, Complete=passage of all tissue, Missed=fetal death <20weeks without passing tissue, Septic=abortion+infection

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14
Q

Molar pregnancy/GTN symptoms (2)


A
  1. Vaginal bleeding (90%)
    
2. Hyperemesis (26%)

  2. Beta-HCG SKY HIGH. Uterine size much bigger than dates. 

  3. Ultrasound shows grapes in clusters

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15
Q

Which drugs can you use in hyperemesis gravidarum (3)


A
  1. Diclectin (doxylamine with pyridoxine)

  2. Ondansetron

  3. Maxeran
    
4. Diphenhydramine
    *Ketonuria is a sign of dehydration. Use D5W for rehydration. 

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16
Q

Define: chronic hypertension in pregnancy, gestational hypertension, pre-eclampsia, eclampsia, HELLP syndrome (5)


A
  1. Chronic hypertension in pregnancy – BP >140/90 before 20 weeks. Rx lifestyle unless severe

  2. Gestational hypertension – hypertension after 20 weeks. 

  3. Pre-eclampsia – hypertension + proteinuria after 20 weeks, +/- HA, visual changes, pulm edema, RUQ pain/elevated LFTs, thrombocytopenia, oliguria, impaired fetal growth
    
4. Eclampsia

  4. HELLP syndrome – abdominal pain, N+V, malaise, hemolysis, elevated liver enzymes, low platelets, DIC, maternal/fetal death

17
Q

Medications to treat hypertension in pregnancy (2)


A
  1. Labetalol: 100mg PO TID
    
2. Nifedipine: 30mg po qDaily

  2. Hydralazine 5mg IV q20min

  3. HCTZ 12.5mg po qDaily
18
Q

Treatment of severe pre-eclampsia or eclampsia (1)


A

Pre-eclampsia = BP>140/90, Proteinuria >0.3g/24h, >20weeks gestation

Eclampsia is seizures >20weeks to 4 weeks post-partum (seizure, coma, encephalopathy)

1. Magnesium 4g over 20min, then 2g/hour
2. Deliver the baby

19
Q

Signs of magnesium toxicity (2)


A
  1. Decreased respirations

  2. Decreased reflexes

  3. Hypotension

20
Q

Treatment of asymptomatic bacturia in pregnancy (1)


A
  1. Nitrofurantoin (not in third trimester) or cefixime. 

21
Q

Approach to query DVT in pregnancy (2)


A
  1. Well’s score not validated in pregnancy but consider those risk factors/symptoms
  2. Ultrasound is the first line test
  3. You can use D dimer as a good rule out (good sensitivity but lots of false positive, especially in third trimester). Only useful in first trimester (50% will be positive at baseline!)
    * If US is negative consider serial US on day 3, or a negative D-Dimer is a good rule out

22
Q

What is the risk of PE in pregnancy? Is pregnancy a PE risk factor? (2)


A
  1. Risk of PE in pregnancy 1:10,000


2. Pregnancy is a risk factor (RR ~10, but most of that is the peripartum period!)


23
Q

Workup of query PE in pregnancy (2)


A
  1. Start with leg US only if they have leg symptoms. If positive you’re done.
  2. If CXR normal, do a VQ

  3. If CXR abnormal, do a CT-PE
24
Q

What is the radiation from a VQ or CT? What is the background radiation over 9months? (1)


A
  1. Radiation from a VQ/CT = 0.5mSv


2. Background radiation over 9 months = 5mSv

25
Q

DDx vaginal bleeding over 20 weeks (3)


A
  • Do not do a digital or speculum exam until TV US rules out placenta previa
    
1. Placental abruption – painless vag bleeding. Spontaneously, or after very minor trauma
    
2. Placenta previa (painless vaginal bleeding) – no pelvic
    
3. Vasa previa – late pregnancy, fetal bleeding. Needs stat delivery.
26
Q

Causes of post-partum hemorrhage (4)


A
  • 10% drop in HGB, 500mL vaginal, 1000mL CSx
    1. Tone (uterine atony)

    2. Trauma (laceration or tear)

    3. Tissue (retained products)

    4. Thrombin (coagulopathy)

27
Q

A peri-mortem C-section needs to be performed with ____ minutes (1)


A
  1. 4 minutes to begin: baby out in 5 minutes
28
Q

Treatment of post-partum hemorrhage (2)


A
  1. Fluid and blood resuscitation
  2. Oxytocin 10units IM, 40units in 1L saline over 1 hour
    
3. Bimanual uterine massage, examine for trauma

29
Q

Post-partum fever is ______ until proven otherwise (1)


A
  1. Endometritis (even with scant discharge). Consider antibiotics. Also consider Wound, Wind, Water, Weins
30
Q

DDx of vulvovaginitis (5)


A
  1. BV – fishy odour. Thin white discharge. Clue cells. Rx. Flagyl 500mg PO BID 5/7
    
2. Yeast (vaginal candidiasis) – thick, curdy discharge. Rx Vagifem or Fluconazole 150mg PO x1.
    
3. Trichomoniasis – frothy discharge. Rx Flagyl 2g PO x1. 

  2. PID (infection: C, G, polymicrobial)

  3. Foreign body

  4. Contact vaginitis

  5. Atrophic vaginitis
31
Q

Which position to Bartholin gland abscesses appear? (1)


A
  1. 4 and 8 o’clock
- Do an I+D.. definitive Tm requires marsupialization 

32
Q

Treatment of breast mastitis (2)


A
  1. Keep breastfeeding (or pumping)
    
2. Keflex

    *Do a bedside US to make sure no abscess.

    *If infection/abscess fails to resolve, do a prompt mammogram and Bx to rule out malignancy
33
Q

After laparoscopic surgery, when should sub-diaphragmatic air/CO2 be absorbed? (1)


A
  1. By post-op day 3

34
Q

Significant pain after laparoscopy is ________ until proven otherwise? (1)


A
  1. Bowel injury

    * Thermal burns are not recognized at the time: can lead to bowel, vascular and urinary tract injury. Also consider dehiscence and wound infection.
Flank pain? Consider ureteral injury.

35
Q

Sign of shoulder dystocia (1) and treatment of dystocia (1)

A
  1. Shoulder dystocia = turtle head in and out
  2. Treatment of dystocia = HELP. Help!.. call for it. Episiotomy. Legs flexed (McRobert’s maneuvre), Pressure, deliver posterior shoulder, corkscrew, break clavicle, CSx
36
Q

Tocolytics (2), and contraindications to tocolysis (5)

A
  1. Magnesium 4g bolus over 30minutes
  2. Terbutaline
    * Consider corticosteroids to enhance lung maturity if baby <36 weeks
    * Contraindications to tocolysis: sepsis, fetal distress, acute vaginal bleeding, eclampsia, DIC, basically if anyone is SICK.
37
Q

Signs/symptoms of pre-eclampsia (3)

A
  1. Edema
  2. HTN (Mild >140/90, Severe >160/90)
  3. Proteinuria (Severe >3g/24hours)
    +/- headache
38
Q

Overian cancer tumor marker (1)

A
  1. CA-125

* Any ascites in an older female (>55years) think ovarian Ca

39
Q

Symptoms of PID (4). Treatment of PID (1)


A
  1. Lower abdominal pain

  2. Vaginal discharge or bleeding

  3. Post-coital bleeding

  4. Irritative voiding, fever, malaise, N+V
    
5. Signs = cervical motion tenderness, adnexal tenderness, purulent cervicitis

    Bugs=C+G, HSV1/2, Trichomonas, mycoplasma, anaerobes, E.coli, often POLYMICROBIAL

  5. EMPERIC TREATMENT! Clinical Dx. Ceftriaxone 250mg IM + Doxy 100mg po BID 14 days

    If sick Ceftriaxone 2g IV + Doxy PO/IV
    
If not improving consider tubo-ovarian abscess and get an US.
    *RUQ/shoulder pain + PID = Fitz-Hugh-Curtis syndrome

Emergency Medicine - BT (16 decks)

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