Ch 11. Obstetrics Gynecology Flashcards
Most common coagulation disorder in women with heavy uterine bleeding (1)
- Von Willebrand’s disease
* 20% of women with HUB have a coagulation disorder
DDx of uterine bleeding (non-pregnant) (9)
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
Treatment of severe vaginal bleeding (4)
- 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
PCOS triad (3)
- Hirsutism
- Obesity
- Oligomenorrhea
Classic symptoms of ovarian torsion (2).
Diagnostic study and sensitivity (1)
- Sudden onset severe lower abdo pain, +/- N+V. * Often a large cyst or tumor is present on the ovary.
- 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
Estimated beta-HCG level at 1-4-8-12 weeks (4)
How often does beta-HCG double? (1)
- 1 week = 100
- 4 weeks = 1000
- 8 weeks=10,000
- 12 weeks=100,000
- Beta-HCG should double every 2 days in early pregnancy (but can increase 50%-200%)
When is a urine B-HCG unreliable (2)
- Needs to be at least 20mIU/mL
- Urine needs to be specific gravity > 1.015
Always use a serum B-HCG to exclude ectopic. Urine is 95% Sn and Sp.
Risk factors for ectopic pregnancy (5)
* 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
Rate of heterotopic pregnancy in normal and IVF populations (1)
- Heterotopic pregnancy normally less than 1:3,000.
In IVF populations can be up to 5%
Beta-HCG discriminatory zone to visualize an IUP (2)
- Transvaginal=1500
2. Transabdominal=3000-6000 (differs depending on source)
Treatment of ectopic pregnancy (3)
- Surgery (salpingectomy)
- Methotrexate – small ectopic, stable patient, good FU
3. Rhogam for Rh- (50mcg if <12 weeks, or 300mcg ok too)
DDx for bleeding in first trimester pregnancy (4)
- Ectopic/heterotopic
- Abortion/miscarriage
- implantation bleeding
- Gestational trophoblastic neoplasm
Define threatened abortion, inevitable, incomplete, complete, missed, septic (6)
- 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
Molar pregnancy/GTN symptoms (2)
- Vaginal bleeding (90%)
2. Hyperemesis (26%) - Beta-HCG SKY HIGH. Uterine size much bigger than dates.
- Ultrasound shows grapes in clusters
Which drugs can you use in hyperemesis gravidarum (3)
- Diclectin (doxylamine with pyridoxine)
- Ondansetron
- Maxeran
4. Diphenhydramine
*Ketonuria is a sign of dehydration. Use D5W for rehydration.
Define: chronic hypertension in pregnancy, gestational hypertension, pre-eclampsia, eclampsia, HELLP syndrome (5)
- Chronic hypertension in pregnancy – BP >140/90 before 20 weeks. Rx lifestyle unless severe
- Gestational hypertension – hypertension after 20 weeks.
- Pre-eclampsia – hypertension + proteinuria after 20 weeks, +/- HA, visual changes, pulm edema, RUQ pain/elevated LFTs, thrombocytopenia, oliguria, impaired fetal growth
4. Eclampsia - HELLP syndrome – abdominal pain, N+V, malaise, hemolysis, elevated liver enzymes, low platelets, DIC, maternal/fetal death
Medications to treat hypertension in pregnancy (2)
- Labetalol: 100mg PO TID
2. Nifedipine: 30mg po qDaily - Hydralazine 5mg IV q20min
- HCTZ 12.5mg po qDaily
Treatment of severe pre-eclampsia or eclampsia (1)
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
Signs of magnesium toxicity (2)
- Decreased respirations
- Decreased reflexes
- Hypotension
Treatment of asymptomatic bacturia in pregnancy (1)
- Nitrofurantoin (not in third trimester) or cefixime.
Approach to query DVT in pregnancy (2)
- Well’s score not validated in pregnancy but consider those risk factors/symptoms
- Ultrasound is the first line test
- 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
What is the risk of PE in pregnancy? Is pregnancy a PE risk factor? (2)
- Risk of PE in pregnancy 1:10,000
2. Pregnancy is a risk factor (RR ~10, but most of that is the peripartum period!)
Workup of query PE in pregnancy (2)
- Start with leg US only if they have leg symptoms. If positive you’re done.
- If CXR normal, do a VQ
- If CXR abnormal, do a CT-PE
What is the radiation from a VQ or CT? What is the background radiation over 9months? (1)
- Radiation from a VQ/CT = 0.5mSv
2. Background radiation over 9 months = 5mSv
DDx vaginal bleeding over 20 weeks (3)
- 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.
Causes of post-partum hemorrhage (4)
- 10% drop in HGB, 500mL vaginal, 1000mL CSx
1. Tone (uterine atony)
2. Trauma (laceration or tear)
3. Tissue (retained products)
4. Thrombin (coagulopathy)
A peri-mortem C-section needs to be performed with ____ minutes (1)
- 4 minutes to begin: baby out in 5 minutes
Treatment of post-partum hemorrhage (2)
- Fluid and blood resuscitation
- Oxytocin 10units IM, 40units in 1L saline over 1 hour
3. Bimanual uterine massage, examine for trauma
Post-partum fever is ______ until proven otherwise (1)
- Endometritis (even with scant discharge). Consider antibiotics. Also consider Wound, Wind, Water, Weins
DDx of vulvovaginitis (5)
- 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. - PID (infection: C, G, polymicrobial)
- Foreign body
- Contact vaginitis
- Atrophic vaginitis
Which position to Bartholin gland abscesses appear? (1)
- 4 and 8 o’clock - Do an I+D.. definitive Tm requires marsupialization
Treatment of breast mastitis (2)
- 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
After laparoscopic surgery, when should sub-diaphragmatic air/CO2 be absorbed? (1)
- By post-op day 3
Significant pain after laparoscopy is ________ until proven otherwise? (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.
Sign of shoulder dystocia (1) and treatment of dystocia (1)
- Shoulder dystocia = turtle head in and out
- Treatment of dystocia = HELP. Help!.. call for it. Episiotomy. Legs flexed (McRobert’s maneuvre), Pressure, deliver posterior shoulder, corkscrew, break clavicle, CSx
Tocolytics (2), and contraindications to tocolysis (5)
- Magnesium 4g bolus over 30minutes
- 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.
Signs/symptoms of pre-eclampsia (3)
- Edema
- HTN (Mild >140/90, Severe >160/90)
- Proteinuria (Severe >3g/24hours)
+/- headache
Overian cancer tumor marker (1)
- CA-125
* Any ascites in an older female (>55years) think ovarian Ca
Symptoms of PID (4). Treatment of PID (1)
- Lower abdominal pain
- Vaginal discharge or bleeding
- Post-coital bleeding
- 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 - 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
