Emergancy Obs and Gyn Flashcards
What are the top acute pelvic pain differentials in a negative pregnancy test female?
Ovarian cysts rupture or torsion
Acute PID
Tubo-ovarian abscess
Appendicitis
UTI/ Pyelonephritis
Renal calculi
What are the top causes of early pregnancy bleed/ pain?
Threatened miscarriage
Ectopic pregnancy
Cervical ecotopian
Retained products of conception
Endometritis
What US findings are suggestive of an ectopic pregnancy?
Empty uterus
Pelvic mass
Free fluid
What are acute presenting symptoms of PID?
Pelvic pain
- bilateral
PV discharge
Deep Dyspareunia
Abnormal menstrual cycle
Sepsis
What are the top causes of swollen vulva?
Sebaceous cyst
Bartholin’s cyst
Solid tumours
- Fibromas
- Lipoma
Wolffian duct cyst
How should a woman be managed with sever hyperemesis gravidas?
Pregnancy unique quantification of emesis score
>12
Fluid replacement
Anti-emetics
- H1 antagonists (Cyclizine)
- Hydrocortisone (3rd line)
VTE prophylaxis
Vitamin replacement
- thiamine
Dietician review
What are the clinical signs of a ectopic pregnancy?
Amenorrhoea 6-8 weeks
or
Vaginal bleeding
Lower abdominal pain/ Lower quadrant pain
Shoulder tip pain
Cervical excitation
D&V
+/-
Peritonism
What investigations should be done into an ectopic pregnancy?
Examination:
- ABCDE
- Bimanual examination (look for cervical excitation)
- Speculum - products of conception
Bloods:
- FBC
- Cross match - 6 Units of blood
- Serum Beta- hCG
Imaging:
- Abdominal ultrasound
- TVS
If diagnostically unsure:
- serial beta hCG levels
or if unstable and diagnostically unsure:
- Laparoscopy
What is the management of an ectopic pregnancy?
Medical:
- Stable patient
- No fetal heart beat
- Unruptured
- <1500iU B-hCG
- Methotrexate
Surgical:
*contact Gynaecology, anaesthetics and haematology
*anti - D prophylaxis
*Laparoscopic salpingectomy
or
*laparoscopic salpingotomy
What is a serious complication that can occur with IVF treatment and clomiphene? what are the symptoms and how should it be managed if severe??
Ovarian Hyperstimulation Syndrome:
Symptoms:
- Abdominal pain - ovarian enlargement
- Ascites
- Dyspnoea - pleural effusion
- Dehydration / hypotension - fluid shifts
- symptoms usually begin 3-7 days after administration of GnRH
Management: - admit - IV fluids (colloids?) - Analgesia (not NSAIDs) - Prophylactic VTE \+/- - Paracentesis
Highlight how to interpret a CTG:
DR C BRAVDO
DR - Define risk (is the pregnancy high risk)
C - Contraction (how many, how intense)
BRA - Baseline rate
V - Variability
D - Deaccelerations
O - Overall impression
What are the signs of cord prolapse and how is it managed?
Deceleration of fetal heart
Single long deaceleration
Visible cord
Bleeding per vagina
Management:
- Avoid handling of cord
- Reduce pressure on cord
- place mother on all 4’s with knees to chest
- tocolytics if delivery can not be done immediately
- Forceps delivery if cervix is open
- C-section if cervix is closed
In a pregnant mother who presents with bleeding, what questions do you want to ask?
OATS
- Onset
- Associated symptoms
- Timing
- Severity
+ history of pregnancy and PMH
+ fetal movements
HIghlight the management of a pregnant woman presenting with bleeding:
ABCDE
- haemodynically stablise
- call for help
- fluids
- Oxygen <94%
Bloods:
- FBC
- Cross Match
- U&Es
- Calcium and LFTs
Fetal monitoring
*consider tranexamic acid
In a major haemorrhage protocol for obstetric emergency, package A should be requested. What does this contain? and what do you request if this is ongoing?
6 RBC
4 FFP
1 Platelets
Package B 6 RBC 4 FFP 1 Platelets \+ 2 pools of cyropercipatate
Which factor does cryoprecipitate contain high amounts of?
VIII \+ Fibrinogen \+ Von Willie Brand Factor
What is a useful imaging tool that can be used in the setting of severe lower quadrant pain and PV bleeding?
FAST scan
Which specialty needs to be called in an ectopic pregnancy?
gynaecological
Whats the best way to hand over?
RSBAR:
Recommendations Situation Background Assessment Recommendations
What are some symptoms of pre-eclampsia which suggest severe disease?
Headache Blurry vision Clonus Swelling of hands and feet Flashing lights Reduced fetal movements
In the management of severe pre-eclampsia, what medications would you be wanting to give?
Labetalol
- IV is best but only in high risk maternity setting
Magnesium sulphate
- only in high risk maternity setting
When a patient with preeclampsia has moved to HDU what is the management?
Active monitoring
Regular bloods
Labetalol/ nifedipine
+
Magnesium sulphate
Steroids if delivery is likely in <36 weeks gestation
Fetal monitoring
Early contact with paediatrics
What are thematernal and fetal complications of pre-eclampsia?
Maternal:
- Intracerebral bleed
- pulmonary oedema
- HELLP syndrome
- AKI
Fetal: Placental abruption Intrauterine growth restriction Intra-uterine death Early labour
When ever a mother presents during 3rd trimester with a potentially serious complication - what is an important thing to ask with regard to the fetus?
Movements
- fetal movements gives a good idea of the intergrity of the child
What are the major sources of sepsis in pregnant women? and highlight the other important management aspects outwith sepsis 6.
Sepsis secondary to chorioamnionitis
Sepsis due to UTI
Intraperitoneal sepsis
Management outwith sepsis 6:
- Speculum examination
- Urine dipstick
- CTG
- Inform SHO
What are the drugs used in chorioamnionitis?
IV co-amoxiclav
+
IV gentamicin
What fluid should be prescribed to pregnant women?
Hartmanns
What are the most common organisms to cause sepsis in a pregnant woman?
Beta Haemolytic Strep (Group A)
Group B
E.Coli
Staph
*remember this is for female infection
What is the immediate First management steps of sepsis in a pregnant lady?
Blood cultures
IV antibiotics
Serum Lactate
MEOWS chart
What dose of labetalol is used in the first line of management for pre-eclampsia?
200mg
There are some physiological changes that occur in the pregnant woman, which can make resuscitation and identifying serious disease more difficult, list some:
Plasma volume: Increased 50%
- dilutional anaemia
Increased HR: Increased 20bpm
- masks sepsis
- reduced reserve
Reduced systemic resistance
- unable to maintain BP as well
- more pooling of blood
Decreased BP
- reduced reserves
Oxygen requirements increase
- Hypoxia develops more quickly
Gastric mobility and LOS relaxation:
- higher risk of aspiration
IN preeclampsia when is it considered a medical emergency? and what is the target blood pressure?
Treat at 150/100mmHg
Admit if >160/110mmHg
What chart is used to assess vitals of a pregnant women?
Modified Early Obstetric Warning Score:
- MEOWS
What is the strict fluid input for a woman with pre-eclampsia? and how often should urine measurements be taken?
1ml/kg or 80ml/hour
Every 4 hours, wanting >100ml/4 hours
What is the initial loading dose of Magnesium sulphate used in eclampsia?
4g/ 5mins
What measurements/ examinations are needed when using magnesium sulphate in pregnancy?
and how do you manage magnesium sulphate toxicity?
Hourly urine measurements
- Mg is secreted out the urine therefore, oliguria can lead to toxic levels
Respiratory rate
Deep tendon reflex
Management of toxicity:
- call for help
- stop drug
- Oxygen/ intubate early
- Calcium gluconate 1g - 10ml/10%
List the medication which can be given to promote uterine contractility during PPH and note how they are given:
Syntocinon (Oxytocin)
- IV infusion
Ergometrine (alpha/ dopaminergic/ serotonergic receptor)
- IV or IM
Carborpost (prostaglandin E2)
- IM
Misoprostol (Prostagladin E2)
- Suppository
Highlight the investigations that should be carried out into a miscarriage:
Examination
- check haemodynamic stability
- assess pain
- Examination for products of conception
Imaging:
- TVS
Bloods:
- FBC
- Blood group
- Serum HCG tracking
Outline the main options for miscarriage include the need for anti-D prophylaxis:
Seen in early pregnancy centres:
- conservative
- let the products be expelled naturally
* contraindicated in infection - Misoprostol
- promotes uterine contraction and cervical dilation - Surgical:
- manual Vacuum aspiration (+LA)
- Electrical vacuum aspiration (+GA)
Anti- D prophylaxis needed if:
- Severe pain and bleeding
- Surgical approach
- any potential sensitising event
List the risk factors for ectopic pregnancy:
PID
Pelvic surgery
IUD
Smoking
Maternal age
Endometriosis
In an ectopic pregnancy the Beta hCG is measured 48 hours apart. What do the difference in measurements tell you?
If hCG is >1500iU then it is ectopic until proven otherwise
After 48hours, the following are suggestive of:
> 66% increase/ doubles = intrauterine pregnancy
Remains same or does not exceed a <66% increase = ectopic
If it halves = miscarriage
What are the GTD risk factors?
Extremes of age:
<20, >40
Previous molar pregnancy
Ethnicity
- South East Asia
When is Anti D prophylaxis required in ectopic pregnancy?
If mother is Rhesus negative then Anti - D prophylaxis is required after surgery
What are some of the severe complications of hyperemsis gravidum?
P.E
- hyperviscosity
Wernicke’s encephalopathy
Central pontine myelinolysis (over correction of hyponatremia)
Maternal death
DKA
What is the definition for shoulder dystonia?
Anterior shoulder compresses against the maternal pubic symphysis
or
Posterior shoulder compresses against the maternal sacral promontory
**officially diagnosed when head delivery has occurred but the child then remains stuck
List some features suggestive of shoulder dystonia:
Head retraction between contractions
Difficulty delivering the chin
Turtle sign
List some of the maternal and fetal complications that can occur in shoulder dystocia:
Maternal:
- PPH
- Soft tissue injury (tears, uterine rupture)
- symphyseal separation
Fetal:
- hypoxic ischemic injury
- Erbs palsy (waiter tip hand/ lateral)
- Klumpe’s palsy (claw hand/ medial)
Fractures to clavicle
What are some of the risk factors and Clinical features of cord prolapse?
Risk factors:
- polyhydramnios
- Breach position
- Preterm
- Placenta previa
- multiparity
- male pregnancy
- external cephalic rotation
Clinical features:
- Decelerations
- Single long deaccerleration
- visible cord
- bleeding
There are two bleeding types of placental abruption, what are they?
Revealed
- where the blood shows on a PV bleed
Concealed
- where the blood is trapped retroplacental.
this can bleed through myometirum
- Couvelaire uterus
What is the key sign in a placental abruption?
Severe pain with a tense uterus
What is the term used to describe a placental abruption which has bled through?
Couvelaire uterus
What are the cardinal signs of hypermagnesemia?
Hypotension
Respiratory Depression
Loss of tendon reflexes
Arrhythmias
Neurological impairment
What scoring system can be used to help identify women at risk of collapse or deterioration?
Modified Obstetric Early Warning Score (MOEWS)
What are the neurological symptoms of preeclampsia?
Visual defects
- scotoma
- floaters
Headache
Hyperreflexia
- sustained clonus
Seizures
Stroke/ SAH
What are some of the haematological complications of pre-eclampsia and what investigations do you want to conduct into them?
Thrombocytopenia
Haemolysis of RBCs
DIC
FBC Platelet level Hb Coagulation LDH
Outline the signs and symptoms of chorioamnionitis:
Maternal:
- tachycardia
- fever
- offensive discharge
- abdominal/ uterus pain
- raised CRP
- raised WCC unreliable
Fetus:
- tachycardia
- distress
What are the investigations and management of chorioamnionitis?
Bloods:
- FBC
- Blood cultures
- CRP
- U&Es
- ABG
Orifices:
- High vaginal swap
- urine dip
Management: - Sepsis - broad spectrum \+/- delivery of fetus *do not use spinal for this
If there is an non-reassuring CTG during labour what things can be done immediately to try and resolve the fetal distress?
Change maternal position by getting her to lie on the left side
- reduce compression on IVC improving cardiac output
Improve dehydration of mother
If epidural has been given then IV fluids can be given to try and improve hypotension
Reduce oxytocin rate if hyperstimulation is occurring
What is the three rule of severe fetal bradycardia?
3 mins - call for help.
6 mins - move to theatre
9 mins - prepare for delivery
12mins - aim to deliver baby
How is Chorioamnionitis managed with regard to delivery and if it is pre-term what is an importance difference in management?
Delivery is usually indicated.
Prolonging the fetus to the environment massively increases the risk of cerebral palsy
If preterm usually steroids are given. However in the setting of chorioamnionitis this is not recommended due to risk to mother.
What tests can be done to confirm PPROM?
Sterile speculum examination to assess for fluid in the posterior fornix of vagina
TVS
- assess for oligohydramnios
