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Emergancy Obs and Gyn Flashcards

1
Q

What are the top acute pelvic pain differentials in a negative pregnancy test female?

A

Ovarian cysts rupture or torsion

Acute PID

Tubo-ovarian abscess

Appendicitis

UTI/ Pyelonephritis

Renal calculi

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2
Q

What are the top causes of early pregnancy bleed/ pain?

A

Threatened miscarriage

Ectopic pregnancy

Cervical ecotopian

Retained products of conception

Endometritis

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3
Q

What US findings are suggestive of an ectopic pregnancy?

A

Empty uterus

Pelvic mass

Free fluid

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4
Q

What are acute presenting symptoms of PID?

A

Pelvic pain
- bilateral

PV discharge

Deep Dyspareunia

Abnormal menstrual cycle

Sepsis

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5
Q

What are the top causes of swollen vulva?

A

Sebaceous cyst

Bartholin’s cyst

Solid tumours

  • Fibromas
  • Lipoma

Wolffian duct cyst

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6
Q

How should a woman be managed with sever hyperemesis gravidas?

A

Pregnancy unique quantification of emesis score
>12

Fluid replacement

Anti-emetics

  • H1 antagonists (Cyclizine)
  • Hydrocortisone (3rd line)

VTE prophylaxis

Vitamin replacement
- thiamine

Dietician review

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7
Q

What are the clinical signs of a ectopic pregnancy?

A

Amenorrhoea 6-8 weeks
or
Vaginal bleeding

Lower abdominal pain/ Lower quadrant pain

Shoulder tip pain

Cervical excitation

D&V

+/-

Peritonism

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8
Q

What investigations should be done into an ectopic pregnancy?

A

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

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9
Q

What is the management of an ectopic pregnancy?

A

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

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10
Q

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??

A

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
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11
Q

Highlight how to interpret a CTG:

A

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

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12
Q

What are the signs of cord prolapse and how is it managed?

A

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
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13
Q

In a pregnant mother who presents with bleeding, what questions do you want to ask?

A

OATS

  • Onset
  • Associated symptoms
  • Timing
  • Severity

+ history of pregnancy and PMH
+ fetal movements

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14
Q

HIghlight the management of a pregnant woman presenting with bleeding:

A

ABCDE

  • haemodynically stablise
  • call for help
  • fluids
  • Oxygen <94%

Bloods:

  • FBC
  • Cross Match
  • U&Es
  • Calcium and LFTs

Fetal monitoring

*consider tranexamic acid

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15
Q

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?

A

6 RBC
4 FFP
1 Platelets

Package B 
6 RBC 
4 FFP 
1 Platelets 
\+ 
2 pools of cyropercipatate
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16
Q

Which factor does cryoprecipitate contain high amounts of?

A 
VIII 
\+ 
Fibrinogen
\+
Von Willie Brand Factor
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17
Q

What is a useful imaging tool that can be used in the setting of severe lower quadrant pain and PV bleeding?

A

FAST scan

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18
Q

Which specialty needs to be called in an ectopic pregnancy?

A

gynaecological

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19
Q

Whats the best way to hand over?

A

RSBAR:

Recommendations 
Situation 
Background 
Assessment 
Recommendations
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20
Q

What are some symptoms of pre-eclampsia which suggest severe disease?

A 
Headache 
Blurry vision 
Clonus 
Swelling of hands and feet 
Flashing lights
Reduced fetal movements
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21
Q

In the management of severe pre-eclampsia, what medications would you be wanting to give?

A

Labetalol
- IV is best but only in high risk maternity setting

Magnesium sulphate
- only in high risk maternity setting

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22
Q

When a patient with preeclampsia has moved to HDU what is the management?

A

Active monitoring
Regular bloods

Labetalol/ nifedipine
+
Magnesium sulphate

Steroids if delivery is likely in <36 weeks gestation

Fetal monitoring

Early contact with paediatrics

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23
Q

What are thematernal and fetal complications of pre-eclampsia?

A

Maternal:

  • Intracerebral bleed
  • pulmonary oedema
  • HELLP syndrome
  • AKI
Fetal:
Placental abruption 
Intrauterine growth restriction 
Intra-uterine death 
Early labour
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24
Q

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?

A

Movements

- fetal movements gives a good idea of the intergrity of the child

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25
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
26
What are the drugs used in chorioamnionitis?
IV co-amoxiclav + IV gentamicin
27
What fluid should be prescribed to pregnant women?
Hartmanns
28
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
29
What is the immediate First management steps of sepsis in a pregnant lady?
Blood cultures IV antibiotics Serum Lactate MEOWS chart
30
What dose of labetalol is used in the first line of management for pre-eclampsia?
200mg
31
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
32
IN preeclampsia when is it considered a medical emergency? and what is the target blood pressure?
Treat at 150/100mmHg Admit if >160/110mmHg
33
What chart is used to assess vitals of a pregnant women?
Modified Early Obstetric Warning Score: | - MEOWS
34
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
35
What is the initial loading dose of Magnesium sulphate used in eclampsia?
4g/ 5mins
36
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%
37
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
38
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
39
Outline the main options for miscarriage include the need for anti-D prophylaxis:
Seen in early pregnancy centres: 1. conservative - let the products be expelled naturally * contraindicated in infection 2. Misoprostol - promotes uterine contraction and cervical dilation 3. Surgical: - manual Vacuum aspiration (+LA) - Electrical vacuum aspiration (+GA) Anti- D prophylaxis needed if: - Severe pain and bleeding - Surgical approach - any potential sensitising event
40
List the risk factors for ectopic pregnancy:
PID Pelvic surgery IUD Smoking Maternal age Endometriosis
41
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
42
What are the GTD risk factors?
Extremes of age: <20, >40 Previous molar pregnancy Ethnicity - South East Asia
43
When is Anti D prophylaxis required in ectopic pregnancy?
If mother is Rhesus negative then Anti - D prophylaxis is required after surgery
44
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
45
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
46
List some features suggestive of shoulder dystonia:
Head retraction between contractions Difficulty delivering the chin Turtle sign
47
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
48
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
49
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
50
What is the key sign in a placental abruption?
Severe pain with a tense uterus
51
What is the term used to describe a placental abruption which has bled through?
Couvelaire uterus
52
What are the cardinal signs of hypermagnesemia?
Hypotension Respiratory Depression Loss of tendon reflexes Arrhythmias Neurological impairment
53
What scoring system can be used to help identify women at risk of collapse or deterioration?
Modified Obstetric Early Warning Score (MOEWS)
54
What are the neurological symptoms of preeclampsia?
Visual defects - scotoma - floaters Headache Hyperreflexia - sustained clonus Seizures Stroke/ SAH
55
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 ```
56
Outline the signs and symptoms of chorioamnionitis:
Maternal: - tachycardia - fever - offensive discharge - abdominal/ uterus pain - raised CRP * raised WCC unreliable Fetus: - tachycardia - distress
57
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 ```
58
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
59
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
60
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.
61
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

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