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Specialities > Emergancy Obs and Gyn > Flashcards

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
Q

What are the major sources of sepsis in pregnant women? and highlight the other important management aspects outwith sepsis 6.

A

Sepsis secondary to chorioamnionitis

Sepsis due to UTI

Intraperitoneal sepsis

Management outwith sepsis 6:

  • Speculum examination
  • Urine dipstick
  • CTG
  • Inform SHO
26
Q

What are the drugs used in chorioamnionitis?

A

IV co-amoxiclav
+
IV gentamicin

27
Q

What fluid should be prescribed to pregnant women?

A

Hartmanns

28
Q

What are the most common organisms to cause sepsis in a pregnant woman?

A

Beta Haemolytic Strep (Group A)

Group B

E.Coli

Staph

*remember this is for female infection

29
Q

What is the immediate First management steps of sepsis in a pregnant lady?

A

Blood cultures
IV antibiotics
Serum Lactate
MEOWS chart

30
Q

What dose of labetalol is used in the first line of management for pre-eclampsia?

A

200mg

31
Q

There are some physiological changes that occur in the pregnant woman, which can make resuscitation and identifying serious disease more difficult, list some:

A

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
Q

IN preeclampsia when is it considered a medical emergency? and what is the target blood pressure?

A

Treat at 150/100mmHg

Admit if >160/110mmHg

33
Q

What chart is used to assess vitals of a pregnant women?

A

Modified Early Obstetric Warning Score:

- MEOWS

34
Q

What is the strict fluid input for a woman with pre-eclampsia? and how often should urine measurements be taken?

A

1ml/kg or 80ml/hour

Every 4 hours, wanting >100ml/4 hours

35
Q

What is the initial loading dose of Magnesium sulphate used in eclampsia?

A

4g/ 5mins

36
Q

What measurements/ examinations are needed when using magnesium sulphate in pregnancy?

and how do you manage magnesium sulphate toxicity?

A

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
Q

List the medication which can be given to promote uterine contractility during PPH and note how they are given:

A

Syntocinon (Oxytocin)
- IV infusion

Ergometrine (alpha/ dopaminergic/ serotonergic receptor)
- IV or IM

Carborpost (prostaglandin E2)
- IM

Misoprostol (Prostagladin E2)
- Suppository

38
Q

Highlight the investigations that should be carried out into a miscarriage:

A

Examination

  • check haemodynamic stability
  • assess pain
  • Examination for products of conception

Imaging:
- TVS

Bloods:

  • FBC
  • Blood group
  • Serum HCG tracking
39
Q

Outline the main options for miscarriage include the need for anti-D prophylaxis:

A

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
Q

List the risk factors for ectopic pregnancy:

A

PID

Pelvic surgery

IUD

Smoking

Maternal age

Endometriosis

41
Q

In an ectopic pregnancy the Beta hCG is measured 48 hours apart. What do the difference in measurements tell you?

A

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
Q

What are the GTD risk factors?

A

Extremes of age:
<20, >40

Previous molar pregnancy

Ethnicity
- South East Asia

43
Q

When is Anti D prophylaxis required in ectopic pregnancy?

A

If mother is Rhesus negative then Anti - D prophylaxis is required after surgery

44
Q

What are some of the severe complications of hyperemsis gravidum?

A

P.E
- hyperviscosity

Wernicke’s encephalopathy

Central pontine myelinolysis (over correction of hyponatremia)

Maternal death

DKA

45
Q

What is the definition for shoulder dystonia?

A

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
Q

List some features suggestive of shoulder dystonia:

A

Head retraction between contractions

Difficulty delivering the chin

Turtle sign

47
Q

List some of the maternal and fetal complications that can occur in shoulder dystocia:

A

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
Q

What are some of the risk factors and Clinical features of cord prolapse?

A

Risk factors:

  • polyhydramnios
  • Breach position
  • Preterm
  • Placenta previa
  • multiparity
  • male pregnancy
  • external cephalic rotation

Clinical features:

  • Decelerations
  • Single long deaccerleration
  • visible cord
  • bleeding
49
Q

There are two bleeding types of placental abruption, what are they?

A

Revealed
- where the blood shows on a PV bleed

Concealed
- where the blood is trapped retroplacental.
this can bleed through myometirum
- Couvelaire uterus

50
Q

What is the key sign in a placental abruption?

A

Severe pain with a tense uterus

51
Q

What is the term used to describe a placental abruption which has bled through?

A

Couvelaire uterus

52
Q

What are the cardinal signs of hypermagnesemia?

A

Hypotension

Respiratory Depression

Loss of tendon reflexes

Arrhythmias

Neurological impairment

53
Q

What scoring system can be used to help identify women at risk of collapse or deterioration?

A

Modified Obstetric Early Warning Score (MOEWS)

54
Q

What are the neurological symptoms of preeclampsia?

A

Visual defects

  • scotoma
  • floaters

Headache

Hyperreflexia
- sustained clonus

Seizures

Stroke/ SAH

55
Q

What are some of the haematological complications of pre-eclampsia and what investigations do you want to conduct into them?

A

Thrombocytopenia
Haemolysis of RBCs
DIC

FBC 
Platelet level 
Hb 
Coagulation 
LDH
56
Q

Outline the signs and symptoms of chorioamnionitis:

A

Maternal:

  • tachycardia
  • fever
  • offensive discharge
  • abdominal/ uterus pain
  • raised CRP
  • raised WCC unreliable

Fetus:

  • tachycardia
  • distress
57
Q

What are the investigations and management of chorioamnionitis?

A

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
Q

If there is an non-reassuring CTG during labour what things can be done immediately to try and resolve the fetal distress?

A

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
Q

What is the three rule of severe fetal bradycardia?

A

3 mins - call for help.

6 mins - move to theatre

9 mins - prepare for delivery

12mins - aim to deliver baby

60
Q

How is Chorioamnionitis managed with regard to delivery and if it is pre-term what is an importance difference in management?

A

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
Q

What tests can be done to confirm PPROM?

A

Sterile speculum examination to assess for fluid in the posterior fornix of vagina

TVS
- assess for oligohydramnios

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