Emergencies Flashcards
What are 8 risk factors for ectopic pregnancy? (LTC)
- Previous salpingitis (PID)
- Previous ectopic/tubal surgery (Tubal ligation)
- Hormonal - Progestin induced
- Intrauterine device (IUD)
- Smoking
- Increasing age
- Fertility rx
- Regular douching
In ectopic pregancy, what are six HIGH risks? (U2D)
1) Previous ectopic pregnancy
2) Previous tubal ligation
3) Tubal ligation
4) Tubal pathology
5) In utero DES exposure
6) Current IED use
In ectopic pregancy, what are six MODERATE risks? (U2D)
1) Infertility
2) Previous Cervicitis (Gonorrhea/Chlamydia)
3) History of Pelvic Inflammatory Disease
4) Multiple secual partners
5) Smoking
In ectopic pregancy, what are six LOW risks? (U2D)
1) Previous pelvic/abdominal surgery
2) Vaginal douching
3) Early age intercourse (
What are the prevalent locations in order of precedence of ectopic pregancy in natural conception or assisted reproductive technology (ART)?
Ovarian, Fibral, Ampullary, Isthmic, Cornual, Cervical?
What are 6 SYMPTOMS of ectopic pregnancy? (LTC)
1) Abdominal pain (>80%)
2) Amenorrhea (>75%)
3) Vaginal bleeding (>50%)
4) Pregnancy sx (>10%)
5*) Shoulder pain—diaphragm irritation
6*) Defecatory urge—pooling in pouch of Douglas
What are 3 SIGNS of ectopic pregnancy?
1) Abdominal TTP (>80%)
2) Adnexal TTP (>75%)
3) Adnexal mass (>50%)
What are 5 GYNECOLOGICAL DDx of ectopic pregnancy?
1) Threatened/incomplete Ab
2) Ruptured CL cyst
3) Acute PID
4) Adnexal torsion
5) Degenerating leiomyoma
What are 3 NON-GYNECOLOGICAL DDx of ectopic pregnancy?
1) Acute appendicitis
2) Pyelonephritis
3) Pancreatitis
What is the standard of diagnosis for ectopic pregnancy and what lab needs to be above threshold?
TVUS - Transvaginal Ultrasound
Provides definitive diagnosis when hCG levels are above the discriminatory threshold.
TVUS differentiates _______ from ______ ______?
Differentiates ectopic from threatened abortion
In diagnosing ectopic pregnancy, what are the 3 milestones in weeks and from what date are they calculated from?
1) Gestational Sac (5 weeks)
2) Fetal pole (6-7 weeks)
3) Cardiac activity (8 weeks)
They are calculated from last menstral period (LMP)
What is the “discriminatroy threshold” of hCG and what ultrasound diagnostic needs to be done?
1) >6500 ng/ml = TAUS (Transabdominal)
2) >1500 ng/ml = TVUS (Transvaginal)
What is a heterotopic pregnancy?
What is the incidence between spontaneous gestation and IVF?
Coexistance of an intrauterine pregnancy AND an ectopic pregnancy.
1: 10,000 spontaneous gestations
1: 100 IVF
What is a pharmaceutical treatment of an ectopic pregnancy?
How is it dosed?
Methotrexate (MTX)
Dose by body surface area (BSA) (50mg/sqm)
What are the 8 indications for use of pharmaceutical treatment in an ectopic pregnancy?
1) Hemodynamically stable
2) Desires fertility
3) “Small” “Early”
4) No fetal cardiac activity
5)
6) No med hx (liver, renal disease)
7) No breast feeding
8) Good follow-up candidate
What are the possible surgical interventions for ectopic pregnancy?
Laparoscopy/-otomy
1) Linear salpingotomy
2) Salpingectomy
What are 7 indications of SURGICAL treatment in ectopic pregnancy?
1) Hemodynamic instability
2) Contraindications to MTX
3) Coexisting IUP
4) Desire for permanent sterilization
5) Failed medical treatment
6) Impending or ongoing ectopic rupture
7) Not able or willing to comply with medical post-tx follow-up
What is the leading cause of spontaneous abortion?
50% attributed to chromosomal abnormalities, ie increasing maternal age
80% of spontaneous abortinos occur prior to _______ weeks.
12 weeks
What type of spontaneous abortion has;
closed cervix but bleeding (before 20 wks)?
Threatened
25-50% eventually result in loss of pregnancy
What type of spontaneous abortion has;
documented pregnancy that spontaneously passes all products of conception (usually
Complete
What type of spontaneous abortion has;
open cervix + bleeding, +/-cramp-like pain, +/- ROM
Inevitable
What type of spontaneous abortion has;
partial passage of products of conception and IS A MEDICAL EMERGENCY
Incomplete
What type of spontaneous abortion has;
retention of a failed pregnancy for extended period (>6 wks)
Missed
What type of spontaneous abortion has;
2 or more consecutive spont. Ab or 3 total Ab
Recurrent
What type of spontaneous abortion is;
more frequently associated with induced abortions
Septic
What are 5 signs/symptoms of an incomplete abortion?
1) Cramping
2) Vaginal bleeding
3) Passage of tissue
4) Dilated internal cervical os
5) Orthostasis/hypotension
What is the PRIMARY CARE management of an incomplete abortion?
Stabilize the patient
2 large bore IV catheters
NS or LR with oxytocin
What is the SPECIALTY CARE management of an incomplete abortion?
Evacuate products of conception
1) Anesthesia
2) Ring forceps
3) Dilation & Curettage (D&C)
What is shoulder dystocia and how does it “present”?
Failure of shoulders to deliver after vertex
“Turtle sign”
What are some risk factors for shoulder dystocia?
Macrosomia
Obesity
Diabetes
What are some maternal and fetal consequences of shoulder dystocia?
Maternal consequences
1) PPH d/t atony
2) Vag/cerv lacs
Fetal consequences
1) Brachial plexopathy
2) Clavicular fxs (100 newtons)
3) Hypoxic injury
What is the shoulder dystocia management mnemonic?
H: Help !
E: Episiotomy, empty bladder
L: Legs back (McRoberts)
P: Pressure (suprapubic)
E: Enter (Woods screw)
R: Rotate posterior shoulder (Rubins maneuver)
R: Remove posterior arm (Barnums maneuver)
What are the radical maneuvers for shoulder dystocia?
Clavicle fracture
Zavanelli and Cesarean section
Symphysiotomy
What are some risk factors for cord prolapse?
1) Non-vertex presentations - Transverse lie or Breech
2) Multiple gestation
3) Prematurity
4) Polyhydramnios
4) Iatrogenic (FSE, IUPC, AROM, ECV)
How do you treat cord prolapse?
Tocolytics and cesarean section
Trauma effects __% of pregnancies? What 2 types and 2 severities are there?
6% of all pregnancies
Blunt or Penetrating
Major or Minor
What are the sources of maternal blunt trauma?
1) Motor vehicle accident (MVA)
2) Fall
3) Assault
What is the #1 cause of non-obstetric fetal demise?
Blunt trauma from
Motor vehicle accident (MVA)
What are the can the sequelae be of maternal blunt?
1) Placental abruption
2) Uterine rupture
3) Fetal injury?
4) Fetomaternal hemorrhage
What are the sources of penetrating maternal trauma? What are the associated mortality rates of mother and fetus?
Sources - Gunshot or Stab
Mortality - Up to 70% fetal & 5% maternal
In minor trauma (“Fender bender”, fall, abuse), what else needs to be assessed in addition to the non-obstetric trauma management?
Placement of lap-belt
Vaginal bleeding
Rupture of membranes
Fetal movement
Viability
Rule-out placental abruption (monitor for 4-6 hrs)
K-B (kleihauer-betke) and Rho-gam
What is the most common cause of Abruptio Placentae? When does it occur? What else can cause abruptio placentae?
Most common cause—hypertension (chronic or pre-eclampsia) Could also be caused by cocaine use.
At >20 wks gestation
AP also Associated with:
50% major trauma
5% minor trauma
What are some signs and symptoms of the mother and fetus in abruptio placentae?
Symptoms:
Vaginal bleeding, contractions, significant uterine tenderness or irritability
Nonreassuring fetal heart rate pattern
Fetal tachycardia, late decelerations, demise
What are some Risk Factors for Abrupted Placenta?
1) Maternal hypertension
2) Previous abruption (10% p 1, 25% p 2)
3) Trauma
4) Polyhydramnios with rapid decompression
How is Abruptio Placentae diagnosed?
CLINICAL !!!!
If abruptio placentae is suspected, how often is monitoring suggestions and what criteria needs to be met for discharge?
Recommended monitoring 4-6 hours—release only if:
Contracting
No vaginal bleeding
No abdominal pain or tenderness
FHR reassuring
No visible bruising
Is vaginal bleeding or ultrasound useful in diagnosing abruptio placentae?
Vaginal bleeding is not reliable (2L concealed)
Ultrasound is NOT sensitive; U/S may detect only 2% of abruptions
What are the types of abruptio placentae?
1) Partial separation (Concealed hemorrhage)
2) Partial separation (Exposed hemorrhage)
3) Complete separation (Concealed hemorrhage)
What is Placenta Previa and when does it usually happen (week)?
Painless vaginal bleed (unless in labor)
1 in 200 pregnancies
Mean GA 30 weeks
How do you manage placenta previa?
1) Pelvic rest
2) Maturity
3) Lower transverse cesarian section
4) Rho-gam prn
What are the types of placenta previa?
1) Total
2) Partial
3) Marginal
What are risk factors for placenta previa?
1) Multiparity
2) Increased maternal age
3) Prior placenta previa (4-8X risk)
4) Multiple gestation
What are complications of placenta previa?
1) IUGR
2) Anomalies
3) Malpresentations
4) PPROM
How do you diagnose placenta previa?
1) TAUS—95%—may miss marginals
2) TVUS—100%
What can cause a ruptured uterus?
1) Trauma
2) Labor
3) Spontaneous
How do you diagnose Chorioamnionitis?
Maternal fever (>100.4) + at least 2 of these:
1) Tachycardia (maternal (>100 or fetal >160)
2) Abdominal/fundal tenderness
3) Leukocytosis (>15K)
4) Foul or culture-positive amniotic fluid
What is the main management goal for Chorioamnionitis?
Delivery! (Induce)
NOT an indication for emergent C-section
Increased risk of maternal bacteremia, wound infx/abscess
Avg time from dx to delivery is 3-5 hours
Obtain cultures prior to induction
With the known risk of infective pathogen, what and how should empiric antibiotic therapy be used?
Ampicillin & gentimicin
*or* Clindamycin if LTCS anticipated
Culture without delay in administration
What is the definition of Post Partum Hemorrhage?
>500cc in vaginal delivery
>1000cc in c-section
What are the 4 “T’s” in Post Partum Hemorrhage etiology?
1) Tone = uterine atony(most common—75-80%)
2) Tissue = retained placenta/accreta
3) Trauma = vaginal/cervical laceration
4) Thrombin = coagulopathy
What can cause uterine atony; the most common cause in post partum hemorrhage?
1) Prolonged labor
2) Oxytocin administration
3) Grand multiparity
4) Twins or more
5) Halogenated anesthetics (general anesthetics)
6) Precipitous labor
What are the management measure for post partum hemorrhage?
Call for help! EXAMINE.
Bimanual uterine compression
“Always give Pitocin”?
Medications
Tamponade/uterine packing- “risky”
IV fluids— may need volume 3X EBL
Uterine balloons – “bahkri?”
Surgical intervention—including hysterectomy
