exam 1 - OBGYN Flashcards
Young female complaining of “urinary tract infection”.
BP 120/63 mmHg; HR 71; RR 18; SaO2 100% RA; Temp 37°C (98.6°F).
Nurse triage note states: “Patient presents today with 3 weeks of dysuria, urinary frequency, and lower abdominal pain despite a full course of nitrofurantoin prescribed by a local urgent care clinic, followed by a full course of ciprofloxacin prescribed by her primary care provider.”
When you examine the patient, she claims mild improvement in her symptoms 2 days prior, but now has persistent dysuria again. Initial physical exam is positive only for mild suprapubic discomfort with palpation.
Urinalysis (-) pregnancy test, (+) small leukocyte esterase, and(-) nitrite.
You wonder whether to prescribe a third antibiotic and send a urine culture, or if there is something else you should be considering . . .
BP 120/63 mmHg; HR 71; RR 18; SaO2 100% RA; Temp 37°C (98.6°F).
Nurse triage note states: “Patient presents today with 3 weeks of dysuria, urinary frequency, and lower abdominal pain despite a full course of nitrofurantoin prescribed by a local urgent care clinic, followed by a full course of ciprofloxacin prescribed by her primary care provider.”
When you examine the patient, she claims mild improvement in her symptoms 2 days prior, but now has persistent dysuria again. Initial physical exam is positive only for mild suprapubic discomfort with palpation.
Urinalysis (-) pregnancy test, (+) small leukocyte esterase, and(-) nitrite.
You wonder whether to prescribe a third antibiotic and send a urine culture, or if there is something else you should be considering . . .
Initially treated inappropriately for UTI
Pelvic exam: mucopurulent discharge and friable cervical mucosa
Gc/Chl and trich NAAT swabs obtained
Repeat U/A, U-HCG, and urine culture obtained
Treated her empirically for gonorrhea/chlamydia
Referred her to GYN
3 days later she was +chlamydia, informed her of results, abstain from intercourse 2 weeks, inform partners
Follow up 2 weeks later showed resolution of symptoms
cervicitis and urethritis
-MC organisms:
-Gonorrhea
-Chlamydia
-Trichomoniasis
-History:
-Sometimes asymptomatic
-Discharge
-Dysuria
-Absence of lymphadenopathy and genital ulcers
-Female patients: dyspareunia, post-coital bleeding, or abnormal spotting
-Often co-infection! w/ gonorrhea and chlamydia
-Difficult to distinguish based off PE
-Use APTIMA swabs for NAAT -> can take 24-48hrs
-High sensitivity and specificity
-Endocervical swab
-Urethral swab
-Urine swab (first void)
-Oropharyngeal swab
-Rectal swab
-!!!!!!!!!if results are pending, and you are concerned, treat for both gonorrhea and chlamydia
gonococcal infection
->300,000 cases in the US annually
-Organism: NEISSERIA GONORRHEA
-Humans are the only reservoir
-Male pts will have copious discharge
-thick yellow discharge with no irritation around penile opening
-Female pts are more likely to be asymptomatic
-Present once the infection has ascended
-Can also cause:
-Pharyngitis
-Disseminated infection
-Septic arthritis
-Tenosynovitis
-Conjunctivitis
-Proctitis
chlamydia infection
-MC reported STI in the US
-High rates of asymptomatic infection
-Less discharge than gonorrhea
-More thin, clear and straw-colored than gonorrhea
-Untreated can also progress to upper tract infection:
-Women: PID
-Men: epididymitis, orchitis, prostatitis, proctitis
-chlamydia conjunctivitis
-chlamydial cervicitis
gonorrhea tx (need to know doses)
-CEFTRIAXONE 500mg IM once* (1g if >150kg)
-If allergy: Gentamicin 240mg IM x 1 dose + Azithromycin 2g PO x 1 dose
-Expedited partner therapy (EPT): Cefixime 800mg PO once
-if over 150 kgs -> double the dose
chlamydia tx
-DOXYCYCLINE 100 mg PO BID x 7 days* - treatment of choice
OR
-AZITHROMYCIN 1g PO once (pregnancy)
gonorrhea and chlamydia discharge instruction
-Educate! Non-judgemental approach!
-Minimize disease transmission:
-Abstain from sexual activity for 7 days after treatment AND
-Obtain additional STI testing
-Offer HIV PrEP initiation
-Test of cure:
-Unnecessary in uncomplicated urogenital or rectal GC/CHL
-Recommended 10-14 day test of cure for PHARYNGEAL!!!! gonorrhea
-Retesting recommended 3 months after tx
trichomonas vaginalis
-MC curable STI worldwide
-Most men are asymptomatic
-Vaginitis symptoms:
Pruritis, dysuria, frequency, dyspareunia
-Cervical exam:
Malodorous, greenish, frothy discharge
-“Strawberry cervix”
-Wet prep exam will show flagellated protozoa and WBCs
-Treatment:
-Metronidazole (Flagyl) PO
-Disulfram-like reaction warning
mycoplasma genialium
-Cause of non-gonococcal urethritis in men
-Cause of non-gonococcal cervicitis or PID in women
-!!!!Consider in patients with recurrent signs and symptoms of STI with negative testing (esp recurrent UTI in men)
-TX: Azithromycin 500mg PO x 1 dose + 250mg PO once daily x 4 days
A 23-year-old G2P1011 presents to the emergency department complaining of lower abdominal pain and vaginal discharge for the past week. She also noticed some spotting over the last 2 weeks. Her BP is 128/76, HR 86, RR 16, Temp 98.8F. The patient appears well and in no distress.
Pelvic inflammatory disease(PID)
Polymicrobial infection that ascends to the uterus, fallopian tubes and ovaries.
pelvic inflammatory ds
-ascending tract infection:
-endometritis
-salpingitis
-oophoritis
-myometritis
-causative organisms:
-polymicrobial!!!
-STI 22-50%
-anaerobes (BV)
-enteric organisms
-short term complications:
-TOA
-peritonitis
-pyosalpinx
-perihepatitis- Fitz-huge-Curtis- need to do laparoscopy- violin strings
-long term complications:
-infertility
-chronic pelvic pain
-dyspareunia
-ectopic pregnancy
PID hx and PE
-Sx range from mild to severe
-!!Midline lower abdominal pain (MC)
-!!Vaginal discharge, dysuria, dyspareunia
-Abnormal bleeding
-Fever, N/V, general malaise
-RFs to ask about:
-Prior STI, # of sexual partners, IUD, recent cervix instrumentation
-PE:
-!!Lower abdominal tenderness
-!!Cervical motion tenderness (CMT)- chandelier sign
-!!Adnexal tenderness
-If worse on one side, suggests TOA
-Purulent cervical os discharge
-Friable cervix
-RUQ tenderness - Suggests Fitz-Hugh-Curtis syndrome
PID dx
-Clinical diagnosis!
-Send the following routinely :
-!NAAT for gonorrhea and chlamydia
-Wet mount for BV/Candida/Trich
-Pregnancy test
-!Strongly consider HIV, syphilis tests
-US to assess for assoc TOA
-Can find ruptured ovarian cyst, ovarian torsion
-CT can also show TOA
-Can also evaluate for appendicitis
TOA on US
-Tuboovarian abscess is a walled-off abscess that originates in the infected fallopian tube and extends to involve the ovary.
-complications of PID
-appear ill, and will often have severe !!unilateral adnexal tenderness and fullness!! on bimanual pelvic exam
-fever
-Rupture can cause severe sepsis
-Ultrasound will show a complex, thick-walled, adnexal structure.
PID tx
-CDC recommends empiric PID tx in:
-SA young woman with
-lower abdominal/pelvic pain
and no other identifiable cause of illness other than PID
+ 1 or more of the following:
-1. cervical motion tenderness
-2. uterine tenderness
-3. adnexal tenderness
-Outpt care is often appropriate
-Remind pt to avoid sexual contact, to refer their partners for tx, and f/u in 72 hrs, unless sx worsen
-Admit if:
-Pregnant, prepubertal, person has an IUD
-TOA, Fitz-huge-Curtis ± operating room
-Intractable vomiting, sepsis, peritonitis
-MC tx:
-Ceftriaxone 500mg IM
+
-Doxycycline 100mg PO BID x 14 days
+
-Metronidazole 500mg BID x 14 days
-Alternatives:
-Cefotetan + Doxycycline
-Cefoxitin + Doxycycline
-Clindamycin + gentamicin
-Ampicillin-sulbactam + doxy
pelvic exam
-Provider collected and self-collected vaginal swabs both have high sensitivity and specificity for detecting STI
-Great for asymptomatic screening tests!
-Sx = speculum and bimanual examination
-Broad differentials for vaginal discharge, including PID, which you might miss!
sexual assault screening
-Tests and tx are similar to PID plus a few extra things
-Test for: HIV, syphilis, Hep B, Gonorrhea, Chlamydia, Trichomonas
-Sexual Offense Evidence Collection Kit (SOECK) -> Collects DNA evidence
-Drug Facilitated Sexual Assault (DFSA) kit -> Drug facilitated SA
-Forensic evidence can be given to police immediately, or, held in storage w/o investigation for up to 20 years in NYC
-Treatment:
-Ceftriaxone 500mg IM single dose
-Doxycycline 100mg PO BIG x 7 days
-Metronidazole 500mg PO BID x 7 days (not in males)
-Valacyclovir 1gm PO QID x 5 days (not typically done)
-Emergency contraception
-HIV PEP with Truvada (if <72 hour post exposure)
A 25 year-old female presents to the ED with a chief complaint of RLQ abdominal pain. She tells the triage nurse that she has had intermittent episodes of the pain but over the past 45 minutes the pain has become unbearable and excruciating. She complains of persistent nausea and multiple episodes of vomiting. She denies fever, vaginal bleeding, discharge, dysuria or change in bowel habits. She has no past medical history, is a social alcohol drinker, and does not use tobacco products.
On exam she is clearly in distress, clutching her right lower abdomen.
Vital signs reveal BP 145/90, HR 110, RR 21, Tmax 98.9 SpO2 99%RA.
She is slightly obese but is otherwise well-appearing. She is mildly tachycardic with intact distal pulses and has clear equal breath sounds.
Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly.
A pelvic exam demonstrates right adnexal fullness and significant pain on exam without bleeding or discharge.
On exam she is clearly in distress, clutching her right lower abdomen.
Vital signs reveal BP 145/90, HR 110, RR 21, Tmax 98.9 SpO2 99%RA.
She is slightly obese but is otherwise well-appearing. She is mildly tachycardic with intact distal pulses and has clear equal breath sounds.
Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly.
ovarian torsion
-Point of Care urine pregnancy test and urinalysis were negative.
Gynecology was emergently consulted who recommended proceeding to the OR for laparoscopy.
ovarian torsion
-Ovary and fallopian tube twists upon its blood supply
-Initially venous and lymphatic obstruction, then arterial obstruction
-MC in reproductive age due to development of cysts
-MC in ovaries >5cm, ovarian tumors, or cysts
-Right > left
-Assoc w/ infertility tx
due to enlargement of ovary
-Inquire about hx of: Infertility tx, cysts, torsion, pregnancy
-Classic presentation
-Sudden onset
-Severe, stabbing, unilateral lower abdominal pain
-Assoc w/ N/V
± radiation to the groin
-Atypical presentations
-40% will report gradual pain or intermittent pain (intermittent torsing)
-Infants and children will present with feeding intolerance, distension, vomiting, irritability, and/or a palpable pelvic mass
ovarian torsion PE and dx
-Abdominal exam:
Lower abdominal tenderness
Peritoneal signs are concerning for ovarian necrosis
-Bimanual exam:
Unilateral adnexal tenderness
Palpable adnexal mass (rarely)
-Pregnancy test
-!!!US (transvaginal) -> modality of choice
-Enlarged ovary
-absent flow
-Cyst or mass
-CT scan
-Evaluate for other possible diagnosis
-Enlarged ovary or mass may be seen
-Normal appearing ovary is reassuring
-Laparoscopy is gold standard for definitive dx
-Low threshold for consultation with OBGYN
-Labs cant dx, but are more useful to point towards alternate dx
-!!!!!!!no single finding can definitively rule in or out -> If all tests are neg and still suspect -> call gynecologist to discuss taking pt to OR for laparoscopy
ovarian torsion diff dx
Other ovarian pathology
Ovarian cysts ± hemorrhage
TOA
Other gynecologic pathology
PID
Ectopic pregnancy*
Diverticulitis
Kidney stone
UTI
transvaginal US for ovarian torsions
-modality of choice
-Asymmetric enlarged ovaries is MC finding
-Mass or cyst may be present
-Absence of blood flow is highly specific
-Doppler findings inconsistent
-60% with surgically proven torsion had blood flow on doppler
-Ovaries have dual blood supply (ovarian and uterine artery)
-Cut off from one supply leaves another showing +doppler flow
-Decreased venous flow occurs early
-Later stages can show free pelvic fluid indicating hemorrhag
-no color (blood flow) over the torsed ovary
ovarian torsion tx
-Pain control
-Antiemetics
-IVF rehydration
-NPO for OR
-STAT gyn consult
-Ovarian salvage time is 36 hours
vaginal bleeding
-LMP, frequency and amount of bleeding
-Contraception use
-If currently SA
-Sex and # of partners
-Dyspareunia
-Hx of STI and whether they were treated
-Previous pregnancies and delivery method
-Previous gynecologic procedures
-Bleeding more than 6 days in a row and/or changing a pad at least every 3 hours is associated with significant blood loss
-Look for S&S of:
-Hemodynamic compromise
-Symptoms of anemia
-Trauma, sexual abuse, infection, suspected bleeding diathesis, and foreign bodies are conditions that should be ruled out in the ED through a combination of history and exam
evaluating vaginal bleeding
-Stable:
-!Minimum of a pregnancy test and CBC
-STI testing
-Pelvic US -> can be done outpt if necessary
-Endometrial bx for peri-/post- menopausal women
-Unstable, severe bleeding:
-Pregnancy test
-CBC
-Coags
-T&S and T&C
-Thyroid studies
-GYN consult for further intervention
-Transfusion of packed RBC is indicated for any woman with active bleeding who is hemodynamically unstable or has a hemoglobin level <7 g/dL (<70 g/L).
abnormal uterine bleeding (AUB) in non-pregnant persons: tx and discharge
-Admission / OR / Surgery
-Uncontrolled severe heavy bleeding
-Emergency procedure: D&C
-Emergency procedure: Hysterectomy
-Arterial embolization by IR
-Discharge
-Most pts can be discharged
-Discharge instructions should include strict return precautions; for example, if bleeding increases or the patient is changing her pad more than once per hour.
-Give clear, time-specific follow-up instructions for continued evaluation with gynecology.
-Postmenopausal women with vaginal bleeding are at increased risk for malignancy; if timely follow-up with gynecology is not possible, consider pelvic ultrasound in the ED.
Approach to the critical patient
30-year-old female presents with 3 days of heavy vaginal bleeding. She reports feeling dizzy and lightheaded. She states this is her usual time for menses, but she has been bleeding more than normal and is now using one large pad an hour.
BP 80/60mmHg, HR 120bpm, Temp 99.0F, RR 22, SPO2 98%
She is pale appearing on exam and tachycardic.
What would you do?
30-year-old female presents with 3 days of heavy vaginal bleeding. She reports feeling dizzy and lightheaded. She states this is her usual time for menses, but she has been bleeding more than normal and is now using one large pad an hour.
BP 80/60mmHg, HR 120bpm, Temp 99.0F, RR 22, SPO2 98%
She is pale appearing on exam and tachycardic.
What would you do?
hyperemesis gravidarum
-N/V in 1st 12 wks of pregnancy that is unrelieved with dietary or med modifications AND:
-!!Dehydration (high urine specific gravity)
-Wt loss (>5%)
-!!Ketonuria
-Electrolyte abnormalities (hypokalemia, alkalosis)
-Common causes:
-Molar pregnancy
-Multiple pregnancy
-Obtains labs including CBC, BMP, ketones, UA, BHCG
-High beta hcg = ?molar pregnancy
-Consider LFTs and lipase (↑ in preeclampsia, HELLP, eclampsia)
-Obtain TVUS to assess for molar pregnancy or multiple gestation
hyperemesis gravidarum management
-1st line anti-emetic in pregnancy: !Vitamin B6 10-25mg TID-QID!
-Can also give !doxylamine or diphenhydramine!
-Severe disease
-Fluid resuscitation -> !D5NS or D5LR until ketonuria clears!
-Thiamine to prevent Wernickes encephalopathy in these nutritionally stressed patients (found in prenatal vitamins)
-Admit if not tolerating PO
-Discharge if tolerating PO, corrected electrolytes, reversal ketonuria
A 28-year-old G3P0121 presents with vaginal bleeding and abdominal pain that started a week ago. This morning, the pain got suddenly worse and the patient feels lightheaded. She also mentions that her right shoulder hurts. When asked for a urine sample, the patient states that she and her partner use condoms and insists that there is no way that she could be pregnant.
Her BP is 86/48, HR 124, RR 22, SpO2 98%, Temp is 99.6F.
Her BP is 86/48, HR 124, RR 22, SpO2 98%, Temp is 99.6F.
1st trimester bleeding ddx
-Physiologic
-Ectopic
-Abortion (miscarriage)
-Structural pathology
-Cervical
-Vaginal
-Uterine (molar pregnancy, tumor [fibroid])
1st trimester bleeding eval
-Every pt will receive the following:
-Pelvic exam
-Ultrasound:
-transvaginal US (TVUS)- test of choice for pregnancy location
-Differentiates ectopic vs. miscarriage
-Determines gestational age, multiple gestations, molar, heterotopic pregnancy
-Labs:
-Serial quantitative HCGs
-CBC
-Type&Screen / Rh
-RHOGAM within 72 hours if mom is Rh negative
HCG and US
-In a NORMAL pregnancy, an intrauterine pregnancy (IUP) can be seen on transvaginal ultrasound (TVUS) at !HCG levels >1,500 mlU/ml!
-However, ectopic can be seen at very low levels of HCG, so !order the ultrasound regardless if suspected abnormality!
-If an IUP is not visualized on ultrasound, and B-HCG is above 1500 – can be either a non-viable IUP or ectopic
miscarriages
Consider in IUP + vaginal bleeding
ectopic pregnancy
-Pregnancy that implants outside the uterus
-Ectopic rupture causes profound hemorrhage which can be fatal
-Is the 3rd leading cause of maternal mortality
-10% of pts with vaginal bleeding, abdominal pain in early pregnancy will have an ectopic pregnancy
-triad- missed period, abdominal pain (peritoneal signs if ruptured), vaginal bleeding
-Every single woman of child-bearing age should get a pregnancy test
-Most will not know they are pregnant
-It is a cheap and easy test
risk factor for ectopic
-History of pelvic inflammatory disease*
-Tubal surgery
-Assisted reproduction
-Prior ectopic
-Abnormal endometrium
-Smoking
-Advanced material age
-IUD in place
-Prior surgical abortion
ectopic PE and S&S
-tachycardia from pain
-abdominal exam- tender
-pelvic exam:
-CMT
-adnexal mass 10-20%
-general light vaginal bleeding
-IF RUPTURED:
-tachycardia, hypotension
-cool, pale skin
-lightheaded/syncope
-GI/GYN- severe abdominal pain, peritoneal signs, n/v
US showing empty uterus (unknown location)
-Vaginal bleeding in early pregnancy showing an empty uterus (no ectopic, but no IUP)
-“Indeterminant ultrasound”
-“Pregnancy of unknown location (PUL)”
-Unclear diagnosis!
-Ectopic is more likely if HCG<1000
-Amenorrhea, vaginal bleeding, abdominal pain, +BHCG, extrauterine mass, and empty uterus is an ectopic pregnancy until proven otherwise
ectopic: serum HCG
-HCG is a hormone secret from growing fetus
-In the first 6-7 weeks of a normal pregnancy, !HCG doubles every 2 days!
-Ectopic pregnancy will NOT have the normal doubling
-QED – we can follow serial HCG levels and ultrasounds!
indeterminant US (PUL)
-serial HCG levels 48 hrs
-repeat US
-strict return precautions
US showing free fluid in abdomen
-FAST- 4 places
-looking for intraperitoneal fluid:
-epigastric- subxiphoid
-RUQ, LUQ
-suprapubic
-FREE FLUID ANYWHERE IN THE ABDOMEN IS A ECTOPIC
ectopic initial tx
-UNSTABLE:
-ABCs
-IVF
-transfusion if significant blood loss
-CALL OBGYN for OR
-MOTHER RH-STATUS:
-if bleeding
-if Rh-neg
-administer 50mcg RhoGAM
-OPTIONS:
-medical management
-surgery
ectopic tx
-!Methotrexate!
-Medical abortion
-85-93% success rate
-Need to follow serial HCG levels to ZERO
-Strict return precautions
-Use in pts who are/have:
-Clinically stable
-No evidence of rupture
-No fetal cardiac activity
-Mass < 3.5 cm
-HCG <5000 mIU/mL
-Reliable patients
-Normal kidney/liver fxn
-SURGERY:
-Indications for surgical management:
-Unstable
-Mass > 3.5 cm
-HCG >5000 (usually because of high risk of failure of MTX)
-Laparoscopy is MC
-Salpingostomy is preferred over salpingectomy
communication: ectopic
-Remember to be kind
-Let the patient know up front that you may not know for sure whether this is a miscarriage/non-viable pregnancy. No matter what, will need to follow-up with their OB/GYN doctor in 2-3 days to see how the pregnancy is progressing.
-Pregnancy loss can have a variety of meaning to a person and their family
-Be honest, straight forward, compassionate
-Patients will grieve in different ways
-Feel comfortable showing products of miscarriage or fetal loss if asked
ionizing radiation in pregnancy (dont need to know)
summary approach to vaginal bleeding
42 year old female complaining of epigastric pain
No PMH, recent delivery 1 week ago, no complications, full term
Reports occasional pelvic discomfort with spotting that was treated with motrin 800mg TID PRN, pain has improved
Dull achy 8/10 epigastric gnawing pain, attempted antacids + motrin without relief
Vital signs: HR 110, BP 165/96, Temp 98.7F, RR 20, O2Sat 100%
Tenderness in epigastric and RUQ without guarding or rebound
She is hypertensive and in pain with epigastric and RUQ pain
Differentials for this patient include:
Non-OB related: Gastritis, PUD, cholecystitis
OB related: Pre-clampsia (within 6 weeks post partum)
Pain medication
Labs
Ultrasound
Pain is only minimally relieved
180/105mmHg now with headache and flashing lights
Labs unremarkable
Ultrasound showed some sludge without pericholecystic fluid or wall thickening
Headache, visual symptoms … pre-eclampsia!
Labetolol and magnesium sulfate infusions began immediately
OB team intervenes, more labetolol until BP reaches 140/90mmHg and admitted for BP control
No PMH, recent delivery 1 week ago, no complications, full term
Reports occasional pelvic discomfort with spotting that was treated with motrin 800mg TID PRN, pain has improved
Dull achy 8/10 epigastric gnawing pain, attempted antacids + motrin without relief
Vital signs: HR 110, BP 165/96, Temp 98.7F, RR 20, O2Sat 100%
Tenderness in epigastric and RUQ without guarding or rebound
She is hypertensive and in pain with epigastric and RUQ pain
Differentials for this patient include:
Non-OB related: Gastritis, PUD, cholecystitis
OB related: Pre-clampsia (within 6 weeks post partum)
Pain medication
Labs
Ultrasound
Pain is only minimally relieved
180/105mmHg now with headache and flashing lights
Labs unremarkable
Ultrasound showed some sludge without pericholecystic fluid or wall thickening
Headache, visual symptoms … pre-eclampsia!
Labetolol and magnesium sulfate infusions began immediately
OB team intervenes, more labetolol until BP reaches 140/90mmHg and admitted for BP control
hypertension in pregnancy
RF for pre-eclampsia and eclampsia
-History of eclampsia
-Extremes of maternal age (>40yo)
-Nulliparity
-Multiple gestations
-Obesity
-Diabetes
-Renal disease
-Collagen vascular disease
-Pre-term delivery at <32 weeks gestation
-Eclampsia more common in black or Hispanic
-Likely multifactorial related to social determinants and prenatal care access
maternal fetal outcomes in severe pre-eclampsia, HELLP, eclampsia
-Pulmonary edema
-Congestive heart failure
-Myocardial infarction
-Stroke (ischemic or hemorrhagic)
-ARDS
-Coagulopathies
-Renal injury or failure
-Retinal injury
-Coma
-Maternal death
-Abruptio plaecentae
-In neonates:
-Small gestational age due to intrauterine growth restriction
-Premature birth
-Neonatal respiratory distress syndrome
-Fetal death
pre-eclampsia
-headaches- 66-82%
-visual changes- 27-44% -> blurry vision, diplopia, scotoma, transient blindness
-epigastric pain
-SEVERE:
-SBP ≥ 160 or DBP ≥ 110 (can be confirmed within a short interval to facilitate timely antiHTN therapy)
-Thrombocytopenia (platelet count < 100,000/microliter)
-elevated LFT not accounted for by alt dx (to > 2x upper limit normal concentrations), or by severe persistent RUQ or epigastric pain unresponsive to meds
-Renal insufficiency (serum creatinine concentration > 1.1 mg/dL or a doubling of serum creatinine concentration in absence of other renal ds)
-Pulmonary edema
-New-onset headache unresponsive to meds and not accounted for by alt dx
-Visual disturbances
pre-eclampsia eval
-Call obstetric consult immediately if patient presents with pre-eclampsia with severe features and/or eclampsia
-Labs: CBC, CMP, T&S, Uric acid, PT/PTT/INR, Fibrinogen
-Brain imaging if unremitting headache or neurologic symptoms
Pre-eclampsia management
-MILD PRE-ECLAMPSIA tx:
-BP between SBP 140-159, DBP 90-119mmHg (with proteinuria) w/o sx -> managed by obstetrics, usually outpt
-PRE-ECLAMPSIA with SEVERE FEATURES (BP>160/110, or, sxs e.g. headache)
-Start within 30-60 mins of presentation
-Goal is to reduce BP to SBP 140-150mmHg, and, DBP 90-100mmHg
-Remember appropriate positioning of pt -> i.e. falsely low BP if supine, correct cuff sizing
-Delivery recommended at 34 wks
-!!!Definitive tx of pre-eclampsia and eclampsia is delivery of fetus and placenta!!!!
-SEVERE:
-1. ABCs, call OBGYN, maternal repositioning (left lateral decubitus)
-2. Seizure prevention:
-Magnesium sulfate 4-6g IV followed by continuous infusion 1-2g/hr IV x 24 hrs
-Contraindicated in myasthenia gravis, pulmonary edema, renal failure.
-Anti-convulsants (for recurrent seizures, or if magnesium is contraindicated)
-Lorazepam (Ativan): 2-4 mg IV x 1 dose -> Can repeat once after 10-15 minutes
-Diazepam (Valium): 5-10 mg IV q 5-10 min
-3. Antihypertensives
pre-eclampsia with severe features or eclampsia management
-Anti-hypertensive options:
-LABETOLOL**
-Avoid in active asthma, heart disease, or congestive heart failure
-Avoid if pulse <60bpm
-Initial dose 20mg IV over 2 minutes
-Repeat BP in 10 minutes
-Second dose if required is 40mg IV over 2 minutes
-3rd dose if required is 80mg IV over 2 minutes
-If SBP >160, DBP >110 still, give hydralazine 10mg IV
-HYDRALAZINE- Initial dose is 5-10mg IV over 2 minutes
-NIFEDIPINE- Oral nifedipine 10mg capsules
pre/eclampsia: delivery considerations
-Definitive tx for pre-eclampsia/eclampsia is DELIVERY
-Every attempt is made to keep the pt pregnant until at least 34 wks or above
-If <34 weeks gestation, give antenatal corticosteroids
-!!BETAMETHASONE is given to help fetus lung maturity
-Eclampsia should be delivered after stabilization
eclampsia
-Generalized tonic-clonic seizure in a patient who has preeclampsia
-Essentially a form of hypertensive encephalopathy
-First line medication is still magnesium sulfate 4-6g IV load followed by 2-3g/hr (IM option up to 10g if no IV access)
-Definitive tx (if antepartum) is DELIVERY
-TREATMENT:
-ABCs
-Maternal repositioning -> left lateral decubitus position -> Increases placental blood flow and reduces risk of aspiration
-Magnesium sulfate is given for the prevention and tX of eclampsia
-ACOG recommendation: IV loading dose of 4-6g over 10-15 minutes, followed by 2g/hr continuous infusion
-Repeat 2g bolus if recurrence of seizure activity
-If third convulsion, can consider using lorazepam 4mg over 3-5 minutes
-STAT OBGYN consult, early transfer when stable
-Neuroimaging not recommended
Unless concerned for other cause of seizure such as cerebral edema, infarction, hemorrhage (consider in those with atypical presentations such as recurrent convulsions, prolonged coma, focal deficits)
postpartum hemorrhage
-Potential obstetrical emergency!
-First 24 hours after delivery (up to 6 weeks)
-Can be due to:
-Uterine atony (80%)
-Undiagnosed/unrepaired lacerations
-Retained POC
-Coagulopathies
-~500mL of bleeding or more is considered hemorrhage
-Exam:
-Uterus fundus: may feel boggy in atony (abd or bimanual exam)
-Vagina: Look for lacerations or uterine inversion
-Skin: Look at previous venipuncture sites for oozing/bleeding to indicate DIC
post partum hemorrhage: tx
-ABCs + Large Bore IV x 2
-Volume expansion: O negative to start
-Call OBGYN early!
-Oxytocin or misoprostol (immediately after birth to prevent)
-Fundal massage
-Bimanual uterine massage if bleeding continues
-TXA
-balloon tamponade
fever, lower abdominal pain, vaginal discharge, uterine/adnexal/cervical tenderness, (-) HCG
-tx?
-admit?
-tx?
-admit?
-PID
-tx- ceft, doxy, mitronidazole
-admit- pregnant, perihepatitis, prepubertal, cant eat or drink
sudden onset, unilateral lower abdominal pain with n/v + ovarian cyst
-RF?
-PE?
-imaging?
-RF?
-PE?
-imaging?
-ovarian torsion
-RF- cysts, fertilization txs
-PE- unilateral adnexal tenderness
-enlarged ovary, with no blood flow
23yo female with unilateral lower abdominal pain, vaginal bleeding, +hcg, empty uterus
-likely ectopic- can also be spontaneous/complete abortion or early pregnancy
-IVF, previous PID, IUD, previous ectopic
-quant beta hcg test
definition of pre-eclampsia
->140/>90 between 20 weeks -6 weeks post partum w/o hx of HTN
-visual changes, headache, abdominal pain
-mag sulfate- prophylaxis- 4-6!!!
-labetalol, hydralazine
-def tx- delivery
-if <34 weeks -> consider steroids- beclomethasone
-tx for recurrent seizures despite mag -> Ativan or lorazepam
onger study habits.
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