Genitourinary, Gynecology, and Obstetrical Emergencies Flashcards
1. Explain concepts related to the assessment of an emergency department patient experiencing a GU/GYN/OB emergency. 2. Describe various patient presentations related to GU/GYN/OB emergencies. 3. List interventions necessary for a patient presenting with a GU/GYN/OB emergency.
define renal calculi
kidney stone that can lead to renal colic
renal calculi overview
80% of stones are Ca
size does not correlate to ain
sx renal calculi
sudden onset severe, colicky flank pain pain radiating to genitals restlessness CVA tenderness urgency, frequency dysuria, hematuria N/V diaphoresis, low-grade fever
assessing renal calculi
assess bruits, pulsatile masses
r/o aortic, iliac aneurysms
intervene renal calculi
strain urine fluids opioids, antiemetics NSAIDs if Cr normal possible stent
define urinary retention
inability to completely empty bladder
causes of urinary retention
urethral strictures enlarged prostate clots, calculi neurogenic bladder pelvic organ prolapse MS med side effects
sx urinary retention
low abd pain
bladder distention
intervene urinary retention
Foley
Coude catheter
UTI overview
mostly bladder (acute cystitis) usually e.coli
risk of UTI
women:
- higher than men
- shorter urethra
- new sexual partner
men:
- incomplete bladder emptying
- enlarged prostate
sx UTI
dysuria, urgency, frequency nocturia suprapubic pressure back pain cloud, foul urine low grade fever retention in males AMS in elderly
abx in UTI
trimethoprim and sulfamethoxazole
nitrofurantoin
ciprofloxacin
pain management in UTI
NSAIDs
phenazopyridine
urosepsis overview
elderly, diabetic, immunocompromised
present atypically: AMS in elderly
dc teaching in UTI
fluids
phenazopyridine will make urine orange
define acute pyelonephritis
inflammation/infection of kidneys
acute pyelonephritis overview
more common in women
can lead to urosepsis
causes of acute pyelonephritis
usually bacterial
mechanical obstruction
can be upstream from UTI and ascend down from blood infection
sx acute pyelonephritis
CVA tenderness F/C, HA N/V/D sx of lower UTI pyuria, hematuria, bacteriuria
intervene acute pyelo
fluids, rest
nephrostomy tube possibly
broad-spectrum abx
chlamydia overview
chlamydia trachomatis
most common STI
often w/ gonorrhea
sx chlamydia
75% asymptomatic
cervicitis
PID
endometriosis
salpingitis
tx for chlamydia
azithro PO x 1
dozycycline x 7 days
syphilis overview
treponema pallidum
more in females and drug users
sx primary syphilis
painless ulcer or chancre on mouth or anogenital area
sx secondary syphilis
4-10 wks after primary infection myalgia lymphadenopathy flu-like sx rash on palms, soles
sx tertiary syphilis
2-19 years later if untreated
psychosis, delirium, dementia
sx for syphilis
penicillin IM x 1
doxycycline x 14 days
tetracycline x 14 days
gonorrhea overview
neisseria gonorrhoeae
second most common STI
leading cause of cervicitis, PID in females, urethritis in males
complications of gonorrhea
infertility, ectopic, chronic pelvic pain
sx gonorrhea
UTI sx
mucoid discharge from cervix/penis
men may be asymptomatic
tx for gonorrhea
ceftriaxone IM x1
cefixime PO x1
cephalosporin IM x1 + azithro PO x1
doxycycline x 7 days
herpes simplex overview
chronic, incurable viral STI with remissions and exacerbations
sx herpes simplex
painful vesicles, ulcerations on genitalia
fever, malaise
myalgia
lymphadenopathy
dysuria
70% asymptomatic
dc teaching for all STIs
meds as prescribed PCP condoms inform sexual partners treat past sexual partners
dc teaching for chlamydia
no sex x 7 days after tx
dc teaching for herpes
avoid sex during outbreak
increased risk of transmission to fetus - C-section recommended
cremasteric reflex
when inner thigh is stroked, cremaster muscle contracts raising ipsilateral testis
testicular torsion overview
urological emergency can occur in infants rare after 30 yo cremasteric reflex absent US shows ischemia
acute epididymitis overview
cremasteric reflex intact
US shows increased blood flow
most common cause of intrascrotal inflammation
define testicular tosion
twisting of testicle or spermatic cord, causing strangulation
onset of acute epididymitis vs testicular torsion
epididymitis: gradual
torsion: sudden
pain in acute epididymitis
mild to severe
unilateral
pain in testicular torsion
severe
unilateral
tenderness
swelling, erythema
cause of acute epididymitis
infection (chlamydia or gonorrhoeae)
causes of testicular torsion
congenital
undescended testicle
cold weather
sex
common ages in acute epididymitis vs testicular torsion
epididymitis: sexually active postpubertal males
torsion: 12-18
ureteral discharge in acute epididymitis vs testicular torsion
epididymitis: yes
torsion: no
scrotal elevation in acute epididymitis vs testicular torsion
epididymitis: may decrease pain
torsion: worsens pain
assessing acute epididymitis
scrotal US
ureteral smear
UA, culture
assessing testicular torsion
cremasteric reflex
doppler US
intervene acute epididymitis
abx
sx management
intervene testicular torsion
manual detorsion
uro consult
surgical repair
define priapism
prolonged, painful erection
common ages in priapism
any age but:
5-10 with SCC
20-50
causes of priapism
spinal cord injury
tumors
SCC
meds for ED
sx priapism
vaso-oclusive:
- persistent, painful
- > 4 hours
non-ischemic:
-erect but nontender
assessing priapism
penile doppler
arteriography
CBC if c/f malignancy
intervene priapism
analgesia, sedation
inject epi, phenylephrine, pseudoephedrine, or terbutaline into penis
irrigate corpora with NS
uro consult
define phimosis
inability to fully retract foreskin over glans penis
define paraphimosis
retracted foreskin becomes entrapped, occluding blood flow to glans
sx paraphimosis
swollen, painful, edematous glans
tight ring of skin behind glans
discolored, necrotic areas
hx of increasing difficulty advancing foreskin
intervene phimosis/paraphimosis
manual reduction
small incision with local anesthesia
encourage consideration of circumcision or dorsal slit
NSAIDs, abx
define caute prostatitis
inflammation of prostate gland
common causes of prostatitis
bacterial infection that ascended via ureter or refluxed from bladder
associated with acute cystitis
sx prostatitis
sudden onset dysuria, malaise frequency, urgency perineal pain low abd, penile, suprapubic discomfort f/c hematospermia
assessing prostatitis
UA, cultures
prostate-specific antigen
boggy, tender prostate
intervene prostatitis
analgesia
Foley
abx - fluoroquinolones
fluid intake
causes of renal trauma
blunt trauma (MVC)
fall w/ lower rib fractures
penetrating trauma
types of renal trauma
laceration
contusion
vascular injury
sx renal trauma
abd, flank, back pain
flank ecchymosis
hematuria
intervene renal trauma
bed rest
observe
fluids
surgery for lacs or uterine extravasation
types of urethral/bladder trauma
contusion
rupture
causes of urethral/bladder trauma
straddle injury
genital trauma
foreign bodies
what injuries are associated with urethral/bladder trauma?
full bladder
pelvic fractures
pediatric patients
sx urethral/bladder trauma
inability, difficulty voiding suprapubic, perineal, genital pain with voiding blood at urinary meatus hematuria hypovolemia low abd or peritoneal hematoma bladder distension
characteristics of urethral/bladder trauma
“pop” after blow to bladder
pelvic fx with bony fragment
cystogram
no urine in Foley
intervene urethral/bladder trauma
analgesia, abx
cath only by urologist
surgery
reasons for surgery in urethral/bladder trauma
hemodynamic instability
renal pedicle damage
most injuries
define penile fracture
rupture of tunic albuginea or corpus cavernosa of penile shaft d/t torque
causes of penile fracture
during sex
direct trauma
fall
sx penile fracture
"pop" at time of injjry penile pain, loss of erection BRB from urethra ecchymosis edema
intervene penile fracture
surgery w/in 24-36 hours
supportive measures
causes of pelvic pain
ectopic kidney stones UTI Mittelschmerz ruptured ovarian cyst endometriosis PID diverticulitis appendicitis ovarian neoplasm
causes of abnormal uterine bleeding
hormone dysfxn hemorrhagic cystitis coagulopathies neoplasms trauma uterine/vaginal foreign body sexual assault uterine, cervical polyps uterine fibroids urethral prolapse gyn infections pregnancy complications
gyn infections causing abnormal uterine bleeding
gonorrhea
chlamydia
trich
cervicitis
pregnancy complications causing abnormal uterine bleeding
ectopic spontaneous abortion placental abruption placenta previa postpartum hemorrhage
define bartholin cyst
obstruction of Bartholin duct
unilateral
complications of bartholin cyst
infections caused by STI, vaginal organisms
sx bartholin cyst
painful, unilateral cystic mass
intervene bartholin cyst
warm compress sitz bath I and D, drainage abx r/o carcinoma if over 40 yo
define dysfunctional uterine bleeding
irregular uterine bleeding from vagina that occurs in absence of recognizable pelvic pathology, general medical disease, or pregnancy
dyspareunia
painful bleeding or pain with intercourse
usually associated with endometriosis
causes of dysfunctional uterine bleeding
uterine fibroids trauma infection malignancy coagulopathies hormone replacement therapy steroids, androgens digitalis, anticoags low caloric diets, obesity rapid weight change thyroid, adrenal disorders cirrhosis HTN
sx dysfunctional uterine bleeding
fewer than 21 days between episodes
usually painless
normal menses
25-60 ml/day for 4-5 days
average tampon holds 20-30 ml if saturated
intervene dysfunctional uterine bleeding
low dose PO contraceptive
iron supplements
IV fluids
suction, curettage
define ovarian cyst
pockets on ovaries which may contain fluid, semi-fluid, solid material
types of ovarian cysts
follicular corpus luteum Mittelschmerz polycystic ovarian syndrome chocolate cysts dermoid cysts
follicular cyst rupture
with strenuous exercise or sexual intercourse w/in first 2 weeks of menstrual cycle
corpus luteum cyst rupture
last 2 weeks of menstrual cycle
Mitelschmerz cyst rupture
mid-cycle, unilateral pain
chocolate cyst
caused by endometriosis
dermoid cyst
contains teeth, hair
sx ovarian cyst
varies pain w/ sex sharp, unilateral days to weeks of pain biopsy to r/o uterine CA hypovolemia if blood-filled cyst
intervene ovarian cyst
NSAIDs, opioids
surgery
complication of ovarian cysts
fallopian tube torsion with ovarian ischemia
sx fallopian tube torsion
sudden, sharp, unilateral pain
fever
dysuria
N/V
define sexual assault/battery
involuntary sexual act
threatened, coerced, forced sexual contact w/w/o penetration
who should assess possible victim of sexual assault/battery?
SANE - sexual assault nurse examiner
define PID
polymicrobial infection of upper genital tract
examples of PID
endometriosis
salpingitis
tubo-ovarian abscess
pelvic peritonitis
common causes of PID
gonorrhea
chlamydia
risk factors for PID
IUD previous STIs multiple partners substance use frequent douching
sx PID
abd pain, dyspareunia
abnormal vag discharge
fever
cervical motion tenderness
intervene PID
abx, analgesia admission for: -not responsive to tx -unstable -tubo-ovarian abscess -pregnant
dc instructions for PID
increased risk of ectopic
can result in infertility
PCP in 72 hours
define tubo-ovarian abscess
complication of PID
surgery emergency if ruptures
sx tubo-ovarian abscess
ill appearing
severe abd pain
peritoneal signs w/ palpation
fever
intervene tubo-ovarian abscess
admit
surgery
-hysterectomy, oophorectomy possible
abx
define toxic shock syndrome
toxin-mediated systemic response usually d/t Staph aureus
causes of TSS
retained tampon, sponge
strep infections
necrotizing fasciitis
burns
sx TSS
sudden onset f/c hypotension N/V/D HA, myalgia classic rash confusion multisystem organ failure
intervene TSS
contact iso ABCs, intubation fluids, pressors remove infection abx art line, CVC ICU
sx vulvovaginal candidiasis
irritation, itching
inflammation
cottage-cheese discharge
diagnosing vulvovaginal candidiasis and trich
wet prep
tx vulvovaginal candidiasis
OTC creams, suppositores
diflucan PO x 1
dc teaching vulvovaginal candidiasis
diflucan contraindicated in pregnancy
PCP
sx trich
vulvar irritation
dyspareunia
“fishy” odor
yellow/green discharge
tx trich
metronidazole PO x1 or
tinidazole PO x1
dc teaching trich
no alcohol with metronidazole
treat sexual partners
PCP
sx bacterial vaginosis
“fishy” odor
gray discharge
diagnosing bacterial vaginosis
discharge that smoothly coats vaginal wall
clue cells
ph > 4.5
+ “whiff” test
tx bacterial vaginosis
metronidazole 7 days or
metronidazole gel 5 days or
clinda cream 7 days
dc teaching bacterial vaginosis
partners don’t need tx
meds as directed
PCP
avoid douching, bubble baths
complications with diaphragm
unable to remove - use ring forceps
complications with IUD
unable to remove
lost string
partial expulsion
abnormal cavity migration
intervening for IUD complications
remove with ring forceps
imaging
additional contraception
poss. exploratory laparotomy
define spontaneous abortion
death or expulsion of fetus or products of conception before age of viability
15-20% of all pregnancies
complications of spontaneous abortion
bleeding
vag bleeding should improve and stop
infection
causes of spontaneous abortion
first trimester: -chromosomal after first trimester: -infection -endocrine disorder -anatomic abnormalities of mother
define threatened abortion
cervical os closed despite bleeding/cramping
define inevitable abortion
cervical os open bleeding/cramping membranes ruptured
define incomplete abortion
cervical os open
tissue in cervix
incomplete expulsion of products
define complete abortion
complete expulsion of products of conception
define missed abortion
prolonged retention of dead products of conception after os closed
define septic abortion
intrauterine infection d/t retained products of conception
intervene spontaneous abortion
labs, US oxytocin, abx suction curettage uterine evacuation psychosocial care referrals
dc instructions for spontaneous abortion
vag bleeding 1-2 weeks slight cramping x few days avoid douching, tampons, sex x 2 weeks rest 2-3 days temp bid x 5 days
reasons to seek medical care after spontaneous abortion
fever > 100F
chills
severe N/V, cramps
excessive bleeding
define excessive bleeding after spontaneous abortion
consistently soaking pad in < 1 hr
bleeding > normal period
clots > quarter sized
define ectopic pregnancy
embryo implants at site other than endometrium of uterus
ectopic pregnancy overview
usually in fallopian tube and will eventually rupture
usually 6th week of gestation
2% of all pregnancies
locations for ectopic pregnancies
peritoneal corneal isthmic tubal ampullar tuba fimbric tubal ovarial cervical intramural
sx ectopic pregnancy
late, irregular period abnormal vag bleeding sudden onset unilateral pelvic pain palpable pelvic mass \+ pregnancy N/V
sx ruptured ectopic pregnancy
shoulder pain (Kehr sign)
signs of shock
decreased LOC
labs in ectopic pregnancy
+ hcg
progesterone > 25
intervene ectopic pregnancy
fluids, Rhogam
surgery if rupture
methotrexate
contraindications for methotrexate after spontaneous abortion
unstable
bleeding
unreliable patient
methotrexate overview
cytotoxic
don’t handle if pregnant
wear PPE, chemo gloves
pharm overview of methotrexate
interferes with DNA synthesis and disrupts cell multiplication
define placenta previa
implantation of placenta in lower uterine segment or over internal os
complications of placenta previa
placenta may bleed as fetus grows and uterus expands
associated with life threatening hemorrhage, fetal loss
sx placenta previa
sudden, painless bleeding
BRB
maternal hemorrhagic shock
intervene placent previa
urgent ob consult recumbent position IVs, fluids CBC, T and S, Rh no vag exam until after US poss. C-section
define abruptio placentae
placental separation from uterine wall
pathophysiology of abruptio placentae
arterial vessel rupture
hemorrhagic, hypovolemic shock
inhibits oxygen, nutrient supply to fetus
most common cause of fetal demise 2/2 maternal trauma
sx abruptio placentae
backache, painful contractions, abd pain
uterine rigidity
frank, dark-red vag bleeding or concealed bleeding
maternal hemorrhagic shock
abnormal fetal heart tones
lab results in abruptio placentae
elevated d-dimer
decreased platelets
intervene abruptio placentae
continuous fetal heart monitor OB transport high flow O2 fluids, transfusion emergent delivery
define hyperemesis gravidarum
intractable N/V, dehydration in pregnancy leading to electrolyte imbalances, malnutrition
causes of hyperemesis gravidarum
suspected elevated hcg
define preeclampsia
multisystem disorder associated with decreased oxygenation and perfusion
preeclampsia overview
associated with coagulopathies, liver fxn abnormalities
characterized by gestational HTN, gestational proteinuria
mild to severe
uncommon postpartum
sx mild-moderate preeclampsia
SBP >140 or DBP >90 protineuria, oliguria edema weight gain 2+ lb/week HA, N epigastric, RUQ pain
sx severe preeclampsia
SBP>160, DBP>110 proteinuria >2g/24hr Cr > 1.2 platelets < 100,000 elevated LDH, ALT, AST persistent HA, visual disturbance, epigastric pain oliguria pulm edema
intervene preeclampsia
minimize stimulation
antiHTN
OB admit
mag sulfate
administering mag sulfate for preeclampsia
loading dose
VS q5 min
neuro status qh
monitor urine output
sx magnesium toxicity (in preeclampsia)
loss of patellar reflexes SOB, hypoxia CNS depression N treat w/ calcium gluconate
define HELLP syndrome
life threatening pregnancy complication
considered as a variant of severe preeclampsia that involves liver
sx in HELLP
H - hemolysis
EL - elevated liver enzymes
LP - low platelets
define eclampsia
preeclampsia progressing to convulsive state
risks of eclampsia
delivery only cure
at risk for up to 3 weeks postpartum
sx eclampsia
preeclampsia sx
generalized SZs
significant HTN
decreased fetal HR
intevene eclampsia
ABCs, high flow continuous fetal monitor mag sulfate antiHTN meds OB admit
causes of obstetrical trauma
MVCs, falls, domestic violence
risks of obstetrical trauma
risk of death comparable for pregnant vs non pregnant
risk of death for fetus 5-7x greater with traumatic injury
priority with obstetrical trauma
maternal resuscitation - provides fetus best chance of survival
complications of obstetrical trauma
placental abruption preterm labor uterine rupture fetal skull, liver injuries perimortem C-section deliery
assessing obstetrical trauma
fetal US
doppler US for fetal HR
monitor for min 4hours if pregnancy viable
intervene obsstetrical trauma
ABCs, trauma interventions
left later recumbent position
imaging
indicators of fetal stress/distress during obstetrical trauma
fetal HR > 160 or < 110
no FHR accels w/w/o contractions
periodic FHR decels w/w/o contractions
decreased fetal movement
intervene for fetal distress during obstetrical trauma
O2 life side, manually displace uterus to L fluids emergent C-section maternal steroid injection
mechanism of injury in uterine rupture
sudden deceleration
severe abd compression
complications of uterine rupture
usually causes fetal demise
< 1% of pregnant patients with major trauma
sx uterine rupture
sudden onset severe abd pain vag bleeding fetal parts outside uterus fetal bradycardia, asystole maternal hypovolemic shock
intervene uterine rupture
emergent C-section
possible hysterectomy
define preterm labor
regular contractions < 37 weeks gestation
complications of preterm labor
risk for preterm birth
most common OB complication after trauma
sx preterm labor
contracts q10 min or less abd cramping, backache pelvic pressure change in vag discharge onset of vag bleeding
assessing preterm labor
pelvic exam
fetal monitoring
assess contractions
intervene preterm labor
terbutaline if viable at 20-35 weeks
sx emergent delivery
bloody show ruptured membranes frequent painful contractions bulging membranes crowning fetal head
mother statements during emergent delivery
desire to bear down, push
need to have a BM
“the baby is coming”
mother interventions for emergent deliery
low fowler, knees bent or side lying, buttocks raised
clean perineum
have mother pant to decrease chance of explosive delivery
gentle pressure while delivering head
assess membranes, nuchal cord, position and presentation
direct head down to deliver anterior shoulder and up to deliver posterior shoulder
neonate interventions for emergent delivery
clamp cord 4-5 cm from abdomen and 4-5 cm towards mother 30 seconds after pulsating stops
thoroughly dry- #1
assess breathing, suction
gentle stimulation, resuscitation if not breathing
APGAR at 1 and 5 min
warm newborn
APGAR
appearance (color) pulse grimace (muscle tone) activity (reflex irritability) resp effort
0 points in APGAR
A: blue, pale P: absent HR G: limp A: absent activity R: absent resp effort
1 point in APGAR
A: pink body, blue extremities P: < 100 bpm G: some flexion A: some motion R: weak cry
2 points in APGAR
A: pink P: > 100 bpm G: good flexion A: good motion R: strong cry
APGAR scores indicating outcome
7-10: good
4-6: moderate
1-3: poor
define prolapsed cord
umbilical cord precedes the neonate out of vagina, reducing or eliminating blood flow
intervene prolapsed cord
knee-to-chest position insert hand to elevate fetal head do not handle or replace cord wrap exposed cord in saline gauze immediate C-section
characteristics of neonatal resuscitation
two-thumb encircling technique
depress 1/2 AP diameter of chest
chest recoil
meds for neonatal resuscitation
epi
naloxone
glucose
IV fluids 10 ml/kg
define postpartum hemorrhage
excessive vaginal bleeding after delivery or abortion for up to 6 weeks
parameters of postpartum hemorrhage
losses > 500 ml w/in 24 hours of delivery
primary postpartum hemorrhage is w/in 24 hours of delivery
four Ts of postpartum hemorrhage
tone - uterine atony
trauma - vaginal, perineal, rectal tearing
tissue - retained products
thrombin - DIC
sx postpartum hemorrhage
steady BRB nausea pale, clammy skin soft, boggy uterus signs of shock
intervene postpartum hemorrhage
uterus massage
manual pressure to lacs
treat hemorrhagic shock
oxytocin
define postpartum infection
fever > 24 hours and up to 10 days postpartum with confirmed infection
causes of postpartum infection
endometriosis laceration episiotomy surgical site infection retained uterine tissue UTI mastitis
sx postpartum infection
fever redness pain, tenderness foul smelling lochia drainage from surgical site erythema, pain, engorgement of breasts
risk factors for postpartum infection
delivery hx
premature membrane rupture
hx antepartum infection
intervene postpartum infection
fluids
sepsis protocols
abx