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Clin Specialties - EMed > Lecture 9 - Women's Health > Flashcards

Lecture 9 - Women's Health Flashcards

1
Q

Vaginitis

A

General term for disorders of the vagina caused by infection, inflammation or changes in the normal flora

2 classes:
Not sexually transmitted
Sexually transmitted

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2
Q

What is the most common cause of bacterial vaginosis?

A

Gardnerella vaginalis

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3
Q

Bacterial vaginosis

A

Polymicrobial:
Gardnerella vaginalis (MC), mycoplasma hominis
NOT an STD
Sxs: gray/white malodorous discharge
Dx: clue cells on wet mount, “whiff test” fishy odor after adding KOH, pH>4.5 (more basic than normal)

Tx:
Metronidazole 500mg PO BID for 7 days

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4
Q

Candida Vaginitis

A

Most common cause of vaginitis
NOT STD
Risk factors:
Abx use, pregnancy, oral contraception, steroid use, DM, tight cloths

Signs/Sxs: pruritic, sticky “cottage cheese” discharge

Dx: budding yeast and pseudo-hyphae on wet mount, pH<4.5

Tx: nonpregnant fluconazole 150mg PO once or azole vaginal creams, pregnant vaginal Azole creams (miconazole, fluconazole)

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5
Q

Atrophic vaginitis

A

Decreased vaginal lubrications and thickness of tissue caused by decreased estrogen after menopause

Treat with estrogen cream topically

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6
Q

Trichomonas vaginitis

A

STD

S/s: profuse, pruritic, white/yellow/green, frothy, malodorous discharge, strawberry cervix (hemorrhagic foci)

Dx: wet mount motile tichomonads (flagella)

Tx: metronidazole 2g PO x1
NO ETOH for 24hours
Treat partners

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7
Q

What is the most common STD?

A

Chlamydia

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8
Q

Strawberry cervix

A

Seen with trichomonas vaginitis

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9
Q

Chlamydia

A

MC STD

Can be asymptomatic
Major cause of infertility
S/s: mucopurulent or yellow discharge, dysuria, cervical erythema

Dx: DNA probes or ELISA from endocervical sample or urine

Tx: azithromycin 1g PO x 1 (or doxy 100mg PO BID x 7days)

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10
Q

Reiter Syndrome

A

Urethritis
Conjunctivitis
Rash
Arthritis

(Commonly seen after infections, chlamydia being the most common infection)

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11
Q

Gonorrhea

A

Men are symptomatic in 80-90% of cases (dysuria and discharge)
Women are asymptomatic 30-40%

Can infect pharynx, conjunctiva, and rectum

Can be disseminated GC

S/s: purulent cervical discharge, dysuria, abnormal vaginal spotting

Dx: culture or DNA probe on endocervical sample or urine

Tx: Ceftriazone 250mg IM x 1 + (treatment for chlamydia 1g azithromycin)

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12
Q

PID

A

Acute infection of the upper genital tract structures including the uterus, oviducts, and ovaries
(Including endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis)

Pathogens: 
STIs: chlaymdia, gonorrhea 
(About 1/3 of cases)
Non STIs: anaerobic bacteria 
(Of women who received a dx of acute PID, <50% test positive for either G/C)
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13
Q

What are the risk factors for PID?

A

Unprotected intercourse with several partners

Age 15-25yo

Hx of previous PID

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14
Q

What are the sxs of PID?

A

Asymptomatic
Mild:
Dyspareunia
Abnormal vaginal bleeding, especially post-coital, vaginal discharge

Moderate to severe:
Sepsis, LLQ/RLQ/suprepubic pain, peritonitis

PID should be suspected for any young, sexually active female, who has pelvic discomfort

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15
Q

How is PID dx?

A

CMT (hallmark)
Uterine tenderness
Adnexal tenderness

If a women is experiencing lower abdominal or pelvic pain and one or more of the above sxs, treat empirically for PID

Starting treatment is unlikely to complicate other common causes of lower abdominal pain

Infertility is a major sequela of missed PID dx/tx

One or more of the following additional criteria can be used to enhance specificity of min clinical to support dx of PID:

  • oral temp >101.1 (>38.3)
  • abnormal cervical mucopurulent discharge or cervical friability
  • abundant WBC on saline microscopy of vaginal fluid
  • elevated SED rate
  • elevated CRP
  • lab cx N. Gonorrhoae or C. Trachomatis
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16
Q

What is the treatment for PID?

A

Outpt:
Ceftriaxone 250mg IM x1
Doxycycline 100mg PO BID for 14 days
PLEASE consider adding metronidazole 500mg PO BID for 14 days

Inpt:
Doxycycline 100mg IV BID + cefoxitin 2g IV QID or cefotetan 2g IV BID
Clindamycin 900mg IV TID and gentamicin 5mg/kg IV QD

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17
Q

When should you consider admission for PID?

A

Suspected TOA or pelvic abscess
Pregnant
Vomiting, high fever, failure of outpt therapy
Poor compliance or follow up concern

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18
Q

What do you tell pts being treated with PID in their discharge paperwork?

A

Women should abstain from intercourse until therapy is completed, sxs resolved, and partners have been treated

  • treat all partners within 60 days
  • if the last parter >60days, treat the last partner

Should demonstrate clinical improvement in 3 days after administration of treatment
-hospitalization, evaluate microbial agent, and consider further testing

Retest after 3 months if GC/C positive
-if not possible, retest within 12 months

Consider HIV and syphilis testing

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19
Q

21yo F, present with frothy, maloderous, gray green vaginal discharge x 3 days. Denies abdominal pain, N/V. Vitals: T 98.7, HR 65, BP 100/64, exam shows frothy, yellow discharge. Wet mouth sows flagellated organisms. What is the description of the cervix in this condition?

A

Strawberry

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20
Q

Indication for hospitalization for a women with PID include:

A

Nulliparous women
Tubo-ovarian abcess
Poor compliance
Failure of outpt regimen

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21
Q

Genital Herpes

A

HSV1/HSV2

S/s: painful, grouped vesicules, ulcerated lesions on vagina, pre labial and labial

Primary HSV illness:

  • virus remains in spinal root ganglia
  • last 9-10 days

Dx: PE or ELISA

Tx: acyclovir 400mg PO TID
Famciclovir 250mg PO TID
Valcyclovir Ig PO BID
X 7-10 days

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22
Q

Treponema pallidum

A

Syphilis

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23
Q

Syphilis

A

Spirochete treponema pallidum

HIV coinfection

S/S:
primary: painless ulcer (10-90 days post exposure)
Secondary:
Nonspecific systemic sxs (often missed)
Rash - dull, red, papular rash on palms/soles (also trunk, flexor surfaces)
Tertiary:
Neurogenic and cardiac manifestations, gummas

Dx: dark field microscopy for treponemes, serology testing (RPR, VRDL), treponemal antibody testing (FTA-ABS)

Tx:
Primary and secondary:
PCN or doxy (if PCN allergy)

Tertiary:
PCN IM weekly for 3 weeks

Neurosyphilis:
PCN IV 10-14 days

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24
Q

Chancroid

A

Gram negative bacilluis: Haemophilus ducreyi

HIV/Syphilis coinfection

S/s: PAINFUL papule 4-10 days after exposure

Dx: gram stain - “school of fish pattern”

Tx: azithromcyin 1g PO or ceftriaxone 250mg IM single dose

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25
Q

Condylomata acuminata

A

Venereal warts

HPV (type 6 and 11 MC)

S/s: flesh color, cauliflower like lesion, 1-8 month incubation

Dx: clinically PE

Tx: cryoptherapy, laser and topicals

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26
Q

What is the function of the bartholin gland?

A

Lubricates the vagina

Located between the vaginal wall and labia majora (posterior 2/3s)

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27
Q

Bartholin’s cyst

A

Caused by:
Thickened mucus
Infection
Swelling blocking the gland (MC)

S/s:
Painless lump in posterior 2/3 of vulva
Redness or swelling of vulva
Discomfort during walking, sitting or sex

Tx:
Conservative observation
Tx if it becomes infected

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28
Q

Bartholin’s Abscess

A

Infected bartholins cyst or gland

Faster progression of sxs
Pain +/- fever
-may be difficult to sit, stand, or have sex due to pain

Tx:
Sitz baths
+/- PO Abx
I and D + word catheter

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29
Q

What is the surgical management for a barthlins abscess?

A

I and D with a word catheter

“Marsupialization” is the best management to prevent recurrence (only use after failed I and D twice)

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30
Q

20 yo female presents with grouped painful ulcers on labia that started yesterday. She has unprotected sex, multiple parters. What would be the most appropriate therapy?

A

Acyclovir 400mg TID for 7-10 days

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31
Q

Ovarian cysts

A

Fluid filled sacs in/on ovaries

Typically form during ovulation, and are usually benign

Functional cysts

  • follicle cysts
  • corpus leuteal cysts
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32
Q

Follicle cysts

A

Functional ovarian cysts

During normal cycle, an egg grows inside tiny follicle sac, which opens to release mature egg
Cysts occurs when follicle doesnt release egg
Follicle continues to grow into a cysts

Sxs often asymptomatic and resolve in 1-3 months

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33
Q

Corpus luteum cysts

A

Functional ovarian cysts

During normal cycle, ege is release from the follicle, then the follicle sac shrinks into mass of cells called corpus leuteum secretory gland (makes hormones — estrogen and progesterone needed for conception)
Corpus luteum occurs if follicle sac doesnt shrink and sac reseals itself after egg is release

May resolve within a few weeks
May grow up to 4 inches wide
Most likely to be symptomatic due to size

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34
Q

What are the symptoms of ovarian cysts?

A 
Most small and asymptomatic 
Pressure
Bloating
Swelling
Pain in lower abdomen on side of cyst 
-sharp or dull, come and go vaguely
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35
Q

How are ovarian cysts dx?

A

Best seen on abdominal or transvaginal ultrasound (gold standard)
-internal cystic structure may be categretoized as:
—simple (just fluid filled)
—complex (with areas of fluid mixed with solid material)
—completely solid (with no obvious fluid)

If acute abdomen pain — get CT or MRI —may show presence of cyst, or evidence of ruptured cyst + fluid in cul de sac

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36
Q

What is the management of ovarian cyst?

A

If asymptomatic or incidental:
Observation if small and asymptomatic
Over 70-80% follicular cysts resolve spontaneously

Oral contraception may reduce frequency of follicular cysts

Oral pain medication (NSAIDs)

Referral to OB/GYN for routine follow up
—some cysts may lead to menorrhagia, metrorrhagia, dysmenorrhea, and further complications of cysts

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37
Q

When should you consider surgery for an ovarian cyst?

A

If no resolution in 3 months

>5-10cm, especially if symptomatic (higher rate of ovarian torsion)

38
Q

What is the biggest complication of ovarian cyst?

A

Rupture

39
Q

Ovarian rupture

A

Can be a complication of ovarian cysts

MC corpus luteal cysts
Physiologic cyst rupture = mittelschmerz
Vaginal intercourse increased risk factor for rupture

Sxs:
Acute onset of abdominal pain
Lateralization (most often RLQ)
Hypotension or shock

US may show free fluid in the pouch of Douglas (‘cul de sac’) 40% of cases

Management:
Stable pt: observation
(Move to laparoscopy if no relief of sxs in 48 hours or falling hemoglobin)
Unstable pt (hypotension, tachycardia): laparoscopy

40
Q

Ovarian torsion

A

Surgical emergency to preserve fertility

Torsion = rotation of ovarian vascular pedicle —> obstruction to venous and eventually arterial flow —> can lead to infarction

MC in menstruating females

Higher risk with PCOS, ovarian stimulation, and prior torsion or adhesions

R > L

41
Q

What is the only definitive dx of ovarian cyst?

A

Direct visualization during surgery

42
Q

How do pts with ovarian torsion present?

A

Acute onset of lateralized pain
+/- adenxal mass
N/V
Fever

US: study of choice —absence of blood flow to ovary

Only definitive dx is direct visualization during surgery

43
Q

What is the treatment for ovarian torsion?

A

Laparoscopy to detorse ovary in pre-menopausal women (ovarain function preserved in 90% of cases)

Salpingo-oophrectomy in post-menopausal women
(Prevent recurrent and perform pathological exam on cyst)

44
Q

A 28yo female presents with left sided abdominal pain that started 20 minutes prior. Pt states she was having sex when she developed left sided constant pain. Notes she has noticed similar pain while working out for the last 2 weeks. Hx of ovarian cysts. Pt vitals are T99.3, HR 120, BP 140/90, RR 28. Pregnancy test is negative. What is the presentation most concerning for?

A

Ovarian torsion

45
Q

What is the primary risk factor for ovarian torsion?

A

Ovarian cyst

46
Q

How is ovarian torsion definitively dx?

A

Surgical evaluation

47
Q

What causes abnormal uterine bleeding?

A

Irregular and unpredictable bleeding
Consider OB/GYN consultation (treatment guidelines fall under them)

Causes:
Endometeriosis
Fibroids
Uterine cancer

48
Q

Endometriosis

A

Ectopic growth of endometrial lining in the ovary, pelvic peritoneum, or other distant site

S/s: 30yo women, irregular bleeding, super painful periods

Dx:
Direct visualization with laparoscopy

Tx: hormone therapy, hysterectomy

49
Q

Fibroids

A

(Leiomyoma)

Most common pelvic tumor
MC in 40s and AA women

S/s: pelvic pain, vaginal bleeding

Dx: US

TxL pain control, hormone therapy, surgical interventions

50
Q

Uterine cancer

A

Most common GYN cancer

RF: 
Late menopause
Nulliparity 
Obesity 
DM
HTN
Exogenous estrogen exposure

S/s: postmenopausal bleeding

Dx: biopsy

Tx: surgery, radiation, and chemo

51
Q

Fluid filled sacs in/on ovaries

A

ovarian cyst

typically form during ovulation, and are usually benign

52
Q

Follicle Cyst

A

forms when follicle doesn’t release egg
follicle continues to grow into cyst

often asymptomatic and resolve in 1-3 months

53
Q

Corpus luteum cyst

A

occur if follicle sac doesn’t shrink, and sac reseals itself after egg released

fluid filled

most resolve within a few weeks

54
Q

What is the gold standard for ovarian cyst?

A

abdominal or transvaginal US

55
Q

Leiomyoma

A

fibroids

MC pelvic tumor
MC in 40s
MC in AA

pelvic pain + vaginal bleeding

dx: US
tx: pain control, hormone therapy, surgical interventions

56
Q

What is the most common gyn cancer?

A

uterine cancer

57
Q

What are the risk factors for uterine cancer?

A 
late menopause
nulliparity
obesity
DM
HTN
exogenous estrogen exposure
58
Q

Postmenopausal bleeding

A

uterine cancer

59
Q

What is the goal of treatment for someone with abnormal uterine bleeding?

A

basically just estrogen:

premarin or ethinyl estradiol

60
Q

Vaginal bleeding after ____ weeks might be ______

A

20 weeks

abrupto placentae
placenta previa

61
Q

What is the most common risk factor for ectopic pregnancy?

A

PID (hx G/C)

other RF:
hx ectopic pregnancy
IUD
endometriosis

62
Q

What should you do for a pt who presents to the ER with 1st trimester bleeding, abdominal pain, adnexal mass, and positive betaHCG, but US is undiagnostic?

A

repeat beta in 2 days for doubling

use discriminatory zone for hCG

should be seen by US at 2000
fetal cardiac activity at 6 - 6.5 weeks

63
Q

What is the treatment for ectopic pregnancy?

A

for the hemodynamically stable pt:

methotrexate 1mg/kg x 1

64
Q

What surgical options are there for ectopic pregnancy?

A

Laparoscopy
-CI in hemodynamically unstable

Salpingotomy 
Salpingectomy (remove distal fallopian tube portion)
65
Q

What is the follow up for ectopic pregnancy?

A

follow and check bhCG until they reach 0

many pts receive MTX post-operatively if bhCG remains high (meaning trophoblastic tissue still remains)

66
Q

Spontaneous abortion definition:

A

loss of pregnancy before 20 weeks

most occur within first 8 weeks

67
Q

Threatened abortion

A

vaginal bleeding (50% of women with vaginal bleeding in the first trimester will have a spontaneous abortion)

closed cervix
+ fetal heart motion

68
Q

Inevitable abortion

A

open cervix

+/- fetal heart motion

69
Q

Incomplete abortion

A

open cervix

- fetal heart motion

70
Q

Complete abortion

A

closed cervix

- fetal heart motion

71
Q

What is the work up for a women you suspect of spontaneous abortion?

A

pelvic exam to inspect os
betahCG + type and rh
US

72
Q

What is the treatment for threatened abortion?

A

pelvic rest and close OB follow up

73
Q

What is the treatment for inevitable of missed abortion?

A

D and C with OB

74
Q

Placenta Aburption

A

partial or complete separation of the placenta prior to delivery

presentation: painful vaginal bleeding >20 weeks gestation

RF: trauma, drug use (COCAINE), HTN, pre-eclampsia, PROM, previous abruption, c-sections, smoking

75
Q

What is the management for someone you think has placenta abruption?

A

send to L/D

76
Q

Placenta previa

A

implantation of the placenta over the os

> 20 weeks pregnant with PAINLESS vaginal bleeding (bright red)

RF: previous PP, C-section, multiple gestations, smoking, twins

77
Q

What is the treatment for placenta previa?

A

no sex
weekly US

NO PELVIC EXAM

corticosteroids between 23-34 weeks –mature fetal lungs
rho-gam administration

schedule C-section at 36-37 weeks

78
Q

What are non bleeding complications of pregnancy?

A

hyperemesis gravidum
HTN
HELLP syndrome

79
Q

Hyperemesis gravidarum

A

intractable vomiting causing dehydration, weight loss, hypokalemia, and ketonemia

tx: anti-emetics
rehydration and clearance of ketones

80
Q

Pre-eclampsia

A

hypertension, proteinuria, and peripheral edema after 20 weeks

RF: maternal age, pre-preg HTN, DM, multiple gestations, and renal disease

tx: magnesium sulfate
hydralazine
delivery

81
Q

Eclampsia

A

seizure in the pre-eclamptic pt

tx: 
magnesium sulfate 6g over 15 minutes, then 2g/hr 
monitor DTR and RR
hydralazine to lower BP 
benzos 
prompt delivery
82
Q

HELLP

A

hemolysis, elevated liver enzymes, low platelets
leads to end organ damage and DIC

results from endothelial dysfunction, leading to microvascular thrombi and hemolysis

occurs after 20 weeks, including post partum

83
Q

What are the s/s and tx for HELLP syndrome?

A

RUQ or epigastric pain
symptomatic anemia

tx: OB/GYN
delivery

84
Q

What is considered postpartum hemorrhage?

A

> 500ml blood loss during vaginal delivery
or
1000 ml blood loss during C-section

85
Q

What is the time frame for post partum hemorrhage?

A

immediate: within first 24 hours
delayed: 24 hours to 6 weeks

86
Q

What is the most common cause of postpartum hemorrhage?

A

uterine atony

treat with oxytocin

87
Q

Endometritis

A

a postpartum complication

infection of the endometrial tissue
5% of all pregnancies

RF: c-section, PROM

s/s: fever, uterine tenderness, foul discharge

tx: broad spectrum abx

88
Q

If you have to displace the uterus during a trauma assessment of pregnant pt, what direction to do displace the uterus?

A

LEFT (inferior vena cava)

especially in a hypotensive pt

89
Q

How long do you have after cardiac arrest of a pregnant mother to save the fetus?

A

4 - 5 minutes

90
Q

What is the most common emergency contraception?

A

progestin (leveonorgestrel)

aka Plan B

91
Q

What is the most effective emergency contraception?

A

copper IUD (paragaurd)

Clin Specialties - EMed (11 decks)

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