OB and GYN Emergencies Flashcards
overview of trauma care in pregnancy
2 patients: shorter time frame
change in physiology
- mom blood volume increases from 80cc - 500cc
- mom decreases lung volume capacity
management depends on the following
- gestaional age (fetal viability)
- type of injury: MVA, fall (MC), PIV, GSW
- extent of other materal injuries
- protocols and ability to treat: treat there or tstabilzie and transfer
Risk of what
- preterm labor
- placental abruption
- feto-meteral hemorrhage
- pregnancy loss
placental abruption is the 2nd MCC of fetal feath: while materal death is the MC cause of fetal death
Approach to Trauma in Pregancy
- diagnostic imaging to preform
- physical exam
Diagnostics
- US shoulde be prioritized assesing fetal viability, abruption and other signs of trauma
- essentially: doe a FAST for internal bleeding (abd and thoracic) & get US to look at fetus
- radiologic studies should not be withheld if needed to assess severity of injuries in mom fluroscopy is bad;avoid but radiation if needed is ok
Physical Exam
- VS
- abd and plevic exam prior to pelvic exam: get US to rule out placenta previa due to risk of hemorrhage
- labs: CBC, BMP, blood type & Rh, coags
Rh & Kleihaur-Betke Test: qualitative determination of the presence of fetal hemoglobin in materal blood: helps to estimate amoutn of mixing has occured: determines amoutn of Rh needed to cover amoutn of blood mixed
Rh generally: given to all pt due to unknown status of Rh and to prevent future issue in future preg.
Trauma in Pregancy
- assessing fetal viablity
- determine mom v baby or both
- assesing uterine irritability
Assess Fetal viability
- after clearance, at those 20 weeks + = need to assess fetal heart rate & assess for uterine contrations
- increased uterine irratibility or frequent contractions = increased risk of abruption
Mom, baby or both
- generally: for those where the GA is not viable: need to focus on saving mom: if you save mom you can probaly save baby
- for those with older GA: viability of fetus is possible: focus on mom and baby
- in the setting where respiratory or cardaic arrest is occuring: focuse on delivering baby in order to save mom (redirect blood flow)
Management
- once “cleared from trauma” standpoint (ABCs,etc.)
- tocodynamometric monitoring done for 4-24 hours = assessing fetal HR and uterine irritability (contractions)
- if + irritabiliy: admit and monitor in case of delivery
- admin. Rhogam to Rh negative mothers
Intrapartum Bleeding
management: depends on
possible causes
management depends on
- GA (before or after 20 weeks)
- underlying etiology of the bleed (is it placental cause or no: previa v abruption)
- protocols
Causes
- trauma bleed
- hemorrhage
- abruption of placenta (usually >20 weeks)
- implantation bleed
- ectopic
- miscarriage (those < 20 weeks)
- incomplete abortion
high suspecion for potential demise since mothers are young and healthy: compensate well until they crash quick
What makes GYN emergenices difficult
- location of femal anatomy (lower abd is full of thigns)
- confusing presentation: not always clear picture
- Gyn specializst not everywehre!
Ectopic Pregnancy
etiology
risk factors
what is it
- fertilized oocyte implants naywehre outside the endometrium in uterus
- ampulla of the tube is most common location
- other locations c-section scar, cervix, etc.
- MCC of maternal death in the first trimester : because it ruptures into abd.
Risk Factors for ectopic : whos likely to have one
- PID
- tubal scarring due to previous ectopic, insturmentation,etc.
- smoking
- ART/IVF
- previosu ectopic
- advanced materal age
Ectopic Pregnancy
signs/symptoms
diagnosis and management
Symptoms
- typically abd. pain and bleeding in first trimester (or in those who dont know they’re pregnant)
- ** abd. pain is ectopic until proven otherwise**
- “surgical abd.” = rebound tenderness and guarding indicates potential bleed into abd. cavity
- can have pain without bleeding (early on)
- if ruputer: hemorrhagic bleeding
- but most pt: present before the rupture: thus VS will be normal
Pelvic/vaginal exam: essentail but typically normal expect for bleeding
Diagnosis
- stable pt: can work them up
- unstable: may need to take to OR to explore + consult OB
US is the test of choice
- bHCG test (urine dip or serum)
- seen empty uterus
Treatment
- OR urgently if unstable or cannoy take MTX
- methotrexate and discharge is possible if they are stable and compliant
Contraindications to MTX (inturpprts folic acid synthesis)
- immnodef.
- anemic, leukopenia, low platlets
- pulmonary disease
- peptic ucler disease
- hepatic or reanl disase/dysfunction
- breastfeeding
- mucosal surface issure = cannot use MTX since in interfers with radidly diving cells: and these cells are jsut that
Ovarian Torsion
etiology
Risk Factors
Etiology
- the twisting of the ovary/ovaduct (fallopian tube) causing: venous congestions, decreased blood flow and ischemia
- lost venous flow first: so blood backs up and piles in, cutting off arterial flow = ischemia
- assocaited with ovarian enlargemetn due to cysts, mass, tubo-ovarian abcesses
- majority on the RIGHT SIDE: more room to twist: bcuz on left sigmois colon is there
Risk factors
- Pregnancy: uterus grows & if there is a cyst it gest squished
- Ovarian Induction (IVF): ovary gets big and this increases risk
Ovarian Torsion
Symptoms
Workup and Dx.
Treatment
Symptoms
- sudden, severe, unilatera lower abd. pain
- can present simiarl to ectopic, but when yout get bHCG will be negative here
- nausea and vomiting common
- rebound tenderness and gaurding
- bimanual exam: adenxal mass and tenderness
Dx and Workup
- abd and bimanual exam
- US dx of choice: see the mass and altered flow with doppler
Treatment
- THIS IS A SURGICAL EMERGENCY : GYn consult and surgery asap to reduce and fixate the ovary and save it
Ovarian Cyst
etiology
Presentation
Ovarina Cyst Etiology
- on its own; not an emergecny
- if the cyst ruptures, hemorrhage risk & becomes emergency
- even if it ruptures but not bleeding (jsut serous fluid) not surgical
- pain typically due to the presence of a follicular cysts: prior to ovulation or the bleeding/rupture of teh cyst after ovulation (corpus lut.)
mittelzchmerz ferefs to mid-cycel pain felt by NORMAL follicular enlargement priot to ovulation and bleeding
Presentation
- unilateral lower abd. pain
Ovarian Cyst
Diagnosis and Indications for Intervention
Diagnosis
US is typically used to identify cyst
Indications for intervention
- significant/debiltating pain
- hemorrhage (unstable pt.)
- size > 8cm
- everyone else can be pain controlled and d/c
Intervention
- consutl GYN for transfucion, srugery, etc.
- monitor: signs of shock, serial HCT values
- larger cyst: work up to rule our cancer
- smaller cyst: shoud resolve spontaneoulsy after a few cycles
AUB
Etiology
PALM COEIN
Etiology: Abnormal Uterine Bleeding
- bleeding from the uterus that is irregualr in voulme, frequency or duration in the absence of pregnancy
PALM COEIN
- P = polyp
- A = adenomyosis (endometrial tissue in the muscle layer)
- L = Leiomyoma aka Fibroid (muscalr mass)
- M = malginancy or hypperplasia
- C = Coagulopathy
- O = ovulatory dysfunction (tissue buildup)
- E = Endometrial cause (endometriosis)
- I = iatrogentic
- N = not otehr wise classified
AUB
Evaluation/Workup
Management
Evaluation
- pelvic exam
- bHCG
- CBC
- US helpful to see: leiomyoma, ovarian csts, hydrosalpix, adhesions, tubo-ovarian abcess, endmeotriosis, tumor
Management
- in those hemodynamically unstable: fuids, tranfuse and may need surgery & gyn consult
- those without underlying bleeding d/o, nonpregnant: hormonal agents like OCPS are used
- progesterone: stabilize endometiral lining
- second line (IV estreogen or TXA)
- may require surgical curettage or uterine artery embolization
Tubo-Ovarian Abcess
etiology
Symptoms
Workup
Etiology
- abcess: usually secondary to infection (PID)
Symptoms
- significant, disproportinate unlateral adenexal tenderness
- mass or fullness with extreme pain
- toxic appearing: septic pt. , fever
WOrkup
- US imaging of choice
Complications
- rupture: creating secondary peritonitis, sepsis and bleeding if ruptured vessels
Tubo-Ovarian Abcess
Managemetn
Management
- often: IR drainage + IV abx.
- IV abx. : emperics = cefotetan + doxycycline OR clindamycin + getamicin
- successful IV should be transitioned to oral afterwards
- sometimes IV abx. alone are enough
- if not, then to IR for drainage (IR, lapro or posterior colpotomy)
