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OB/Gyn > OB Emergencies > Flashcards

OB Emergencies Flashcards

1
Q

Pregnancy that occurs outside of the uterus?

A

Ectopic Pregnancy.

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2
Q

Where is the most common location for Ectopic Pregnancy?

A

The Fallopian Tube (90%).

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3
Q

What other sites can ectopic pregnancies occur and what does it lead to?

A
  1. Abdomen (1%), Cervix (1%), Ovary (1-3%), and cesarean scar ((1-3%).
  2. Other sites (than fallopian tube) lead to greater MORBIDITY and MORTALITY due to delayed diagnosis.
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4
Q

Define the epidemiology of an Ectopic Pregnancy?

A
  1. 2% of all reported pregnancies.

2. 18% of all women presenting to the ED with 1st trimester bleeding and/or pain.

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5
Q

What are the risk factors for having an Ectopic Pregnancy?

A
  1. Prior Hx of ectopic pregnancy; incr. recurrence 10%.
    - -25% recurrence risk if 2 or more prior ectopic preg.
  2. Previous damage to fallopian tubes.
  3. Hx of Pelvic Infection.
  4. Prior pelvic or tubal surgery.
  5. Hx of infertility.
  6. IVF.
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6
Q

T or F: Intrauterine devices increase the risk of ectopic pregnancy?

A

False.

Women who use IUDs have a lower risk of ectopic preg than women who are not using contraception because IUDs are highly effective in preventing pregnancy.

But…up to 53% of preg that occur with an IUD (that fails) are ectopic.

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7
Q

What is the most common clinical presentation of an ectopic pregnancy and what is similar?

A

Vaginal bleeding and/or abdominal pain; similar to miscarriage.

*Typical presentation at 6-8 weeks after LMP.

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8
Q

What can rupture of an ectopic pregnancy lead to?

A

Life-threatening hemorrhage.

Will present with an acute abdomen:

  • Severe or persistent abdominal pain; rigid abdomen.
  • Symptoms of blood loss (Tachy, hypotensive, incr. RR, lethargy, pale/cool/clammy, etc).
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9
Q

Any women of reproductive age that presents with abdominal pain or vaginal bleeding should be evaluated for what?

A

An ectopic pregnancy regardless if she is using contraception or not; get an HCG test.

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10
Q

What are the diagnostic tools to evaluate an ectopic pregnancy?

A
  1. Confirm the pt is pregnant – b-hCG.
    - -Urine or Serum hCG, if positive…Quantitative hCG.
  2. Eval Hemodynamic Stability:
    - -VS, PE, CBC, type and screen.
    - -Good idea to get CMP, TSH, eval kidney/liver fxn.
  3. Transvaginal Ultrasound (TVUS):
    - -Determine if preg is intrauterine or ectopic.
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11
Q

If a pt has a positive hCG and record of current intrauterine pregnancy, do we need to proceed with TVUS and rule out ectopic pregnancy?

A

No.

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12
Q

Is the gestational sac alone see on TVUS sufficient to diagnose and IUP or Ectopic pregnancy?

A

No. Whether the gestational sac was seen on TVUS in an ectopic site or IUP (Intrauterine Preg), you would also need to visualize the yolk sac or the embryo within the gestational sac.

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13
Q

What is the hCG discriminatory zone?

A

The concept that a serum ß-hCG level exceeding 1,000–2,000 mIU/mL in a woman who has a normal intrauterine pregnancy should be accompanied by a gestational sac that is visible via transvaginal US.

If the gestational sac NOT seen on U/S at hCG above discriminatory zone, nonviable gestation should be suspected.

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14
Q

Why is it recommended to aim for a higher discriminatory zone, as high as 3,500 mIU/mL?

A

To avoid the potential for misdiagnosis and possible interruption of an IUP.

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15
Q

What is the medical management of an Ectopic Pregnancy? Surgical management?

A

Methotrexate (MTX).

Salpingotomy or Salpingectomy.

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16
Q

What criteria is Methotrexate preferred to meet in order to be indicated?

A
  1. Pt hemodynamically stable.
  2. Serum hCG < 5,000 mIU/mL.
  3. No fetal cardiac activity.
  4. Ectopic mass < 3-4 cm.
  5. Pt able and willing to comply with close follow up.
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17
Q

Contraindications to Methotrexate?

A
  1. IUP/Heterotopic pregnancy.
  2. Breastfeeding.
  3. Hypersensitivity to MTX.
  4. Hematologic, renal or hepatic abnormalities.
  5. Immunodeficiency, active pulmonary disease, PUD.
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18
Q

What serum level is typically used to assess for ectopic pregnancy?

A

Serial hCG.

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19
Q

When is surgery indicated in an ectopic pregnancy?

A

If an ectopic pregnancy is confirmed and the pt is hemodynamically unstable.

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20
Q

What is the most common complication in early pregnancy?

A

Spontaneous abortions.

-10% clinically recognized; may be as high as 31%.

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21
Q

Defined as a nonviable intrauterine pregnancy up to 20 weeks gestation?

A

Spontaneous Abortions.

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22
Q

What are other names of spontaneous abortions?

A

Pregnancy loss, miscarriage.

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23
Q

What are the risk factors associated with Spontaneous Abortions?

A
  1. Increasing age.
  2. Prior pregnancy loss.
  3. Maternal medical conditions:
    - -Infection, DM, Obesity, Thyroid disease, thrombophilias.
  4. Medications and substance use.
  5. Subchorionic hematoma:
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24
Q

What is a subchorionic hematoma?

A

The accumulation of blood between the uterine lining and the chorion (the outer fetal membrane, next to the uterus) or under the placenta itself. It can cause light to heavy spotting or bleeding, but it may not.

*Increases risk of SAB, preterm labor, placental abruption, PROM.

25
Q

What is the most common clinical presentation of a spontaneous abortion (SAB) and what is concerning about it?

A

Vaginal bleeding and cramping, which is similar to an ectopic pregnancy.

  • *A thorough eval is needed to distinguish it from an ectopic pregnancy.
  • If prior established IUP, diagnosis is more straight-forward.
26
Q

What is the preferred modality to diagnose pregnancy loss?

A

Ultrasound – there are specific U/S criteria.

27
Q

Name the different types of spontaneous abortions?

A

Threatened, Inevitable, Incomplete, Missed, Complete Abortions.

28
Q

Defined as vaginal bleeding present, but ‘cervical os is closed,’ and diagnostic criteria for SAB has not been met?

A

Threatened abortion.

29
Q

Defined as vaginal bleeding present, and ‘cervix is dilated’?

A

Inevitable abortion.

30
Q

Defined as vaginal bleeding/pain present, ‘cervix is dilated,’ and there is products of conception in cervical canal?

A

Incomplete Abortion.

31
Q

Defined as SAB in a patient with or without symptoms with a closed cervical os?

A

Missed abortion.

32
Q

Defined as products of conception have completely passed and cervix is closed?

A

Complete abortion.

33
Q

What is the management of spontaneous abortions?

A
  1. Expectant:
    - -Patient preference, GA < 14 wks, stable pt w/o evidence of infection.
  2. Medical:
    - -Misoprostol or Mifepristone + Misoprostol.
  3. Surgical Evacuation (D and C).
34
Q

What are some complications that happen in the second and third trimester?

A

Placenta previa, Abruptio placenta, and PROM or Prelabor rupture of membranes.

35
Q

The presence of placenta tissues that extend over the internal cervical os and suspected in pregnancy who present with vaginal bleeding AFTER 20 weeks gestation?

A

Placenta previa.

36
Q

Epidemiology of placenta previa?

A
  1. Prevalence about 4 per 1,000 births.
  2. At 20 wks, prevalence can be as high as 2%.
    - -Most previas identified early in pregnancy resolve before birth.
37
Q

Risk factors for placenta previa?

A
  1. Previous placenta previa.
  2. Previous cesarean delivery.
  3. Multiple gestation.
  4. Increasing parity and maternal age.
  5. Previous abortion.
  6. Smoking.
38
Q

What is the clinical presentation of a placenta previa?

A
  1. PAINLESS Vaginal Bleeding; although, 10-20% can present with contraction, pain and bleeding.
  2. Up to 90% are asymptomatic found incidentally on a antepartum visit found on U/S.
39
Q

Diagnosis of placenta previa?

A

In a pt presenting with vaginal bleeding w/o known placenta location – obtain U/S prior to digital exam.

40
Q

What is the preferred diagnostic tool to diagnose placenta previa?

A

TVUS to describe extent of previa (mm extending over cervical os).

41
Q

Define “low-lying” placenta?

A

The placenta edge < 2 cm from internal cervical os, but not over it.

42
Q

When is placenta previa considered an issue?

A

If it happens earlier on in the pregnancy before 20 weeks and there is presence of bleeding.

43
Q

What is the management of an asymptomatic placenta previa identified at 20 weeks?

A
  1. F/U TVUS at 32 weeks to evaluate if resolved, low-lying or placenta previa.
    * See slide 25 of ppt.
44
Q

What is the management of a symptomatic placenta previa that is bleeding?

A

Admit for maternal and fetal assessment and stabilization.

45
Q

What are the indications for delivery in a symptomatic placenta previa?

A

*Cesarean Delivery is indicated.

  1. Active labor.
  2. Category III fetal heart tracing.
  3. Hemodynamic stability cannot be maintained.
  4. Significant bleeding after 34 weeks.
46
Q

What is the expectant management of stable placenta previa after a bleed?

A
  1. Antenatal corticosteroids.
  2. Correction of anemia.
  3. Anti-D immune globulin (if Rh neg).
  4. Discharge criteria:
    - -Reliable pt who will comply with bed rest and avoid sexual activity.
    - -Able to return to the hospital w/in 20 minutes.
47
Q

Partial or complete placental detachment prior to delivery of the fetus?

A

Placenta Abruption or Abruptio Placenta

48
Q

Epidemiology and risk factors of Abruptio Placenta?

A
  1. Occurs in 2-10 per 1,000 births.
  2. Previous abruption, abdominal trauma, cocaine or other drug use, Eclampsia/Preeclampsia/HTN, PROM, Chorioamnionitis, Polyhydramnios.
49
Q

What is the clinical presentation of placenta abruption?

A
  1. Acute onset of BLEEDING, ABDOMINAL PAIN/BACK PAIN, CONTRACTIONS.
  2. Uterus is firm, rigid, tender.
  3. High frequency contractions w/low amplitude.
  4. Labor may proceed rapidly.
50
Q

Diagnosis of placenta abruption?

A
  1. Clinical diagnosis (based on suspicion).
  2. RETROPLACENTAL HEMATOMA on U/S is the classical finding, but sensitivity only 25-60%.
  3. Labs: DIC if severe.
    - -Disseminated Intravascular Coagulation.
  4. Abruption – cesarean.
  5. Placenta pathology after delivery.
51
Q

What is the initial management of Placenta Abruption?

A
  1. Admission for maternal and fetal assessment and stabilization.
  2. UNSTABLE MOTHER – cesarean if vaginal deliver not imminent.
  3. STABLE Mother, nonreassuring fetal status – assisted vaginal delivery if imminent, or cesarean section.
52
Q

Continued management of a placenta abruption in a stable mother and reassuring fetal status?

A
  1. Deliver if >36 weeks, vaginal delivery is preferred.
  2. If 34-36, may consider delivery or expectant management depending of signs and symptoms.
  3. If < 34 wks, expectant management.
53
Q

Defined as rupture of membranes before the onset of labor?

A

PROM – prelabor rupture of membranes.

54
Q

If the PROM occurs before 37 weeks gestation…what is it called?

A

Preterm prelabor rupture of membranes (PPROM).

55
Q

What is the epidemiology of PROM?

A

PROM approx. 8% of all pregnancies.

PPROM approx 2-3% of all pregnancies.

56
Q

Risk factors for PROM?

A

Hx of PPROM, Infection, Short cervical length, 2nd/3rd trimester bleeding, short interval pregnancy, low BMI, smoking and illicit drug use.

57
Q

What is the clinical presentation of PROM?

A

Leakage of fluid from vagina.

58
Q

Diagnosis of Preterm rupture of membranes (PROM)?

A
  1. Clinical with History of present illness.
  2. Sterile speculum exam:
    - -Amniotic fluid passing from cervical canal.
    - -Pooling in the vagina.
  3. Microscopic evaluation of dried cervical fluid (FERNING).
  4. FETAL FIBRONECTIN – sensitive but not specific.
  5. U/S can be used as an adjunct, but not diagnostic.
59
Q

Management of Prelabor rupture of membranes?

A
  1. TERM (37 wks or more):
    - proceed towards delivery.
    - GBS prophylaxis if indicated (Group B Strep).
  2. LATE PRETERM (34-36w6d):
    - Expectant mgmt or delivery (delivery is preferred).
    - Antenatal corticosteroids.
    - GBS screening and prophylaxis.
  3. PRETERM (24wk-33w6d):
    - Expectant mgmt.
    - Abx to prolong latency.
    - GBS screening and prophylaxis.
    - Mag sulfate for neuroprotection before delivery if < 32 wks.
  4. PREVIABLE – Neonatology/MFM consult.

OB/Gyn (14 decks)

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