OB-GYN emergencies Flashcards
1
Q
What should be done if pt w/ vaginal bleeding isn’t hemodynamically stable when presenting to ER?
A
- begin approp measures for fluid resuscitation and stabilization
- immediately determine if pt is preg
- emergently refer to OB/GYN for possible OR intervention
2
Q
What should be done if pt w/ vaginal bleeding presents to ER and is hemodynamically stable?
A
- determine if pt is pre
- determine amt and length of time of bleeding
- do complete pelvic exam UNLESS you suspect placenta previa (US first)
3
Q
Hx ?s to ask pt that presents w/ vaginal bleeding?
A
- assess amt of bleeding: number of pads/tampons used, any clots, size?
- pattern of periods: LMP, regularity, missed/late periods - possibility of preg
- sexual hx: number of partners, use of condoms to assess risk of STI/PID
- if pain, where? quality and radiation?
4
Q
PE of pt w/ vaginal bleeding?
A
- vital signs: low BP is late sign of hemodynamic instability
- look for mucosal hemorrhage, petechiae (HELLP, DIC)
- signs of PCOS: oligomenorrhea or amenorrhea, anovulation, acne, hirsutism, infertility
- abdominal exam:
pain, masses, rebound tenderness - pelvic exam:
looking for source of bleding, signs of trauma, cervical motion tenderness, uterine size, contour, masses, and tenderness
5
Q
Tests to order for pt w/ vaginal bleeding?
A
- Qualitative and sometimes quantitative hCG test: sx pts w/ hCG less than 1000 mIU/ml 4x more likely to have ectopic preg
- TVUS can determine a intruterine preg at hCG levels of 1500 mIU/nl
- CBC
- type and cross if sig bleeding
- type and screen if not immediately needing transfusion
- coag tests if suspected infection (PID)
6
Q
DDx of vaginal bleeding in prepubertal pt?
A
- vulvovaginitis: bloody vaginal d/c/pruritus
- fb: bloody vaginal d/c, foul smelling
- trauma: hx is impt
- urethral prolapse: can visualize on exam
- sexual abuse: blood from sexual trauma, may have bruising, c/o pain: must have careful approach and may involve collecting evidence
- hormone secreting tumor
7
Q
DDx for vaginal bleeding in a premenopausal nonpreg pt?
A
- ruptured ovarian cyst
- ovarian torsion
- PID
- dysfxnl uterine bleeding: may be caused by endometrial cancer in pt as young as 35, tx for DUB
- uterine leiomyoma
- uterine polyp
- genital polyp
- genital trauma secondary to sexual abuse
8
Q
DDx for peri/post-menopausal pts w/ vaginal bleeding?
A
- primary concern: endometrial cancer (don’t start on OCPs!!), refer for appropriate eval and dx
- anticoag meds
- hormonal therapy
- other meds
- coagulopathy
9
Q
Bleeding etiology of 1st trimester?
A
- bleeding from implantation
- threatened, impending or incomplete miscarriage
- ectopic pregnancy: abdominal pain, amenorrhea, vaginal bleeding
10
Q
Bleeding etiology of 2nd and 3rd trimesters?
A
- placenta previa
- placental abruption
- genital trauma secondary to abuse (goes up in preg)
11
Q
Most likely bleeding etiology of early post-partum pt?
A
- PPH: need surgery ASAP
12
Q
Initial tx for unstable preg pt? Signs of hemodynamic compromise?
A
- O2, fluids, lateral displacement of uterus
- w/ vaginal bleed: early signs of compromise: tachycardia and tachypnea
- late: hypotension, weak pulse and oliguria
- women who are Rh neg need rhogam after any bleeding episode
13
Q
Etiologies of bleeding in early preg?
A
- ectopic preg
- threatened, impending, incomplete miscarriage
- physiologic (implantation of preg)
- cervical, vaginal or uterine pathology
14
Q
Eval of bleeding in early preg?
A
- hx: amt of bleeding, passed clots or tissue, pain?
- physical: hemodynamic status
- US
- labs: hCG, CBC, UA, cultures as indicated
15
Q
Signs of threatened miscarriage?
A
- no cramping
- closed cervix
- US: + fetal cardiac activity
- 90-96% will go on to term
- expectant management
16
Q
Signs of inevitable miscarriage?
A
- cramping
- increased bleeding
- US: cardiac activity or fetal demise
- open cervical os
- management: expectant or surgical
17
Q
What is an incomplete miscarriage? Sxs? Exam findings?
A
- fetus is passed but placental tissue is retained
- sxs: moderate to severe cramping
- bleeding: can be severe enough to cause hypovolemic shock
- on exam: cervical os is open and gestational tissue may be present, uterus feels boggy on palpation
- US shows tissue in uterus
- surgery usually necessary to remove retained tissue
18
Q
Hx an presentation of ectopic pregnancy?
A
- 1/100 preg in US
- hx: look for RFs -
previous ectopic
tubal surgery
hx of PID
women tx for infertility - presentation:
abdominal pain (MC sx)
vaginal bleeing
amenorrhea
hypovolemic shock
19
Q
DDx for abdominal pain?
A
- UTI or kidney stones
- appendicitis, diverticulitis
- ovarian torsion, neoplasm, ruptured cyst
- endometriosis, PID, endometritis
- implantation of preg
- threatened, inevitable or incomplete m/c
- cervical, vaginal or uterine pathology
20
Q
PE findings of ectopic preg? What else should be done?
A
PE:
- check hemodynamic status
- may reveal abdomial or pelvic tenderness
- may find adnexal mass
- may be unremarkable
TVUS:
- most helpful to determine if IUP is present
- an IUP should be seen if serum hCG greater than 2000mIU/ml
- if it’s an ectopic usually seen in fallopian tube (97%)
- if TVUS is inconclusive and pt is stable serial quantitative hCGs are followed (will start to drop instead of increasing if ectopic)
21
Q
How common is a heterotopic preg?
A
- IUP and extruterine gestation ar concomitant: occur 1/30,000 spontaneous conceptions, but in preg conceived w/ assisted reproductive technologies they can be 1%
22
Q
When does a pt w/ ectopic preg need immediate surgical intervention?
A
- if pt (has + hCG) and is hemodynamically unstable she is considered to have ruptured ectopic pre and needs immediate surgical intervention
- if pt is stable then tx w/ methotrexate and consder OB consult
23
Q
Lower genital tract tests, etiology?
A
- tests (when indicated): chlamydia, gonorrhea, HPV vaginosis, yeast, trich syphillis, HIV, herpes - etiologies: vaginal lacerations, cervicitis growths, infections genital wrts, cervical polyps - if infection concern then test and tx partner
24
Q
Tx of cervicitis secondary to infection?
A
- Rocephin 250 mg IM
- Azithro I gm
25
Q
23 YO F presents w/ lower abominal pain for last 3 days. Deep ache 6/10, fairly constant and has worsened in intensity. Hurts more w/ movement, nothing has made it better. Has had some spotting. LMP last week, 2 partners in last 9 months. + dyspareunia, no d/c. Has elevated temp (101.3) Exam and testing that should be done? Most likely dx?
A
- pelvic exam: cervix erythematous
- bimaual exam: cervix tender, no adnexal masses
- NAT: for gonorrhea and chlamydia
- CBC - will be high
- Most likely dx: PID
- if pt stable, not dehydrated (Not N/V), tx w/ rocephin and azithro
26
Q
How common is ruptured ovarian cyst? Presentation?
A
- common in women in reproductive yrs
- usually present w/ mild-moderate unilateral lower abdominal pain
- sx intensity varies w/ type of fluid from cyst:
- serous fluid - not very irritating, sxs mild
- blood - more irritating, can be at risk for hemorrhage
- sebaceous material (dermoid cyst)- quite irritating: can cause chemical peritonitis
27
Q
W/U of ruptured ovarian cyst?
A
- thorough H and P
- urine or serum hCG to r/o ectopic
- CBC: look for decreased Hgb or platelets
- UA
- if indicated cultrues to r/o STIs
- management and reassurance
28
Q
What is considered pre-term labor? Tx goal?
A
- labor that begins b/f 37 wks
- if it occurs b/f 28th wk: referred to as extreme preterm labor
- goal is to stop pre-term labor w/ tocolytics to attempt to allow fetus more time to develop
- if pre-term labor starts ante-natal steroids are given to mom to aid in maturing of lungs of fetus
29
Q
Mechanism of antenatal corticosteroids? What is used?
A
- enhances maturational lung architecture and induces lung enzymes which results in biochemical maturation
- studies show reduction of RDS by 50%, also decreases risk of IVH, NEC and systemic infection for 1st 48 hrs of life
- betamethasone 12 mg IM 2 doses 24 hrs apart
- dexamethasone 6 mg IM 4 doses 12 hrs apart
30
Q
What is placenta previa? What shouldn’t be done?
A
- 4/100 preg over 20 wk gestation
- classic: painless vaginal bleeding, although some women may have contractions
- Don’t do a vaginal exam w/ fingers or speculum as long as pt is hemodyn. stable. Do a TVUS to dx previa and R/O placental abruption or other etiologies of bleeding
- about 33% have initial bleeding episode less than 20 wks of gestation and are at greater risk of preterm birth
- management: bed rest and monitoring until delivery
- if complete previa - need C section
31
Q
Management of PP?
A
- confirm dx
- if acutely bleeding determine hemodynamic status:
2 large bore IVs, foley for following output (30 cc/hr is goal), CBC, coag studies (can develop DIC), type and cross match 4 units of pRBCs - maintain maternal hgb over 10, if plt less than 100,000 give platelets
- monitor fetal status, consult OB for possible emergent delivery
- if pt has minimal bleedin or it stops, or hemodynamically stable monitor mom and baby
- if baby less than 34 wks gestation consult w/ OB about giving antenatal steroids
- if contracting consult about tocolysis prob mag sulfate
- if not in facility where immediate c-section and neonnatal capabilities consider transfer
32
Q
Rfs, presentation and differential, tx for placental abruption?
A
- RFs: HTN, trauma, polyhydramnios, mult gestation, smoking, cocaine use
- presentation: uterine bleeding (concealed 20%), abdominal pain or contractions, fetal distress
- diff: PP, uterine rupture, labor, cervical or vaginal trauma
- tx: stabilize mom, monitor fetus, tocolysis w/ mag sulfate, consult w/ OB and neonatal services
33
Q
Normal fetal heart?
A
- 120-160 beats/min
- look for variability and accelerations
- decelerations where HB drops ok to decrease slightly during a contraction and then return to normal (cord may be compressing O2 to baby temporarily - seen in late stage labor)
34
Q
bad fetal heart tracing findings?
A
- lack of variability or prolonged (greater than 10 min), HR less than 120 indicates fetal distres
- late decelerations indicate fetal distress
- sinusoidal pattern indicates severe fetal distress - need to deliver ASAP
35
Q
Initial measures if baby is in fetal distress?
A
Try to increase O2 to fetus:
- maternal admin of O2
- change maternal position
- bolus w/ NS
- stop any utertonic drugs and if cont frequent contractions w/ continued fetal distress may consider tocolytic
- if fetal distress continues for 15-20 min may try scalp stim to see if FHR will accelerate which is reassuring - if FHR doesnt’ accelerate - can indicate fetal acidosis - prompt delivery is indicated
36
Q
Definition of mild preeclampsia?
A
- 2 BP measurements 6 hrs apart above 140/90
- + proteinurea of more than 0.1 g/L on urine dipstick or more than 300 mg protein 24 hrs
37
Q
DDx for mild preeclampsia?
A
- DKA
- gallbladder disease
- glomerular nephritis
- hepatic encephalopathy
- TTP
- PUD
- viral hepatitis
- nephrolithiasis
38
Q
Management of mild preeclampsia?
A
- if pt 37 wks or greater: deliver
- 34-36 wks - do expectant management
- labs: CBC w/ platelets, CMP, 24 hr urine
- assessment of fetus:
US to assess size, amt of amniotic fluid - nonstress test
- ana sign of severe preeclampsia –Deliver!!
39
Q
What is severe preeclampsia? Tx?
A
- SBP over 160, DBP over 110
- proteinurea = to or greater than 5 gm in 24 hrs
- edema, signs of end organ damage (blurred vision)
- indication for admission
- start on mag sulfate to prevent seizures
- tx BP w/ labetalol or hydralazine
- delivery: induction initially may reqr c-section
- if less than 30 wks best to go to a tertiary center for management w/ perinatologist
40
Q
Use of Mag sulfate? SEs? Monitoring?
A
- maintenacnce phase given only after patellar reflex is present, loss of reflexes 1st sign of hypermagnesemia
- get baseline DTRs b/f tx
- respirations greater than 12/min and urine output greater than 100 cc/hr are signs that mag level is ok
- SEs:
w/ loading dose: diaphoresis, flushing b/c of vasodilation and decrease in BP, N/V, rare pulmonary edema, chest pain - Fetus: no sig SEs
- Mag sulfate: acting as anticonvulsant
41
Q
Cure for preeclampsia? How long is pt at risk for complications of preeclampsia?
A
- cure: delivery of placenta
- pt still at risk for complications including seizures for 48-72 hrs postpartum so mag sulfate should be cont and pt monitored closely
42
Q
What is ecclampsia?
A
- occurrence of 1 or more general tonic-clonic seizures or coma in preeclamptic woman
- generally lasts no longer than 3-4 min (usually 60-75 sec)
43
Q
Management of preeclampsia?
A
- protect maternal airway
- lower BP if severely high:
hydralazine
labetalol - prevent further seizures by starting Mg sulfate
- monitor fetus: often limited bradycardia
- Can turn into HELLP - need to deliver immed
44
Q
Presentation of death in utero, what should be documented? What should be done?
A
- presentation: usually mom comes in c/o decreased fetal movement
- document: no fetal heart sounds, no cardiac activity on US
- in 2nd and 3rd trimester generally best to induce labor except if prior C section then woman at higher risk for uterine rupture
- mother at risk for coag the longer the fetus remains in uterus
- great loss and should be tx as such - attend to emotional needs of parents
45
Q
Breech delivery and mangement?
A
- usually fetal position is determined well b/f term and most breech babies are delivered C section, but there are times when there is no time for C section
- ***cephalic flexion
- bring out one leg at a time
- delivering arms: once trunk delivered up to scapula, cord pulsation is checked and small loop is pulled down to prevent traction on cord
- w/ next push shoulders should present, along w/ arms folded over chest, if shoulder fail to deliver then lift baby’s legs and trunk and flex elbow jt and deliver w/ arm across chest
- suprapubic pressure and Mcroberts maneuver helps keep head flex and delivery of baby
- if this doesn’t work - have mom get on all 4s
46
Q
Diff shoulder dystocia maneuvers?
A
- drain distended bladder
- McRoberts: 2 assistants sharply flex maternal thighs back against abdomen
- apply suprapubic pressure w/ palm or fist
- cut a generous episiotomy
- rubin maneuver: clinicain places one hand in vagina behind posterior shoulder rotates it anterior towards fetal face
- get mom on all 4s: gaskin all 4s - infant delivered by gentle downward traction on post shoulder
- sympysiotomy: used as last resort when c section not available, anesthetize area, displace urethra w/ finger and cut through carilagenous portion of symphysis
- can replace fetal head and do emergent c section
47
Q
What should be done if extremity is presenting?
A
- may be vertical or breech presentation w/ extremity beside it:
don’t use oxytocin, sometimes extremity will naturally be moves out of the way and vaginal delivery will occur - if extremity persists c section needed
- may be a footling breech or leg first or arm generally these are delivered by c section unless spontaneously deliver
48
Q
Highest risk for newborn to acquire congenital herpes?
What should preg woman do if in labor who has hx of genital herpes?
A
- is to mom who was infected w/ primary HSV-2 during pregnancy (if infected b/f - will have abs)
- should have a c section if:
she has active herpes lesions on or near the birth canal, any prodromal sxs on or near the birth canal
