OB/GYN Emergencies Flashcards
Approach to Vaginal Bleeding
Assess hemodynamic stability
Before pelvic exam, have to rule out placenta previa with transvaginal US
Assess amount of bleeding, period patterns, sexual history
Prepubertal Patient Vaginal Bleeding DDx
Vulvovaginitis - bloody vaginal discharge/pruritis
Foreign Body - bloody vaginal discharge/foul smell
Trauma - varied presentation; history is important
Urethral prolapse - can visualize on exam
Sexual abuse - blood from trauma
Hormone-secreting tumor
Premenopausal Nonpregnant Vaginal Bleed DDx
Ruptured ovarian cyst
Ovarian torsion
PID
Dysfunctional uterine bleeding
Uterine leiomyoma
Uterine polyp
Genital trauma
Peri/Post Menopausal Vaginal Bleeding DDx
Endometrial cancer is primary concern
Anti-coagulant medication
Hormonal therapy
Other medications
Coagulopathy
Vaginal Bleed DDx in the Pregnant Patient
First Trimester: Implantation, Miscarriage, Ectopic pregnancy
Second & Third Trimester: Placenta previa, placental abruption, genital trauma
Early Post-Partum: post-partum hemorrhage
Threatened and Inevitable Miscarriage
Threatened: no cramping, closed cervix; may have fetal activity on monitor
Inevitable: cramping, increased bleeding; no fetal activity with open cervical os
Incomplete Miscarriage
Fetus has passed but placental tissue is retained
Moderate to severe cramping with severe bleeding
Os is open, uterus is boggy to palpation
D&C to remove retained tissue
Ruptured Ovarian Cyst Intensity
Varies with the type of fluid from the cyst
Serious fluid - not very irritating, mild symptoms
Blood - more irritating, may be at risk for hemorrhage
Sebaceous material - quite irritating, can cause chemical peritonitis
Preterm Labor
Occurs before 28 weeks gestation
Goal is to stop labor with tocolytics to allow fetus more development time
Give ante-natal corticosteroid to aid lung maturation
Antenatal Corticosteroids
Enhance maturation of lung architecture and enzymes
Reduces RDS by 50% as well as risk of IVH, NEC, and systemic infection in first 48 hours of life
Betamethasone 12mg IM x2 24 hours apart
Dexamethasone 6 mg IM x4 12 hours apart
Placenta Previa
Classic painless vaginal bleeding: +/- cramping
Do not do a pelvic exam - Get a transvaginal US
33% have initial bleeding episode <20 wks and are at increased risk of preterm birth
Determine hemodynamic status, maintain Hgb >10 w/ platelets if needed
Placental Abruption
Risk: HTN, trauma, polyhydramnios, multiple gestations, smoking, cocaine use
Uterine bleeding with abdominal pain or contractions, fetal distress
Tx: Stabilize mother, monitor fetus, tocolytics with magnesium sulfate, consult with OB and neonatal services
Fetal Heart Monitoring
Normal HR 120-160 bpm
Look for variability and accelerations
Late decelerations indicate fetal distress
Sinusoidal patterns indicate severe fetal distress
Fetal Heart Tracing - Fetal Distress Management
Give mom O2
Change maternal position
Bolus with normal saline
Stop any uterotonic drugs, consider tocolytics
FHR decelerations unresponsive to drugs may indicate fetal acidosis - deliver baby promptly
Mild Preeclampsia
2 BP measurements 6 hours apart >140/90
Proteinuria >0.1 g/L on dipstick or >300 mg protein 24 hours
Triad is proteinuria, edema, and high blood pressure
Deliver if >37 weeks; 34-36 weeks do expectant management
Deliver with severe preeclampsia
Severe Preeclampsia
SBP >160, DBP >110
Proteinuria >5gm in 24 hours
Signs of end organ damage
Tx: Start on mag sulfate, deliver if possible
Magnesium Sulfate
Maintenance phase given only if patellar reflex is present
Loss of reflexes is first sign of hypermagnesemia
Magnesium levels ok if RR >12 and urine output >100 cc/hr
Anticonvulsant - consider 48-72 hours postpartum
HELLP
Hemolysis
Elevated Liver Enzymes
Low platelets
Eclampsia
Occurrence of 1 or more general tonic-clinic seizures or coma in a preeclamptic woman
Lasts no longer than 3-4 minutes
Mag sulfate to prevent seizures; benzos if the mag sulfate doesn’t work
McRoberts Maneuver
Sharply flex maternal thighs back against abdomen while applying suprapubic pressure with palm or fist
Gaskin All-Fours
Have mom on hands and knees
Deliver infant by gentle downward traction on posterior shoulder
Oxytocin CI
Verticle or breech presentation with an extremity beside it
