OB/GYN Emergencies - Exam 3 Flashcards
What does abnormal uterine bleeding cover? How is it divided?
Encompasses all causes of abnormal bleeding in nonpregnant women
structural vs nonstructural causes and ovulatory or anovulatory
What are common causes of premenarcheal vaginal bleeding? ( in that order)
Genital Trauma and/or sexual abuse
Vaginitis
Tumors (vaginal, uterine)
Foreign bodies
Menarche
Precocious puberty
Hematuria
Coagulopathy
What are 2 super important question you need to ask yourself when working a pt up for vaginal bleeding?
how old is the pt!!!! very much changes your ddx
and is there a chance they are pregnant?
What are common causes of vaginal bleeding in a women of reproductive age? these are in order
Coagulopathy
Anovulatory cycles
Pregnancy (including ectopic, abortion)
Endocrine abnormality
Uterine leiomyomas
Cervical and endometrial polyps
Pelvic infections (salpingitis, cervicitis)
Trauma
What are some common causes of vaginal bleeding a postmenopausal women?
Exogenous hormones
Atrophic vaginitis
Endometrial lesions (including cervical or uterine cancer/tumors)
Cervical/endometrial polyps
Trauma
What are important history questions to ask a women when working them up for vaginal bleeding?
how many pads/tampons do you use in 24 hours?
how long as this bleeding been occurring?
any hx of previous STIs?
are there any other signs of bleeding?
What is the management of an unstable pt with vaginal bleeding?
Uterine compression
D&C/laparoscopy/laparotomy
IV estrogen
ADMIT
What is the management for a stable pt with vaginal bleeding?
oral short-term hormonal therapy (ordered by GYN) vs TXA
Discharge and follow up gynecologist
NSAIDs
need to give VERY SPECIFIC return precautions
What are the risk factors for an ectopic pregnancy?
Prior ectopic pregnancy
Prior fallopian tube, pelvic, or abdominal surgery
Sexually transmitted infections
Pelvic Inflammatory Disease
Endometriosis
also mentioned smoking, IUD, and IVF in class
Where is an ectopic pregnancy most likely to implant?
in the fallopian tubes
What is the classic triad of ectopic pregnancy? Will the pain be sudden or gradual? Describe the pain
abdominal pain, vaginal bleeding, amenorrhea
can be EITHER sudden or gradual
Ectopic pregnancy pain can manifest either suddenly or gradually, and may be persistent or come and go; it’s often described as a sharp, stabbing pain on one side of the lower abdomen (but can be both)
If the pt complains of shoulder pain without obvious trauma to the shoulder, what should you be thinking?
pain from the diaphragm can radiate to the shoulder, ectopic pregnancy can irritate the diaphragm
What lab studies should you order when working a pt up for ectopic pregnancy? What imaging? What are you looking for?
HCG (needs to be quantitative), CBC, progesterone, type & screen, comprehensive metabolic panel
transabdominal US first then transvaginal if it is nondiagnostic
visualization of unequivocal IUP without abnormalities excludes ectopic pregnancy
aka it is an assumed ectopic pregnancy until proven otherwise
In a normal healthy intrauterine pregnancy, how often should hCG levels increase? What level of hCG should you be able to visualize the baby in the uterus?
hCG should double every 48 hours
hCG over 1500 should be able to see something in the uterus
What is the definitive tx for an ectopic pregnancy?
sx or medication but both at the discretion of OB/GYN
______ is sometimes given in pregnant vaginal bleeding pts but OBs have differing opinions on the subject so up to their judgement
Rh negative: anti-Rho (D) immunoglobulin
How will gestational trophoblastic dz present? Why?
usually with super severe vomiting because the hCG levels are super super super high
What are the top 3 ddx for a pt who presents late in pregnancy with vaginal bleeding?
placental abruption
placenta previa
preterm labor
What is the difference between placental abruption and placental previa? What is considered preterm labor?
Placental Abruption: premature separation of the placenta from the uterine wall
Placenta Previa: the implantation of the placenta over the cervical os
preterm labor: before 37 weeks
Need to listen for ____ in vaginal bleeding in late pregnancy. What are 3 super important hx questions to ask?
fetal heart tones!!!
associated timing: sudden or gradual and do you have pain?
describe the “blood”: thin, watery fluid with a blood tinge could be amniotic fluid
Describe the onset and pain of placental abruption vs previa? What is the tx?
abruption will be sudden onset with pain -> may need emergency c-section
previa will be PAINLESS!! -> may need emergency c-section
consult OB for both!!
When US a preg pt with vaginal bleeding, what are you looking for?
fetal heart beat
where is the placenta?
amniotic fluid levels
How does PROM present? What do you use to exam?
rush of fluid or continuous leakage of fluid from vagina
STERILE speculum exam with STI testing, consult OB!!!
What is a threatened abortion? **What are the 2 important features?
vaginal bleeding in the first 20 weeks of pregnancy with a CLOSED cervical os, benign examination, and no passage of tissue
in the first 20 weeks
CLOSED cervical os
What is an inevitable abortion?
vaginal bleeding with open cervical os
OPEN cervical os
What is an incomplete abortion?
partial passage of the conceptus, more likely between 6 and 4 weeks
What is a complete abortion?
passage of all fetal tissue before 20 weeks gestation
What is a missed abortion?
fetal death at less than 20 weeks without passage of any fetal tissue for four weeks after fetal death
What is a septic abortion?
evidence of infection during any stage of abortion
When preforming a pelvic exam on a spontaneous abortion, what are 2 things you want to make note about?
need to make a comment on if you can see fetal tissues and clots
What is the tx for threatened/inevitable/complete abortion?
discharge with OB follow up
What is the tx for incomplete or missed abortion?
OB consultation, D&C
What is the tx for a septic abortion?
OB consultation, admission (consider ICU), broad spectrum antibiotics
amp/sulb
OR
clinda and gent
What are the 3 gestational HTN syndromes?
chronic HTN
gestational HTN
preeclampsia
What is chronic HTN in pregnancy?
blood pressure at or above 140/90mmHg prior to pregnancy, prior to 20 weeks’ gestation or lasting more than 12 weeks after delivery
What are the complications of chronic HTN in pregnancy?
abruption, preeclampsia, low birth weight, cesarean delivery, premature birth, and fetal demise
What is gestational HTN? **What is the criteria to official dx?
blood pressure at or above 140/90 mmHg after 20 weeks or in the immediate postpartum period without proteinuria
**a systolic blood pressure greater than/equal to 140mmHg OR diastolic blood pressure greater than/equal to 90mgHg on two occasions at least 4 hours apart
What are the risk factors for gestational HTN?
first-time mothers, women whose sisters and mothers had PIH, women carrying multiples, women younger than 20 years or older than 40 years, women who had high blood pressure or kidney disease prior to pregnancy
What is the tx for gestational HTN?
rest/lying on left side, increase prenatal checkups, consume less salt, drink 8 glasses of water a day, medications, consult OB/GYN
defer medication choice to OB/GYN
Define preeclampsia. What is the classic triad of symptoms?
hypertension greater than 140/90mmHg on two occasions at least 4 hours apart and proteinuria greater than/equal to 300mg in 24 hours in patients at 20 weeks’ gestation
swelling, HTN, proteinuria
What are some alternate criteria to dx preeclampsia?
Alternate Criteria (hypertension without proteinuria): thrombocytopenia, elevation LFTs, new renal insufficiency, pulmonary edema, new-onset mental status/visual disturbance
What are s/s of preeclampsia?
HA
visual disturbances
edema
abdominal pain
What is considered severe preeclampsia? What is eclampsia?
Severe Preeclampsia reflects end-organ involvement and blood pressures typically 160/110mmHg or greater
Eclampsia is preeclampsia with seizures
What category does HELLP syndrome fall under? What are the criteria to dx?
Clinical variant of preeclampsia
Criteria: Hemolysis, Elevated Liver enzymes, Low Platelets
What is one important caveat of HELLP syndrome that you need to NOT forget?
May only complain of abdominal pain and NOT have elevated blood pressure at the time of presentation but it will increase over time
What is the associated timeframe for preeclampsia? need to check for ____. What additional labs should you order?
20 weeks or greater
check for fetal heart tones
LDH and peripheral smear
Why do you need to order a LDH in preeclampsia?
In preeclampsia, an LDH (lactate dehydrogenase) test is ordered to assess the severity of the condition and identify potential complications, as elevated LDH levels indicate cellular damage and dysfunction, which are common in preeclampsia
What is the tx for severe preeclampsia? What HTN meds?
labetalol or hydralazine
If a female pt comes in with pelvic pain, _____ needs to be excluded first
pregnancy!!!
What is primary dysmenorrhea? It is a ______
cramping pelvic pain that comes before or during a period
dx of exclusion!! need to rule all the scary stuff out first
What is mittelschmerz? What are the characteristics?
benign pelvic pain that occurs midcycle (during or after ovulation)
may be one-sided, self-limiting (minutes to hours), range from mild to severe pain
Describe the pain associated with an ovarian cyst? What are 2 complications? What are concerning features of ovarian cysts?
sudden-onset unilateral pain, pain caused by stretching of the capsule
bleeding from cyst wall or cyst rupture
cysts >8cm, multiloculated, or solid
sudden onset of unilateral, severe adnexal pain; may have nausea/vomiting and low-grade fever
What am I?
What are the risk factors?
What might be present?
ovarian torsion
pregnancy, history of large ovarian cysts/tumors, chemical induction of ovulation
VERY SEVERE PAIN, pt might have a hard time speaking in complete sentences due to extreme pain
recurrent pelvic pain associated with menstrual cycles, dyspareunia, and infertility
What am I?
What is the underlying cause?
endometriosis
chronic inflammation within the pelvis resulting from endometrium-like tissue implanted outside of the uterus
_____ are benign smooth muscle tumors, usually in the uterus or gastrointestinal tract. What will they present like?
Leiomyomas (uterine fibroids)
abnormal vaginal bleeding, dysmenorrhea, bloating, backache, urinary symptoms, enlarged uterus, and dyspareunia
What are risk factors for PID?
age, multiple sexual partners, a new sexual partner (last 30 days), presence of other sexually transmitted diseases, and recent intrauterine device insertion (prior 3 weeks)
_______ is an infection of the female reproductive tract from bacteria that ascends from the vagina. What are some s/s? What are 3 complications?
PID
lower abdominal pain, vaginal discharge, vaginal bleeding, urinary discomfort, fever, nausea/vomiting
increased risk of ectopic pregnancy, infertility, chronic pain
What is the minimum criteria to dx PID? What s/s improve diagnostic specificity?
min: uterine or adnexal tenderness and cervical motion tenderness
s/s improve dx specificity: fever, vaginal/cervical secretions, elevated ESR/CRP, positive pelvic culture
How would a pt who is possibly pregnant present? What should you check for on PE?
acute/chronic or intermittent/continuous pain with GI with a relationship to their menstrual cycle
aka can be anything
any uterine enlargement? bleeding?
What is the tx for nonemergent pelvic pain?
reassurance, NSAIDs, gyn referral
What if the PID parenteral tx options?
Cefotetan or cefoxitin PLUS doxy IV
OR
Clinda IV PLUS gent
OR
amp/sulb PLUS doxy
What are the PID outpt oral tx options?
ceftriaxone or (cefoxitin AND probenecid)
OR
cefriaxone PLUS doxy PLUS metro for 14 days
What is the PO PID tx if the pt is allergic to cephalosporins?
levo PLUS metro
A 16-year-old sexually active female complains of pelvic pain and vaginal discharge. On physical, temperature 39.8 and bimanual exam reveals cervical motion tenderness and a mass on the right adnexa. Which treatment is appropriate?
A. Outpatient treatment with IM penicillin
B. Outpatient treatment with ceftriaxone IM plus doxycycline
C.Outpatient treatment with cefoxitin IM plus metronidazole
D. Inpatient treatment with cefoxitin IM plus doxycycline
D. Inpatient treatment with cefoxitin IM plus doxycycline
A 24-year-old female with 6 weeks’ amenorrhea develops continuous lower abdominal pain and minimal vaginal bleeding. The uterus is slightly enlarged, the cervix is soft and tender on motion. There is adnexal tenderness. The history and clinical findings are most suggestive of:
A. Ectopic pregnancy
B. Ruptured ovarian cyst
C. Mittelschmerz
D. Dysmenorrhea
A. Ectopic pregnancy
A 22-year-old G2P1 presents with 1 day history of vaginal bleeding and abdominal pain. Her LMP was 10 weeks ago and she had a positive home pregnancy test 6 weeks ago. She denies any passage of clots. On pelvic, you note blood in the vaginal vault. The internal cervical os is open. Which one of the following best describes the patient’s current condition?
Inevitable abortion
Completed abortion
Threatened abortion
Incomplete abortion
Missed abortion
Inevitable abortion
A 37-year-old G3P2 at 33 weeks EGA reports the onset of brisk vaginal bleeding. The uterus is nontender and pelvic exam reveals the presence of a large amount of bright red vaginal blood. The presentation is most consistent with:
Threatened abortion
Hemorrhagic cystitis
Placenta previa
Placental abruption
Placenta previa
A 33-year-old female presents with 3 months of irregular vaginal bleeding. Prior to this her menstrual cycles were normal. Which one of the following is the most appropriate initial lab test for this patient?
CBC
TSH
Type & screen
HCG
PT/PTT
HCG
