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CCFP(EM) Omar > OBGYN > Flashcards

OBGYN Flashcards

1
Q

Risk factors for Ectopic Pregnancy

A

Infection: PID<div>Drugs: Infertility Rx, IUD</div><div>Iatrogenic: Tubal ligation, tubal surgery</div><div>Age: Older age</div><div>Endocrine: endometriosis</div><div>Smoking</div>

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2
Q

FIRST TRIMESTER BLEEDING:

A

<ul><li>Miscarriage</li><li>Ectopic pregnancy</li><li>Infection</li><li>Cervical/vaginal lesions</li><li>Trauma</li><li>Coagulopathy</li><li>Gestational Trophoblastic disease</li></ul>

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3
Q

<div>History for Vaginal Bleeding in Early Pregnancy</div>

A

<div>•degree and duration of bleeding,</div>

<div>•is the pain lateral or central,</div>

<div>•history of trauma,</div>

<div>•obstetric and fertility history, bleeding disorders, infections,</div>

<div>•previous miscarriage history</div>

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4
Q

“<div><span>When is βhCG Testing Useful in Vaginal Bleeding</span></div>”

A

<div>oβhCG levels become positive 8-11 days after conception</div>

<div>oLevels peak at 10-12 weeks, then gradually decrease.</div>

<div>o**Test all women of child-bearing age regardless of history suggesting possibility of pregnancy (1,2).**</div>

<div>oUrine βhCG becomes positive 1 week later than serum tests, and may be falsely negative if urine is very dilute</div>

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5
Q

“<div><span>Key βhCG facts to remember</span></div>”

A

<div>•At expected time of missed menses: 2000 IU/mL</div>

<div>•IUP visible by transvaginal ultrasound: >1500 IU/mL</div>

<div>•IUP visible by abdominal ultrasound: >3000 IU/mL</div>

<div>•Cardiac activity visible on ultrasound: >1500 IU/mL by transvaginal, >6500 IU/mL by abdominal</div>

<div>•βhCG doubling time = 48-72 hours</div>

<div>•Levels become undetectable at 3-4 weeks postpartum</div>

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6
Q

Indications of Methotrexate in EP

A

<ol> <li>BhCG <5000, </li> <li>no fetal cardiac activity, </li> <li>ectopic mass <3–4cm, </li> <li>hemodynamically stable, </li> <li>no sign of rupture, </li> <li>reliable patient</li></ol>

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7
Q

<div>Prior to MTX treatment</div>

A

<ul> <li>blood tests must confirm normal liver and kidney function, and </li> <li>patients must be counseled to avoid folic acid and alcohol. </li> <li>Strenuous exercise and intercourse must also be avoided due to the risk of tubal rupture. </li> <li>Patients must also discontinue folic acid supplementation.</li></ul>

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8
Q

<ul> <li>AVOID thesemajor pitfallsof diagnosing ectopic pregnancy in the emergency department:</li></ul>

A

“<ul> <li>assuming low BhCG rules out ectopic</li> <li>relying on the “classic triad”</li> <li>relying on inexperienced ultrasonographer or non-hospital ultrasound lab reports</li> <li>assuming no products of conception seen on U/S means it was a complete abortion (and not an ectopic)</li> <li>failure to appreciate degree of blood loss</li> <li>failure to consider heterotopic* if unstable and IUP seen on U/S</li> <ul> <li><span>*heterotopicriskof 1 in 30,000</span><span>pregnanciesrisesto 1 in 100 if thepatient is receiving fertility treatments</span></li> </ul> <li>failure to assure adequate follow up if no IUP is seen or if the ultrasound is indeterminate</li></ul>”

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9
Q

Risk Factors of Placential Abruption

A

Previous PA<div>Trauma</div><div>Cocaine</div><div>Smoking</div><div>HTN</div><div>Polyhydramnios</div><div>Advanced maternal age</div><div>Multiparity</div>

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10
Q

Role of US in plac abruption

A

US is not sensitive to diagnose PA but it is used to exclude placentia previa and to check for fetal distress

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11
Q

Work up for pregnant patient with massive vag bleeding

A

High acuety bed<div>Cardiac minitor</div><div>2 large bore angiocath</div><div>O2 if needed</div><div>Fluid bolus (one litre)</div><div>Uterine monitoring for contraction and FHR (Fetotocography)</div><div>RhoGAM for Rh neg mother</div>

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12
Q

Risk Factor for Placenta Previs

A

Previous PP<div>Anatomy change:</div><div> Previous C-Section</div><div>Fibroid</div><div>Multiparity</div><div>Multiple induced pregnancies</div><div>Advanced maternal age</div><div>Smoking</div><div> </div>

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13
Q

A 20-year-old, 10-weeks pregnant woman presents with severe nausea and vomiting. Her BP is 160/100 mm Hg and her undus is palpable at her umbilicus. <br></br>What test do you per orm to confirm your diagnosis?

A

US to look for a molar pregnancy<br></br>β-hCG.

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14
Q

Unique S/S of H.Mole

A

Severe N/V<div>Intermittent vaginal bleeding in early pregnancy</div><div>Passage of grape-like material</div><div>Uterus larger than expected for date</div><div>B-hCG is higher than expected for dates</div><div>Precelampsia <20 wks and eclampsia <24 wks</div><div>US: chr snowstorm or cystic appearing</div>

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15
Q

Treatment of HEG

A

■ Fluid resuscitation with 5% glucose-containing fluids<br></br>■ Antiemetics (eg, antihistamines, metoclopramide)<br></br>■ Consider thiamine (vitamin B1) 100 mg IV or patients with prolonged symptoms to prevent Wernicke encephalopathy.<br></br>■ Admit patients with:<div> persistent vomiting,</div><div> electrolyte abnormalities, andketosis despite resuscitation, or</div><div> weight loss > 10% of prepregnancy weight.</div>

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16
Q

Preeclamsia

A

New onset HTN<div>PTNuria</div><div>End-organ dysfunction</div><div>>20 wks</div>

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17
Q

Preclampsia risk factors

A

Prior preeclampsia<div>Family Hx</div><div>First pregnancy</div><div>Advanced maternal age</div><div>Pregestaional DM and HTN</div><div>Multiple pregnancies</div><div>Obesity</div><div>Chr kidney dis</div>

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18
Q

DDX of HELLP sybdrome

A

Other causes of abdominal pain (AA, pancreatitis, cholecystitis, gastritis)<div>TTP</div><div>HUS</div>

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19
Q

LAB findings of HELLP syndrome

A

Microangiopathic hemolytis anemia<div>Increased bilirubin</div><div>TCP</div><div>Increased liver enzymes</div>

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20
Q

Complications of bacteruria

A

Preterm birth<div>Low birth wt</div><div>Perinatal mortality</div><div>Pyelonephritis in 30%</div><div><br></br></div><div>Screening UA (12-16 wks)</div>

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21
Q

Vaccines CI in pregnancy

A

MMR<div>Live attenuated vaccines (FluMist)</div><div>Varicella</div><div>TDaP (but Td is safe after 1st trimester)</div>

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22
Q

AB CI in Pregnancy

A

Tetracycline<div>Fluoroquinolones</div><div>Sulfonamides</div><div>Chloramphenicol</div>

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23
Q

AntiEpileptics CI in pregnancy

A

Phenytoin<div>Valproic acid</div><div>Phenobarbital</div>

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24
Q

Sudden change in maternal respiratory status during labor?

A

Pulmonary embolism<br></br>Sepsis<br></br>Anaphylaxis<br></br>Myocardial infarction<br></br>Amniotic fluid embolism

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25
Q

Causes of PPH

A

4 Ts:<div>Tone</div><div>Trauma</div><div>Tissue</div><div>Thrombin</div>

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26
Q

Physical findings of PPH

A

■ An enlarge an “boggy” uterus is seen with uterine atony.<br></br>■ A vaginal mass is seen with uterine inversion. <br></br>■ Vaginal bleeding despite good uterine tone and size is likely due to retaine products.

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27
Q

A 29 year old presents to the emergency room 3 days after discharge from the hospital after a course of IV antibiotics for postpartum endometritis with continued fever and pelvic pain. What diagnosis do you need to consider and how is it treated?

A

Septic pelvic thrombophlebitis; treat with anticoagulation and antibiotics.

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28
Q

Causes of Cervicitis

A

Common infections:<div> Chlamydia</div><div> Gonorrhea</div><div><br></br></div><div>Less common infections:</div><div> HSV</div><div> Trichomonas vaginalis</div><div> Mycoplasma genitalium</div><div> GAB strt</div><div> BV</div><div><br></br></div><div>Inflammatory etiology:</div><div> Mechanical and chemical irritation (douching)</div>

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29
Q

Complications of PID

A

Abscess(T-Ov + Pelv)<br></br>Infertility<br></br>Ectopic pr<br></br>Chronic pelvic pain<br></br>Fitz-Hugh-Curtis synd (perihepatitis)

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30
Q

Rx of PID

A

Hospital: Cefotetan or cefoxitin + doxycycline<br></br>Hospital alternative: Clindamycin + gentamicin<br></br>OP: Ceftriaxone (250 mg) + doxycycline (100 mg po bid x 14 days) +/- metronidazole

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31
Q

Indication of admission in PID

A

“pregnant<div>intractable pain/vomiting</div><div>failed outpatient therapy</div><div>tubo-ovarian abscesses (TOA)</div><div><br></br></div><div><img></img><br></br></div>”

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32
Q

Risk factors for PID

A

Multiple sexual partners,<div>history of sexually transmitted disease,</div><div>young age, <br></br>nonbarrier contraception</div><div>IUD</div>

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33
Q

What other features in Hx for PID

A

Lower abd pain<div>Abn vag D/C</div><div>Post coital bleeding</div><div>Dyspareunia</div><div>Fever, malaise, N/V</div>

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34
Q

What other features in Examination for PID

A

Lower abd tenderness<div>Cx motion tenserness</div><div>Mucopurulent cervicitis</div><div>B/L adnexial tenderness</div><div>Unilateral tenderness/mass = TOA</div>

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35
Q

What are the D/C instructions for pt with PID

A

Test the partner<div>Use condoms</div><div>Other tests for (HIV, hepatitis & syphilis)</div>

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36
Q

Dx of T. vaginalis

A

Wet prep microscopy (+ve in only 60%)<div>Culture of nucleic acid amplification test (NAAT)</div>

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37
Q

Tx of Vag D/C (vaginitis)

A

“BV: Metronidazole 500 mg bid X 7/7<div> Metronidazole gel 0.75 % od pv X 5/7</div><div><br></br></div><div> For pregnant woman:</div><div> Clindamycin 300 mg po bid X 7/7</div><div> Metronidazole 500 mg po bid X 7/7</div><div><br></br></div><div>Trichomoniasis:</div><div> Metronidazole 500 mg bid X 7/7</div><div><br></br></div><div>Vag Candidiasis:</div><div> Noncomplicated: Fluconazole 150 mg po single dose</div><div> Complicated:<span>fluconazole 150 mg every 72</span><span>hours fortwo orthree doses</span></div><div> Pregnancy:Topical clotrimazole or miconazole for7 days<br></br></div>”

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38
Q

Causes of DUB (anovulatory bleeding)

A

Perimenopausal<div>Perimenarchal</div><div>PCOS</div><div>Obesity</div><div>Eating disorders</div><div>Hypo/hyper T4</div>

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39
Q

Rx of unstable pt with vaginal bleeding

A

Fluid and blood transfusion<div>OBGYN consultation:</div><div> Intrauterine temponade</div><div> D&C</div><div> Uterine a. embolization</div><div> High doses iv estrogen</div><div> Hysterectomy</div>

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40
Q

Rx of Endometriosis

A

“Directed towards the woman’s desire for future fertility<div>NSAIDs (Rx of choice for pain)</div><div>Hormonal Rx</div><div>OCP and progestational agents (oral medroxyprogestreone or Depo-Provera IM)</div><div>Gonadotropin-releasing hormone agonist and antagonist.</div><div>Surgical Rx (severe dis or adhesions)</div>”

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41
Q

Describe the dosing, timeline, indications, and contraindications for emergency contraception

A

“Morning after pill” <br></br>3 forms: <br></br>❏ Ulipristal acetate: progesterone receptor modulator, <br></br>❏ Levonorgestrel: Progestogen- progesterone receptor agonist <br></br>❏ OCP: Combination of progestin and estrogen, “Yuzpe method” <br></br><br></br>IUD: Copper vs Mirena (not used as emergency contraception)

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42
Q

DDX of Menorrhagia/Vaginal bleeding

A

“<img></img>”

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43
Q

Causes of spontaneous abortion

A

Chromosomal abnormalities<div>Insufficient progesteron</div><div>ETOH</div><div>Cocaine</div>

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44
Q

At what week gestation is cardiac activity usually present?

A

6 weeks

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45
Q

In which causes of postpartum hemorrhage would oxytocin be contraindicated?

A

Uterine rupture<div>Uterine inversion</div>

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46
Q

Risk factors for ovarian torsion

A

<ul> <li>Ovarian mass ≥ 5 cm</li> <li>Reproductive age</li> <li>Pregnancy</li> <li>Ovulation induction</li> <li>Prior torsion</li><li>Prior pelvis surgery (tubal ligation)</li> </ul>

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47
Q

Clinical features of Candidal vaginitis

A

Vaginal itch<div>Change in D/C (white cottage cheese-like)</div><div>External dysuria</div><div>Dyspareunia</div><div>Leukorrhea</div><div><br></br></div><div>Vulvar erythema and edema</div>

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48
Q

Risk factors of Candida vaginitis

A

DM<div>HIV</div><div>Recent AB use</div><div>Pregnancy</div>

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49
Q

What are the most common side effects of topical antifungal therapies for the treatment of uncomplicated candidial vaginitis?

A

Local burning and tingling.

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50
Q

Risk factors of placenta previa

A

Prior C-section<div>Multiple gestations</div><div>Multiple induced abortions</div><div>Advanced maternal age</div>

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51
Q

What organism is responsible for chancroid?

A

<i>Haemophilus ducreyi</i>

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52
Q

What are the risk factors of endometritis

A

C-section<div>PROM>24 hra</div><div>Active labor > 12 hrs</div><div>Mutliple pelvic examinations</div>

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53
Q

Causes of secondary dysmenorrhea

A

Endometriosis<div>PID</div><div>IUD</div>

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54
Q

Dose of Mg sulfate in eclampsia

A

Bolus of 4-6 g iv over 15-20 minutes followed by infusion of 1-2 g/hr<div>Watch for hypoventilation and hyporeflexia</div><div>Treat overdose with Ca gluconate</div>

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55
Q

Indications for surgery in TOA

A

Failure of improvement after 48-72 hrs of AB<div>Rupture</div><div>Sepsis</div><div>Abscess > 9 cm</div>

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56
Q

AB for TOA

A

<div>Iv adm of:</div>

<ul> <li>doxy + cefoxitin, cefotetan or</li> <li>amp-sulbactam or</li> <li>clindamycin + gentamicin</li> </ul>

<div></div>

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57
Q

Disulfiram-like reaction

A

Flushing<div>Tachycardia</div><div>Hypotension</div>

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58
Q

S/S of uterine rupture

A

Maternal shock<div>Abd pain</div><div>Peritoneal signs</div><div>Abd fetal lie</div><div>Easily palpable fetal anatomy</div><div>Nonreassuring fetal HR</div><div>Fetal demise</div>

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59
Q

Risk factors for uterine inversion

A

forceful traction on the umbilical cord,<div>excessive fundal pressure during delivery,</div><div>prior cesarean section, and</div><div>connective tissue disorders</div>

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60
Q

What is placenta accreta?

A

Placenta accreta is when the placenta adheres to the myometrium without the intervening decidua basilis, which can result in incomplete delivery of the placenta and postpartum hemorrhage.

61
Q

What are three consequences of pelvic inflammatory disease?

A

Tubo-ovarian abscess,<div>infertility,</div><div>ectopic pregnancy</div>

62
Q

U/S findings for a woman with +ve preg test

A

“<img></img>”

63
Q

“<span></span>What pathogen has been associated with late-onset postpartum endometritis?”

A

<i>Chlamydia</i>

64
Q

Which of the following is the strongest risk factor for postpartum endometritis?

A

C-Section

65
Q

What is the most common malpresentation in fetal delivery?

A

Breech presentation (4%)

66
Q

PID Outpt Rx

A

“<img></img>”

67
Q

PID inpt Rx

A

“<img></img><div><img></img><br></br></div>”

68
Q

Dilute urine can lead to a false negative urine beta test

A

True

69
Q

The HELPER mnemonic for shoulder dystocia

A

Help,<div>Episiotomy,<br></br>Leg elevation,</div><div>Pressure,</div><div>Enter vagina,</div><div>Remove posterior arm</div>

70
Q

List 4 immediately relevant questions of active labour:

A

-Gestational age <br></br>-Presence of multiple gestation <br></br>-Is Fluid clear / presence of meconium staining <br></br>-Vaginal bleeding <br></br>-Any additional risk factors in pregnancy (ie AMPLE- including prenatal care, HIV/Hepatitis)

71
Q

When would neonatal resuscitation be considered futile?

A

-Anencephaly <br></br>-GA<24w <br></br>-BW<500g <br></br>-T13/18

72
Q

Describe active management of the third stage of labor and its relevance

A

The third stage of labor is that following delivery of the fetus until delivery of the placenta. <br></br>Active management refers to standardized steps taken in every delivery to decrease the risk of post partum hemorrhage and should include: <br></br> oxytocin 10IU IM (or 20-40IU/1L NS @150ml/h or 5-10IU IV bolus) after delivery of the anterior shoulder <br></br> fundal massage. <br></br> Other advanced therapies may be considered in those at high risk or with demonstrated bleeding

73
Q

Define postpartum hemorrhage (PPH)

A

Multiple de nitions: <br></br>- >500ml/24h <br></br>- 10% drop in the hematocrit <br></br>- a need for transfusion of packed red blood cells <br></br>- volume loss that causes symptoms of hypovolemia.

74
Q

List 4 potential sources of PPH and 1 therapy for each source

A

““Tone” - Uterine Atony <br></br> -Active mgmt 3rd stage <br></br> -Two-handed uterine massage <br></br> -Pharm: oxytocin, ergots, PGs <br></br> -Packing, embolization, hysterectomy <br></br><br></br><div>“Trauma” - Birth Trauma <br></br> -Repair lacerations <br></br><br></br></div><div>“Tissue” Retained POC <br></br> -Uterine digital exploration <br></br> -Manual placental extraction <br></br> -Curettage <br></br> -Hysterectomy <br></br><br></br></div><div>“Tissue” Invasive Placenta (accreta, increta, percreta) <br></br> -Manual/curettage <br></br> -Embolization, hyst <br></br><br></br></div><div>"”Thrombin”” <br></br> -Blood products, reverse coagulopathy</div>”

75
Q

Findings and corresponding β-hCG (mIU/mL)

A

“-Gestational sac (25 mm): 1,000 <br></br>-““Discriminatory zone””: 1,500-2,000 <br></br>-Yolk sac: 2,500 <br></br>-Upper ““discriminatory zone””: 3,000 <br></br>-Fetal pole: 5,000 <br></br>-Fetal heart motion: 17,000”

76
Q

Describe six (6) specific changes in anatomy or physiology of a pregnant patient versus their non-pregnant counterpart. In the same line, also list how this change would alter your evaluation or management of this patient, compared to a non-pregnant counterpart

A

CVS: Increased HR, decreased BP, physical compression of the IVC = Supine hypotension syndrome. Use a wedge to eliminate compression on IVC: LLT 15-30º if GA>20w <br></br><br></br><div>RESP: Hyperpneic compensation -> CO2 ~30 (due to placental progesterone). Difficult airway- rapid desat. <br></br>RESP: Diaphragmatic elevation -> decreased FRC. Tube thoracostomy in T3->2 spaces higher<br></br></div><div><br></br></div><div>GI: Smooth muscle tone (Esophageal sphincter); motility. Difficult airway: higher aspiration risk.<br></br></div><div>GI: Increased displacement of intraperitoneal viscera. Viscera relatively protected from blunt trauma, but at increased risk for injury with stab wounds to upper abdo<br></br></div><div>GI: Abdo wall stretch. Peritoneal signs are masked<br></br></div><div><br></br></div><div>HEME: Increased blood volume, hypercoagulable state. Higher VTE risk <br></br><br></br></div><div>URO: Bladder moves out of boney pelvis >1st trimester (T1), ureteric compression and mild hydronephrosis common in T2-3. Risk of bladder injury increases. <br></br><br></br></div><div>GYNE: Uterus protected by pelvis in T1, not so >T1, receives total blood volume q8-10min in T3. Susceptible to deformation forces of blunt mechanism >T1 leading to abruption,<br></br>susceptible to penetrating trauma >T1 <br></br><br></br></div><div>MSK: Impaired venous return to pelvis, L/E. Pelvic and L/E fractures at risk for high venous blood loss.</div>

77
Q

Mx of Supine hypotensive synd

A

Lt lat tilt (wedge under rt side)<div>Manual leftward retraction of gravid uterus</div>

78
Q

Describe the benefit of anti-Rh Immunoglobulin

A

To neutralize RH+ fetal blood exposed to maternal circulation so as to prevent maternal anti-D immunoglobulin formation that could harm future Rh+ pregnancies.

79
Q

Name one test that this useful in the diagnosis of fetomaternal hemorrhage.

A

-Kleihaur-Betke <br></br>-Flow-cytometry

80
Q

Maternal trauma,What are 2 pregnancy-related concerns in this patient?

A

-Feto-maternal hemorrhage <br></br>-Placental abruption <br></br>-Fetal injury <br></br>-Preterm labour

81
Q

Fetal trauma,What further 3 interventions/investigations are required?

A

-NST/Continuous fetal monitoring x4h <br></br>-Kleihaur-Betke <br></br>-U/S

82
Q

What is the most sensitive test for placental abruption? What indicates a<br></br>positive test?

A

-Electronic fetal monitoring (cardiotocodynamometry), incl NST <br></br>-Any fetal distress is considered positive (100% NPV)

83
Q

NST timing required for maternal trauma

A
  • at least 4 hours of fetal monitoring is required
84
Q

List two findings of NST that are a cause for concern.

A

-Tachycardia or bradycardia (>160/<120) <br></br>-Late decelerations, variable decels, complex variable decels <br></br>- Lack of variability (these are signs of fetal distress)<div><br></br>-If > 3 contractions in one hour (watch for 24 hrs more) <br></br>-If > 12-13 contractions per hour: high risk for abruption</div>

85
Q

Deceleration interpretation:

A

Early | with contraction | Head compression, benign | nil <br></br>Variable | no relation | intermittent cord compression | if persistent: delivery <br></br>Late | after contraction | uteroplacental insufficiency | deliver ASAP

86
Q

Please complete the following table as it pertains to abnormal uterine<br></br>bleeding. Please use a response ONLY ONCE

A

” <span><strong>Group</strong></span> <span><strong>Eitiology</strong></span> <span><strong>Critical ED consideration</strong></span> <strong>Prepubertal</strong> Vaginitis, anovulation, trauma, FB r/o abuse <strong>Adolescent</strong> Anovulation, pregnancy, OCP, Coagulopathy r/o coagulopathy (ie. vWD) <strong>Reproductive</strong> Pregnancy, Anovulation, OCP, Fibroids, Polyps, Thryoid dysfunction r/o pregnancy/ ectopic <strong>Postmenopausal</strong> Endometrial CA, HRT, Atrophic Vaginitis, Cervical/Vaginal, Rectal CA Arrange follow up for biopsy/US to r/o malignancy “

87
Q

A 24F with intermenstrual bleeding has a negative urine pregnancy test. She is afebrile and hemodynamically stable with a hemoglobin of 115. Her pelvic examination is entirely normal with the exception of a small amount of bleeding from her normal appearing cervical os. She has recently had a normal Pap test and STI screening with her primary care provider and has had no new sexual partners.Please outline a systematic approach to three pharmacologic options you might consider for her management from the emergency department AND one contraindication to each agent

A

-<b>NSAIDs</b>: PUD/GIB, HTN/CRF, Allergy <br></br>-<b>TxA</b>: Thrombophilia <br></br>-<b>OCP</b>: Thrombophilia, migraines, smoker, HTN, CA, cirrhosis, valvulare heart disease<div><br></br>* Note: other advanced options include: IUD, Danazol, Desmopressin, and Clomiphene, but are typically NOT appropriate to ED management.</div>

88
Q

List three ultrasound findings indicative of ectopic pregnancy

A

“-Ectopic fetal heart activity <br></br>-Ectopic fetal pole <br></br>-Free uid in cul-de sac/pelvis <br></br>-Adnexal mass* without IUP <br></br>-Empty uterus with Bhcg >3000 on TVUS or >6000 on TAUS<div><br></br>Indeterminate: Lack of the Findings diagnostic of intrauterine pregnancy: <br></br>–"”Double”” gestational sac <br></br>–Intrauterine fetal pole or yolk sac <br></br>–Intrauterine fetal heart activity</div>”

89
Q

Please list three criteria precluding medical management of ectopic<br></br>pregnancy

A

-Mass > 4cm <br></br>-FHR present <br></br>-Hemodynamic instability <br></br>-Decreasing Hb<br></br>-Sonographic evidence of rupture

90
Q

List 3 causes of preterm premature rupture of membranes (PPROM)

A

-UTI <br></br>-Infection (choriaminoitis, Bacterial vaginosis, GBS) <br></br>-Trauma <br></br>-Incompetent Cervix <br></br>-Pre-term labor <br></br>-Cigarette Smoking

91
Q

Critical action in maternal trauma:

A

<p>–Obtaining FHR as vital sign</p>

<p>–Pain control</p>

<p>–Right hip wedge or other offloading to IVC</p>

<p>–Chest tube placement 3rd or 4th intercostal space</p>

<p>–Administration of Rhogam</p>

<p>–Abdominal CT</p>

<p>–Fetal monitoring via non stress testing x min 4h</p>

<p>–Admission to ICU with consult to ObGyn</p>

92
Q

Emergency Mx of PPH in the ER

A

<p>–Large bore IV access</p>

<p>–Blood products / MTP</p>

<p>–Oxytocin</p>

<p>–TXA</p>

<p>–Misoprostol</p>

<p>–Consider Carboprost / Ergot</p>

<p>–Speculum / PV exam</p>

<p>–Disposition to Gyne for OR or to IR for embolization</p>

93
Q

DDx of uterine bleeding in reproductive age

A

OFFICE<div><br></br></div><div>Ovulatory dycfunction (PCOS)</div><div>FB</div><div>Fibroid</div><div>Infections (PID, endometritis)</div><div>Coagulopathy (VWD)</div><div>Endocrinopathy, endometrial polyps</div><div><br></br></div><div>Cancers: cervical, endometrial</div><div>Trauma</div><div>AVM</div>

94
Q

Most common causes of acute gynecological pain

A

Ruptured ovarian cyct<div>Ovarian torsion</div><div>PID</div>

95
Q

<ul> <li>What are some short term management strategies to control the bleeding?</li> </ul>

A

<p>–Oral contraceptive</p>

<ul> <li>Higher estrogen more effective, more risk of VTE</li> <li>May take continuously with one cycle q 3 mo</li> <li>May use in patients with IUD for extra control J</li> </ul>

<p>–Tranexamic acid po</p>

<ul> <li>Ex: Cyclokapron 500mg 2-3 tab po TID – QID prn heavy bleeding for 3 – 5 days.</li> </ul>

96
Q

Longer term Mx options for abn uterine bleeding

A

IUD<div>Endometrial ablation</div><div>Hysterectomy</div>

97
Q

Mx of life threatening vaginal bleeding

A

Treatment of hemorrhagic shock (fluid, blood)<div>TXA (1g iv over 10 min the 1g iv over 8 hrs)</div><div>High-dose estrogen Rx (premarin 25 mg iv/im, repeat 4-6 hrs until gyne arrives)</div>

98
Q

D/C instructions/arrangement for postmenopausal bleeding

A

U/S<div>Endometrial Bx</div><div>PAP</div>

99
Q

What do we mean by Bedside tests?

A

Accucheck<div>Urynalysis</div><div>Urine pregnancy test</div><div>ECG</div><div>Bedside U/S</div>

100
Q

When metronidazole should be added to Rx of PID?

A

Hx of instrumentation<div>BV</div><div>T. vaginalis</div>

101
Q

<ul> <li>What is one thing you must do to prevent recurrence of PID in this patient?</li> </ul>

A

Treat sexual partner

102
Q

<ul> <li>The patient is wondering if she needs to attend a follow up appointment. What do you tell her about short term and long term follow up?</li> </ul>

A

<p>–Short term – 48-72 hour re-assess to ensure improving</p>

<p>–Long-term – negative test of cure typically not required for chlamydia or gonorrhea, do test for cure in pregnancy</p>

103
Q

What are the PID?

A

<p>Ascending genital tract infection usually STI</p>

<ul> <li>Endometritis</li> <li>Parametritis</li> <li>Salpingitis</li> <li>Oopheritis</li> <li>TOA</li> <li>Peritonitis</li> </ul>

104
Q

DDx of vag D/C

A

“<img></img>”

105
Q

“What is the infection<div><img></img><br></br></div>”

A

Bacterial Vaginosis<div>Causative agent: Gardnerella Vaginosis</div><div>IX; Vag swab</div><div>NAAT for GC & chlamydia</div><div>Rx:</div><div> Metro 500 mg po bid x 7/7</div><div> Metro 0.75% gel 5 g pv qhs x 5/7</div><div> Clindamycin 300 mg po tid x 7/7</div><div> Clindamycin 2% gel 5g pv qhs x 7/7</div>

106
Q

“What is the infection<div><img></img><br></br></div>”

A

Chlamydia cervicitis

107
Q

Recommended test for STI

A

HIV<div>Hep B</div><div>Hep C</div><div>Syphylis (RPR, VDRL)</div>

108
Q

Treatment of STI:

A

<ul> <li><b>Chlamydia:</b></li> </ul>

<p>–Axithromycin 1g po once (safe in pregnancy)</p>

<p>–Doxycycline 100mg po BID x 7d</p>

<ul> <li><b>Gonorrhea:</b></li> </ul>

<p>–Ceftriaxone 250mg IM once + Azithro 1g po once</p>

<p>–Cefixime 800mg po once + Azithro 1g po once</p>

<p>–Azithromycin 2g po once</p>

<p>–May replace Azithro with Doxy 100mg BID x 7d if macrolide allergy</p>

<p>–Cephalosporins and azithro safe in pregnancy</p>

109
Q

What defines IUP by U/S?

A

“<p>Must identify 3 structures:</p> <div>A strong echogenic (white) layer, the decidual reaction, within which you will find:</div> <div>A black area (gestational sac) in which you will find:</div> <div>Another white ring (yolk sac)</div> <div></div> <div><img></img><img></img></div>”

110
Q

What would you see by U/S based on weeks of gestation?

A

” <strong>Week of gestation</strong> <strong>Structure found</strong> 4.5 Gestational sac 5 Yolk sac 5.5 Fetal pole 6 Cardiac activity “

111
Q

DDx of bleeding in early Pregnancy

A

EP<br></br>Miscarriage<br></br>Gest trophoblastic tumor<br></br>Implantation bleeding<br></br>postcoital bleeding<br></br>Infections:<br></br> Condylomata accuminata<br></br> Chlamydia<br></br> Gonorrhea<br></br> PID<br></br>Hemorrhoids

112
Q

US findings of early pregnancy failure

A

“<img></img>”

113
Q

Time Based criteria for early pregnancy loss

A

<p>–Absence of embryo with heartbeat 7–13 days after a scan that showed a gestational sac without a yolk sac</p>

<p>–Absence of embryo with heartbeat 7–10 days after a scan that showed a gestational sac with a yolk sac</p>

<p>–Absence of embryo ≥6 wk after last menstrual period</p>

114
Q

<p>Management of Early Pregnancy Loss</p>

A

<ul> <li>Expectant management</li> <li>Medical management with misoprostol</li> <li>Surgical management with suction curettage</li> <li><b>Note</b>: <em>Spontaneous abortion is medically common, and its emotional impact is often underestimated. Ensure patient has appropriate emotional support +/- </em><em>conselling</em><em> prior to discharge.</em></li> </ul>

115
Q

Medical Mx of early preg loss

A

<p>Misoprostol 800 mcg pv, may repeat in 48 hrs if no result.<br></br>Ibuprofen for pain<br></br>RhoGAM within 72 hrs in Rh(-)<br></br>US in 7-14 days to document complete expulsion (or serial BHCG)</p>

<p><strong>Counsel re: what is too much bleeding? Soaking 2 maxi pads per hours for 2 consecutive hours – if this occurs return to ED</strong></p>

<p><strong>If </strong><strong>misoprstol</strong><strong> fails, patient may opt for expectant or surgical management</strong></p>

116
Q

Indications for surgical Mx od early preg loss

A

Hemodynamic instability<br></br>Hge<br></br>Infection<br></br>Severe anemia<br></br>Patient preference

117
Q

Historical features suspicious of intimate partner abuse

A

Delay in seeking medical health<br></br>Multiple ED visits<br></br>Hx not compatible with exam<br></br>Vague historian<br></br>Any inj during pregnancy<br></br>Abn/odd partner behavior

118
Q

<p>Name 8 risk factors for intimate partner violence</p>

A

<p>–Young age</p>

<p>–Low SES / economic stress</p>

<p>–Low academic achievement or low IQ</p>

<p>–Not married or relationship instability</p>

<p>–Unemployed</p>

<p>–Drug/alcohol use disorder</p>

<p>–Unplanned pregnancy</p>

<p>–Social isolation</p>

<p>–Personal history of depression</p>

<p>–Previous suicide attempt</p>

<p>–Witnessing IPV in parents as a child</p>

119
Q

DDx of severe n/v in pregnancy

A

Multiple preg<br></br>Gest troph tumors<br></br>HEG

120
Q

“What is this?<br></br><img></img>”

A

Snow storm appearance<br></br>Gest trophoblastic tumor

121
Q

<p>Gestational trophoblastic disease, What investigation could you order to confirm your diagnosis?</p>

A

<p>–bHCG confirms diagnosis if greater than 100 000</p>

<p>–Lab tests for work up GTN: Cr, liver enzymes, TSH, +/- testosterone level</p>

122
Q

Name two factors that differentiate <br></br>hyperemesis gravidarum from typical nausea and vomiting of pregnancy

A

– Weight loss<br></br>– Dehydration<br></br>– HypoK

123
Q

What are three treatment options for severe nausea and vomiting in pregnancy?

A

– Doxylamine 10mg with Pyridoxine 10mg (Diclectin) 1 tab po QID prn, titrate up to 8 tabs per day as needed<br></br>– Other safe alternatives if Diclectin ineffective: • Add ginger, Gravol<br></br>– If ongoing nausea, consider:<br></br>• Metoclopramide 5 to 10mg po or IM q8h <br></br>• Prochlorperazine 5 to 10mg po/PR/IM q 6-8h<br></br>– Ondansetron has some evidence of cardiac malformation, consider only if benefit outweighs risk

124
Q

Name five differential diagnoses for vaginal <br></br>bleeding greater than 20 weeks

A

– Placental abruption<br></br>– Uterine rupture<br></br>– Placenta previa<br></br>– Vasa previa<br></br>– Preterm labour

125
Q

Management of placenta previa

A

• Consult obstetrics for transfer of patient to L&D<br></br>– Repeat ultrasound to determine if ongoing placenta previa<br></br>• Medications<br></br>– RhoGAM 300mcg IM<br></br>– Steroids for fetal lung maturity<br></br>• Betamethasone 12mg IM q24h x 2 doses<br></br>• OR Dexamethasone 6mg IM q12h x 4 doses<br></br>• Give at GA 240 – 346 for women at risk for preterm birth within next 7d, in <br></br>consult w OBGyn<br></br><br></br>• Some patients eligible for outpatient management, if <br></br>hemodynamically stable, reliable and live close to hospital<br></br>– A decision for the obstetrician

126
Q

What are six risk factors for preterm premature <br></br>rupture of membranes? (PPROM)

A

– Previous PPROM<br></br>– Genital tract infection in pregnancy<br></br> • Ex: Bacterial vaginosis, chlamydia<br></br>– UTI<br></br>– Antipartum bleeding in first trimester<br></br>– Polyhydramnios<br></br>– Trauma<br></br>– Preterm labour<br></br>– Cervical insufficency / previous LEEP

127
Q

What are four methods for diagnosing rupture of membranes?

A

– Pooling in posterior fornix on sterile spec<br></br>– Nitrazine changing from yellow to blue<br></br>– Ferning pattern on microscopy<br></br>– Immunoassay (ex: Amnisure)

128
Q

Management of PPROM:

A

– Expectant mgmt, may delay labour up to 7 days <br></br>– Transfer to ObGyn for admission<br></br>– Avoid pv exam to limit infection risk<br></br>– Screen for UTI, STI and GBS, treat if present<br></br>• Urine culture, GC chlamydia swab, Group B strep swab<br></br>– Steroids for fetal lung maturity<br></br>• Betamethasone 12mg IM q24h x 2 dose for GA 240 – 346<br></br>– Antepartum antibiotics<br></br>• Ampicillin 2g IV q6h AND Erythromycin 250mg IV q6h x48h<br></br>THEN Amoxil 250mg po q8h AND Erythro 333mg po q8h x 5d (total 7d)<br></br>• OR Erythromycin 250mg po q6h x 10d<br></br>– ?tocolysis with nifedipine or indomethacin<br></br>• →controversial, discuss with ObGyn if indicated

129
Q

Name 5 pregnant-specific factors that will make this <br></br>airway more challenging.

A
  • Body habitus / gravid uterus<br></br>- Aspiration<br></br>- Decreased respiratory reserve<br></br>- Airway edema<br></br>- Belly in the way of laryngoscope blade<br></br>- Harder to bag<br></br>- LLD position
130
Q

Name 3 diagnoses that are unique to <br></br>pregnancy that you must consider in <br></br>abdominal trauma.

A

– Placental abruption<br></br>– Preterm labor<br></br>– PPROM<br></br>– Uterine rupture

131
Q

What are 3 things that suggest fetal distress in EFM?

A

– Tachycardia or bradycardia (>160/<120)<br></br>– Lack of variability<br></br>– Late decelerations, variable decels, complex variable decels

132
Q

What 2 findings on EFM will allow this patient to go <br></br>home after 4 hours of monitoring?

A

– No signs fetal distress <br></br>– <3 contractions per hour

133
Q

What blood tests to order in DIC?

A

– CBC – low Hgb and platelets, MAHA on smear<br></br>– Fibrinogen – low (although could be normal)<br></br>– PT – increased <br></br>– PTT– increased<br></br>– D-dimer - increased

134
Q

What are five serious ddx for headache for <br></br>which pregnancy increases risk? What is your leading diagnosis?

A

– Pre-eclampsia<br></br>– Cerebral venous sinus thrombosis<br></br>– Subarrachnoid hemorrage<br></br>– Carotid or vertebral artery dissection<br></br>– Pituitary apoplexy

135
Q

What are some risk factors for pre-eclampsia? Name 5.

A

– Pre-eclampsia in previous pregnancy<br></br>– Chronic hypertension<br></br>– Pregestational diabetes<br></br>– Systemic lupus erythematosus (SLE)<br></br>– Antiphospholipid antibody syndrome<br></br>– Pre-pregnancy overweight or obesity<br></br>– Multifetal pregnancy<br></br>– Nulliparity or first pregnancy with new partner<br></br>– Fx of pre-eclampsia in first degree relative<br></br>– Known fetal growth restriction<br></br>– Previous pregnancy w IUGR or stillbirth<br></br>– Advanced maternal age > 35 yoa and esp. > 40 yoa<br></br>– Use of assisted reproduction technology<br></br>– (Note: Smokers at LOWER risk of pre-eclampsia)

136
Q

Other than eclampsia, what are the DDx of seizures in pregnancy?

A

– Head injury<br></br>– Subarachnoid hemorrhage<br></br>– Hypoglycemia<br></br>– Cerebral venous thrombosis<br></br>– Toxins<br></br>– EtOH withdrawl

137
Q

Mg infusion,What parameters will you monitor to assess toxicity?

A

• Loss of patellar tendon reflexes<br></br>• Decreased RR < 12 <br></br>• Urine output < 100ml in 4h<br></br>• Bradycardia

138
Q

What ECG changes are assoc with HyperMg?

A

Prolonged PR, wide QRS, long QT, peaked T, AV block, asystole (<b>similar to HyperK</b>)

139
Q

Mx of shoulder dystocia

A

ALARMER<br></br><br></br>– <b>A</b>nnounce the problem and <b>A</b>sk for help<br></br>– <b>L</b>IFT/hyperflex Legs (McRobert’s maneuver) <br></br>– <b>A</b>NTERIOR shoulder disimpaction (Suprapubic pressure) <br></br>– <b>R</b>OTATION (Woods maneuver / “corkscrew” maneuver)<br></br>– <b>M</b>ANUAL removal posterior arm <br></br>– <b>E</b>PISIOTOMY<br></br>– <b>R</b>OLL over onto “all fours”

140
Q

What are the components of the APGAR score?

A

– Appearance (color)<br></br>– Pulse<br></br>– Grimace<br></br>– Activity<br></br>– Respiration

141
Q

What are 5 causes of postpartum fever

A

– Endometritis<br></br>– UTI / pyleonephritis<br></br>– Wound infection<br></br>– Septic pelvic thrombophlebitis<br></br>– Pulmonary embolism<br></br>– Mastitis

142
Q

What Hx & P features would increase your suspicion for endometritis?

A

– Midline lower abdominal pain<br></br>– Uterine tenderness<br></br>– Purulent lochia

143
Q

What are the causative organisms for <br></br>endometritis?

A

– Group B strep<br></br>– E. coli<br></br>– Streptococcus agalactiae<br></br>– Staphylococcus aueus<br></br>– Group A strep

144
Q

Treatment for endometritis:

A

• <b>Inpatient:</b><br></br>– Clindamycin 900mg IV q8h + Gentamycin 5mg/kg iv daily<br></br>• <b>Outpatient:</b><br></br>– Amoxi-clav 875/125mg po BID x 14 days<br></br>– Amoxicillin 500mg and Metronidazole po TID x 14 days<br></br>– Clindamycin 600mg po q6h x 7 to 14 days<br></br>• Most infections are mild and respond well to Abx<br></br>• If ongoing fever, consider surgical site abscess requiring drainage, <br></br>retained products or alternate etiology such as septic phlebitis.

145
Q

What are some risk factors for postpartum depression?

A

– Previous history depression<br></br>– Marital conflict<br></br>– Single marital status<br></br>– Young age <25 yrs<br></br>– Fx postpartum depression<br></br>– Intimate partner violence<br></br>– Unintended pregnancy<br></br>– Breastfeeding difficulty<br></br>– Sleep deprivation<br></br>– Childcare stress such as inconsolable crying<br></br>– Onset occurs before delivery in about 50% of cases

146
Q

Historical features often present in postpartum depression

A

– Anxiety about health of infant<br></br>– Self doubt about ability to care for infant<br></br>– Lack of interest in infant’s activities<br></br>– Use of alcohol / illicit drugs<br></br>– Nonadherence to postnatal care<br></br>– Frequent non-routine visits with family physician

147
Q

<p>Reportable STDs in Canada</p>

A

<ul> <li>Chlamydia</li> <li>Gonorrhea</li> <li>Syphilis</li> <li>Chancroid</li> <li>HIV/AIDS</li> <li>Hep B</li> </ul>

148
Q

What physical finding is most predictive of impending eclampsia?

A

Ankle clonus

CCFP(EM) Omar (27 decks)

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