OBGYN Flashcards
Risk factors for Ectopic Pregnancy
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>
FIRST TRIMESTER BLEEDING:
<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>
<div>History for Vaginal Bleeding in Early Pregnancy</div>
<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>
“<div><span>When is βhCG Testing Useful in Vaginal Bleeding</span></div>”
<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>
“<div><span>Key βhCG facts to remember</span></div>”
<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>
Indications of Methotrexate in EP
<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>
<div>Prior to MTX treatment</div>
<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>
<ul> <li>AVOID thesemajor pitfallsof diagnosing ectopic pregnancy in the emergency department:</li></ul>
“<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>”
Risk Factors of Placential Abruption
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>
Role of US in plac abruption
US is not sensitive to diagnose PA but it is used to exclude placentia previa and to check for fetal distress
Work up for pregnant patient with massive vag bleeding
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>
Risk Factor for Placenta Previs
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>
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?
US to look for a molar pregnancy<br></br>β-hCG.
Unique S/S of H.Mole
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>
Treatment of HEG
■ 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>
Preeclamsia
New onset HTN<div>PTNuria</div><div>End-organ dysfunction</div><div>>20 wks</div>
Preclampsia risk factors
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>
DDX of HELLP sybdrome
Other causes of abdominal pain (AA, pancreatitis, cholecystitis, gastritis)<div>TTP</div><div>HUS</div>
LAB findings of HELLP syndrome
Microangiopathic hemolytis anemia<div>Increased bilirubin</div><div>TCP</div><div>Increased liver enzymes</div>
Complications of bacteruria
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>
Vaccines CI in pregnancy
MMR<div>Live attenuated vaccines (FluMist)</div><div>Varicella</div><div>TDaP (but Td is safe after 1st trimester)</div>
AB CI in Pregnancy
Tetracycline<div>Fluoroquinolones</div><div>Sulfonamides</div><div>Chloramphenicol</div>
AntiEpileptics CI in pregnancy
Phenytoin<div>Valproic acid</div><div>Phenobarbital</div>
Sudden change in maternal respiratory status during labor?
Pulmonary embolism<br></br>Sepsis<br></br>Anaphylaxis<br></br>Myocardial infarction<br></br>Amniotic fluid embolism
Causes of PPH
4 Ts:<div>Tone</div><div>Trauma</div><div>Tissue</div><div>Thrombin</div>
Physical findings of PPH
■ 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.
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?
Septic pelvic thrombophlebitis; treat with anticoagulation and antibiotics.
Causes of Cervicitis
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>
Complications of PID
Abscess(T-Ov + Pelv)<br></br>Infertility<br></br>Ectopic pr<br></br>Chronic pelvic pain<br></br>Fitz-Hugh-Curtis synd (perihepatitis)
Rx of PID
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
Indication of admission in PID
“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>”
Risk factors for PID
Multiple sexual partners,<div>history of sexually transmitted disease,</div><div>young age, <br></br>nonbarrier contraception</div><div>IUD</div>
What other features in Hx for PID
Lower abd pain<div>Abn vag D/C</div><div>Post coital bleeding</div><div>Dyspareunia</div><div>Fever, malaise, N/V</div>
What other features in Examination for PID
Lower abd tenderness<div>Cx motion tenserness</div><div>Mucopurulent cervicitis</div><div>B/L adnexial tenderness</div><div>Unilateral tenderness/mass = TOA</div>
What are the D/C instructions for pt with PID
Test the partner<div>Use condoms</div><div>Other tests for (HIV, hepatitis & syphilis)</div>
Dx of T. vaginalis
Wet prep microscopy (+ve in only 60%)<div>Culture of nucleic acid amplification test (NAAT)</div>
Tx of Vag D/C (vaginitis)
“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>”
Causes of DUB (anovulatory bleeding)
Perimenopausal<div>Perimenarchal</div><div>PCOS</div><div>Obesity</div><div>Eating disorders</div><div>Hypo/hyper T4</div>
Rx of unstable pt with vaginal bleeding
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>
Rx of Endometriosis
“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>”
Describe the dosing, timeline, indications, and contraindications for emergency contraception
“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)
DDX of Menorrhagia/Vaginal bleeding
“<img></img>”
Causes of spontaneous abortion
Chromosomal abnormalities<div>Insufficient progesteron</div><div>ETOH</div><div>Cocaine</div>
At what week gestation is cardiac activity usually present?
6 weeks
In which causes of postpartum hemorrhage would oxytocin be contraindicated?
Uterine rupture<div>Uterine inversion</div>
Risk factors for ovarian torsion
<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>
Clinical features of Candidal vaginitis
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>
Risk factors of Candida vaginitis
DM<div>HIV</div><div>Recent AB use</div><div>Pregnancy</div>
What are the most common side effects of topical antifungal therapies for the treatment of uncomplicated candidial vaginitis?
Local burning and tingling.
Risk factors of placenta previa
Prior C-section<div>Multiple gestations</div><div>Multiple induced abortions</div><div>Advanced maternal age</div>
What organism is responsible for chancroid?
<i>Haemophilus ducreyi</i>
What are the risk factors of endometritis
C-section<div>PROM>24 hra</div><div>Active labor > 12 hrs</div><div>Mutliple pelvic examinations</div>
Causes of secondary dysmenorrhea
Endometriosis<div>PID</div><div>IUD</div>
Dose of Mg sulfate in eclampsia
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>
Indications for surgery in TOA
Failure of improvement after 48-72 hrs of AB<div>Rupture</div><div>Sepsis</div><div>Abscess > 9 cm</div>
AB for TOA
<div>Iv adm of:</div>
<ul> <li>doxy + cefoxitin, cefotetan or</li> <li>amp-sulbactam or</li> <li>clindamycin + gentamicin</li> </ul>
<div></div>
Disulfiram-like reaction
Flushing<div>Tachycardia</div><div>Hypotension</div>
S/S of uterine rupture
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>
Risk factors for uterine inversion
forceful traction on the umbilical cord,<div>excessive fundal pressure during delivery,</div><div>prior cesarean section, and</div><div>connective tissue disorders</div>
What is placenta accreta?
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.
What are three consequences of pelvic inflammatory disease?
Tubo-ovarian abscess,<div>infertility,</div><div>ectopic pregnancy</div>
U/S findings for a woman with +ve preg test
“<img></img>”
“<span></span>What pathogen has been associated with late-onset postpartum endometritis?”
<i>Chlamydia</i>
Which of the following is the strongest risk factor for postpartum endometritis?
C-Section
What is the most common malpresentation in fetal delivery?
Breech presentation (4%)
PID Outpt Rx
“<img></img>”
PID inpt Rx
“<img></img><div><img></img><br></br></div>”
Dilute urine can lead to a false negative urine beta test
True
The HELPER mnemonic for shoulder dystocia
Help,<div>Episiotomy,<br></br>Leg elevation,</div><div>Pressure,</div><div>Enter vagina,</div><div>Remove posterior arm</div>
List 4 immediately relevant questions of active labour:
-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)
When would neonatal resuscitation be considered futile?
-Anencephaly <br></br>-GA<24w <br></br>-BW<500g <br></br>-T13/18
Describe active management of the third stage of labor and its relevance
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
Define postpartum hemorrhage (PPH)
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.
List 4 potential sources of PPH and 1 therapy for each source
““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>”
Findings and corresponding β-hCG (mIU/mL)
“-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”
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
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>
Mx of Supine hypotensive synd
Lt lat tilt (wedge under rt side)<div>Manual leftward retraction of gravid uterus</div>
Describe the benefit of anti-Rh Immunoglobulin
To neutralize RH+ fetal blood exposed to maternal circulation so as to prevent maternal anti-D immunoglobulin formation that could harm future Rh+ pregnancies.
Name one test that this useful in the diagnosis of fetomaternal hemorrhage.
-Kleihaur-Betke <br></br>-Flow-cytometry
Maternal trauma,What are 2 pregnancy-related concerns in this patient?
-Feto-maternal hemorrhage <br></br>-Placental abruption <br></br>-Fetal injury <br></br>-Preterm labour
Fetal trauma,What further 3 interventions/investigations are required?
-NST/Continuous fetal monitoring x4h <br></br>-Kleihaur-Betke <br></br>-U/S
What is the most sensitive test for placental abruption? What indicates a<br></br>positive test?
-Electronic fetal monitoring (cardiotocodynamometry), incl NST <br></br>-Any fetal distress is considered positive (100% NPV)
NST timing required for maternal trauma
- at least 4 hours of fetal monitoring is required
List two findings of NST that are a cause for concern.
-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>
Deceleration interpretation:
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
Please complete the following table as it pertains to abnormal uterine<br></br>bleeding. Please use a response ONLY ONCE
” <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 “
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
-<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>
List three ultrasound findings indicative of ectopic pregnancy
“-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>”
Please list three criteria precluding medical management of ectopic<br></br>pregnancy
-Mass > 4cm <br></br>-FHR present <br></br>-Hemodynamic instability <br></br>-Decreasing Hb<br></br>-Sonographic evidence of rupture
List 3 causes of preterm premature rupture of membranes (PPROM)
-UTI <br></br>-Infection (choriaminoitis, Bacterial vaginosis, GBS) <br></br>-Trauma <br></br>-Incompetent Cervix <br></br>-Pre-term labor <br></br>-Cigarette Smoking
Critical action in maternal trauma:
<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>
Emergency Mx of PPH in the ER
<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>
DDx of uterine bleeding in reproductive age
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>
Most common causes of acute gynecological pain
Ruptured ovarian cyct<div>Ovarian torsion</div><div>PID</div>
<ul> <li>What are some short term management strategies to control the bleeding?</li> </ul>
<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>
Longer term Mx options for abn uterine bleeding
IUD<div>Endometrial ablation</div><div>Hysterectomy</div>
Mx of life threatening vaginal bleeding
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>
D/C instructions/arrangement for postmenopausal bleeding
U/S<div>Endometrial Bx</div><div>PAP</div>
What do we mean by Bedside tests?
Accucheck<div>Urynalysis</div><div>Urine pregnancy test</div><div>ECG</div><div>Bedside U/S</div>
When metronidazole should be added to Rx of PID?
Hx of instrumentation<div>BV</div><div>T. vaginalis</div>
<ul> <li>What is one thing you must do to prevent recurrence of PID in this patient?</li> </ul>
Treat sexual partner
<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>
<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>
What are the PID?
<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>
DDx of vag D/C
“<img></img>”
“What is the infection<div><img></img><br></br></div>”
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>
“What is the infection<div><img></img><br></br></div>”
Chlamydia cervicitis
Recommended test for STI
HIV<div>Hep B</div><div>Hep C</div><div>Syphylis (RPR, VDRL)</div>
Treatment of STI:
<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>
What defines IUP by U/S?
“<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>”
What would you see by U/S based on weeks of gestation?
” <strong>Week of gestation</strong> <strong>Structure found</strong> 4.5 Gestational sac 5 Yolk sac 5.5 Fetal pole 6 Cardiac activity “
DDx of bleeding in early Pregnancy
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
US findings of early pregnancy failure
“<img></img>”
Time Based criteria for early pregnancy loss
<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>
<p>Management of Early Pregnancy Loss</p>
<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>
Medical Mx of early preg loss
<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>
Indications for surgical Mx od early preg loss
Hemodynamic instability<br></br>Hge<br></br>Infection<br></br>Severe anemia<br></br>Patient preference
Historical features suspicious of intimate partner abuse
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
<p>Name 8 risk factors for intimate partner violence</p>
<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>
DDx of severe n/v in pregnancy
Multiple preg<br></br>Gest troph tumors<br></br>HEG
“What is this?<br></br><img></img>”
Snow storm appearance<br></br>Gest trophoblastic tumor
<p>Gestational trophoblastic disease, What investigation could you order to confirm your diagnosis?</p>
<p>–bHCG confirms diagnosis if greater than 100 000</p>
<p>–Lab tests for work up GTN: Cr, liver enzymes, TSH, +/- testosterone level</p>
Name two factors that differentiate <br></br>hyperemesis gravidarum from typical nausea and vomiting of pregnancy
– Weight loss<br></br>– Dehydration<br></br>– HypoK
What are three treatment options for severe nausea and vomiting in pregnancy?
– 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
Name five differential diagnoses for vaginal <br></br>bleeding greater than 20 weeks
– Placental abruption<br></br>– Uterine rupture<br></br>– Placenta previa<br></br>– Vasa previa<br></br>– Preterm labour
Management of placenta previa
• 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
What are six risk factors for preterm premature <br></br>rupture of membranes? (PPROM)
– 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
What are four methods for diagnosing rupture of membranes?
– 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)
Management of PPROM:
– 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
Name 5 pregnant-specific factors that will make this <br></br>airway more challenging.
- 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
Name 3 diagnoses that are unique to <br></br>pregnancy that you must consider in <br></br>abdominal trauma.
– Placental abruption<br></br>– Preterm labor<br></br>– PPROM<br></br>– Uterine rupture
What are 3 things that suggest fetal distress in EFM?
– Tachycardia or bradycardia (>160/<120)<br></br>– Lack of variability<br></br>– Late decelerations, variable decels, complex variable decels
What 2 findings on EFM will allow this patient to go <br></br>home after 4 hours of monitoring?
– No signs fetal distress <br></br>– <3 contractions per hour
What blood tests to order in DIC?
– 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
What are five serious ddx for headache for <br></br>which pregnancy increases risk? What is your leading diagnosis?
– Pre-eclampsia<br></br>– Cerebral venous sinus thrombosis<br></br>– Subarrachnoid hemorrage<br></br>– Carotid or vertebral artery dissection<br></br>– Pituitary apoplexy
What are some risk factors for pre-eclampsia? Name 5.
– 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)
Other than eclampsia, what are the DDx of seizures in pregnancy?
– Head injury<br></br>– Subarachnoid hemorrhage<br></br>– Hypoglycemia<br></br>– Cerebral venous thrombosis<br></br>– Toxins<br></br>– EtOH withdrawl
Mg infusion,What parameters will you monitor to assess toxicity?
• Loss of patellar tendon reflexes<br></br>• Decreased RR < 12 <br></br>• Urine output < 100ml in 4h<br></br>• Bradycardia
What ECG changes are assoc with HyperMg?
Prolonged PR, wide QRS, long QT, peaked T, AV block, asystole (<b>similar to HyperK</b>)
Mx of shoulder dystocia
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”
What are the components of the APGAR score?
– Appearance (color)<br></br>– Pulse<br></br>– Grimace<br></br>– Activity<br></br>– Respiration
What are 5 causes of postpartum fever
– Endometritis<br></br>– UTI / pyleonephritis<br></br>– Wound infection<br></br>– Septic pelvic thrombophlebitis<br></br>– Pulmonary embolism<br></br>– Mastitis
What Hx & P features would increase your suspicion for endometritis?
– Midline lower abdominal pain<br></br>– Uterine tenderness<br></br>– Purulent lochia
What are the causative organisms for <br></br>endometritis?
– Group B strep<br></br>– E. coli<br></br>– Streptococcus agalactiae<br></br>– Staphylococcus aueus<br></br>– Group A strep
Treatment for endometritis:
• <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.
What are some risk factors for postpartum depression?
– 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
Historical features often present in postpartum depression
– 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
<p>Reportable STDs in Canada</p>
<ul> <li>Chlamydia</li> <li>Gonorrhea</li> <li>Syphilis</li> <li>Chancroid</li> <li>HIV/AIDS</li> <li>Hep B</li> </ul>
What physical finding is most predictive of impending eclampsia?
Ankle clonus
