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Emergency Medicine > OBGyn > Flashcards

OBGyn Flashcards

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1
Q

Amenorrhea (Primary)

A

No menses by 13 yo w/ no 2/2 sex characteristics or

No menses by 15 yo with normal 2/2 sex characteristics

Eti:

  • Pregnancy
  • Imperforate hymen
  • Gonadal dysgenesis (Turner’s syndrome)
  • HPO axis abnormalities (anorexia, bulimia, wt loss, excessive exercise)

Dx:

  • Quantitative B-HCG
  • FSH
  • prolactin
  • TSH, T3, Free T4
  • estrogen & progesterone

Risk of Osteoporosis in Primary Ovarian failure

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2
Q

Amenorrhea (Secondary)

A

Absence of Menses for 3 mos for those with regular menstruation

or for 6 mos for women with irregular cycles

MCC - Pregnancy, Endometrial atrophy, Premature Ovarian Failure, pitutiary dysfx

Dx:

  • quant B-HCG, TSH
  • Prolactin if > 200 then get CT of Sella Turcica
  • Progresterone challenge
  • FSH

Tx:

underlying cause, use OCP, cyclic progesterone 10 mg for 10 days

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3
Q

Dysfunctional Uterine Bleeding

Eti, sxs

A

Excessive uterine bleeding w/ no organic cause

  • Menorrhagia - prolonged/heavy bleeding (>7d or >80mL[5.4 tbs}); regular intervals
  • Metrorrhagia - variable amt of bleedings at irregular, freq intvls
  • Menometrorrhagia - more blood loss during menses, freq and irregular bleeding btwn menses (heavy, freq, irregular)
  • Polymenorrhea - more freq <21 days
  • Oligomenorrhea - > 35 days

Eti:

PALM - Structural causes

  • Polyp - submucosal fibroid or polyp
  • Adenomyosis
  • Leiomyoma
  • Malignancy

COEIN - Nonstructural causes

  • Coagulopathy
  • Ovulatory dysfx
  • Endometrial
  • Iatrogenic
  • Not classified
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4
Q

DUB

Dx, tx

A

Diagnosis of exclusion

  • r/o organic causes, reproductive, iatrogenic
  • R/o preg
  • med reconcilation

PE: thyromegaly , pelvic structural abns (polyps/fibroids)

Labs - FSH, LH, Prolactin, estradiol, testosterone, TSH/T3/T4, DHEAS, coags

Eval of uterus - EMB, hysterectomy, pelvic US

Uterine D&C (gold std) - diagnostic or therapeutic

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5
Q

Ectopic Pregnancy

eti, sxs

A

eti:

implantation of fertilized ovum outside uterine cavity

MC implantation in Fallopian tube (Ampulla)

RF:

previous abd sx, adhesions, PID, OCPs/IUD, tubal ligation

Sxs:

  • Triad
    • unilateral pelvic/abd pain
    • vaginal bleeding
    • amenorrhea/pregnancy
  • cervical motion tenderness
  • adnexal pain

Ruptured Ectopic - EMERGENCY

  • severe abd pain
  • dizziness
  • N/V
  • Shock signs - syncope, tachycardia, hypotension
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6
Q

Ectopic Pregnancy

dx

A

Serial B-HcG - should double q24-48 hrs

  • initial <1500, repeat 2-3 day

Transvaginal US

  • if HcG > 2000 with no gestational sac = Ectopic
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7
Q

Ectopic Pregnancy

tx

A

Unruptured/Stable

Methotrexate if

  • Hemodynamically stable
  • HcG < 5000
  • No fetal tones
  • Ectopic <3.5cm
  • no renal, hepatic, pulm

Successful if b-HcG >=15% 2 blood draws

Lap Salpingostomy if ruptured

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8
Q

Endometriosis

eti, sxs

A

Presence of endometrial tissues outside uterine cavity - MC in ovaries, fallopian

RFs:

  • nulliparity
  • fam hx
  • early menarche

Sxs

  • 3 D’s
    • Dyspareunia
    • Dyschezia
    • Dysmenorrhea
  • Infertility
  • Cyclic pelvic pain peak 1-2 d before menses onset
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9
Q

Endiometriosis

Dx, Tx

A

Lap with bx - definitive dx

Tx

  • OCPs
  • Leuprolide - gnRH analog
  • Danazol /testosterone - suppresses mid surge LH –> only for 6 mos d/t bone loss
  • Conservative Lap w/ ablation - if desire to conceive
  • Total Abd Hysterectomy w/ Salpingo-oophorectomy - if no desire to conceive
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10
Q

Pelvic Inflammatory Disease

eti, sxs

A

Ascending infection of Upper genital Tract

MC N gonorrhea, Chlamydia

RF:

  • multiple sex partners
  • abd pain
  • unprotected sex
  • prev PID
  • age 15-19
  • iatrogenic causes IUD placement

Sxs

  • lower abd tenderness
  • fever
  • purulent cervical discharge
  • chandlier sign - cervical motion tenderness
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11
Q

Pelvic Inflammatory Disease

dx, tx

A

Dx:

  • Abdominal tenderness
  • Cervical motion tenderness
  • adnexal tenderness plus one of the following:
    • Fever >38C
    • WBC >10,000
    • Pelvic abscess via manual exam or US
    • ESR/CRP

Tx

Outpatient - Doxycycline 100mg BID x 4 d + Ceftriaxone 250mg IM x1

Inpatient - IV Doxycycline + 2nd gen Ceph (Cefoxitin or Cefotetan) OR Clindamycin + Gentamicin

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12
Q

Bacterial Vaginosis

A

MC of vaginitis

D/t Gardnerrella

Sxs

  • thin, copious, grey-white “fish” smell
  • pH > 5
  • clue cells
    • Whiff test

Tx Metronidazole PO 500 mg x 7 days or gel 0.75% 5g intravaginally for 5 days or

Clindamycin gel 2% 5g intravaginally or 300mg PO BID x 7 days

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13
Q

Trichomoniasis

A

D/t Trichomonas vaginalis

Sxs

  • malodorous
  • frothy, yellow green dc
  • Strawberry cervic
  • pH > 5
  • mobile protozoa

Tx metronidazole 2g PO x1

partner also tx’ed

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14
Q

Candiasis

A

MC candida albicans

Sxs

  • vaginal burning, erythema
  • cottage cheese discharge
  • pH <4.5 (normal)
  • hyphae and yeast on KOH mount

Tx with Flucanozol/Diflucan 150mg PO x 1; another dose if sxs still bad

Miconazole/clotrimazole, terconazole x 7 days vaginal cream

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15
Q

Atrophic Vaginitis

A

atrophy of vaginal and vulvar tissues d/t hypoestrogenic state

MC in post menopausal women

Sxs

  • dryness
  • burning
  • irritation
  • low lubrication

Tx:

1st line therapy for sxs relieve - hormonal vaginal lubricants

Estrogen inserts - vaginal ring w/ 2mg estradiol q 3mos

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16
Q

Placenta Abruption

A

Premature separation of placenta from uterine wall after 20 wks

MCC of Painful, third trimester bleeding

RF:

  • maternal HTN MCC
  • High parity
  • Smoking/ETOH/Cocaine
  • Chorioamnionitis

Sxs:

  • dark red blood w/ severe abd pain and/or freq contractions
  • rigid uterus
  • Shock symptoms
  • Fetal bradycardia, fetal distress

Dx

Usually clinical, NO Pelvic exam, pelvic US

Tx

immediate delivery - CSection

17
Q

Placenta Previa

A

abnormal placement of placement, partially covering cervical OS

painLESS bleeding usu >28 wks gestation

suddent onset - BRB, no abd pain, No fetal distress

RF

  • increased age
  • multiparity
  • smoking
  • Prev CS

Dx

Pelvic US, no pelvic exam

Tx:

  • Bed rest - no intercourse, vigorous exercise
  • Tocolytics - to stop contractions - Mg Sulfate
  • Steroids - at 24-34 wks to incr lung maturity
  • Deliver if >36 wks, or blood loss >500mL
  • +/- Vaginal partial /marginal
  • blood transfusion
  • Rhogam if Rh-
18
Q

Pelvic Pain/Dysmenorrhea

(Primary)

A

Uterine pain around the time of menses - either 1ry or 2ry

  • usu lasts 1-2 days - relieved by NSAIDs and OCPs

Primary Dysmenorrhea

  • 6-12 mos of menarche. Patho - excessive prostaglandins and leukotriene production –> increased uterine contractions
    • Severe cramps that start w/ menses & lasts 2-3 days (highest pain in first day)
    • lower abd pain r-> back/thighs
    • HA, N, Diarrhea
  • PE - nl

Tx

  • NSAIDs - first line
  • OCPs
  • Menstrual suppression
  • surgical - endometrial resection
19
Q

Pelvic Pain/Dysmenorrhea

(secondary)

A

D/t to an identifiable cause

Pain with menstruation that begin mid-cycle and increases in severity until end

Women age 20-40s

Eti

  • Endometriosis
  • adenomyosis
  • Polyps
  • fibroids
  • PID
  • IUD
  • tumors
  • adhesions
  • cervical stenosis/lesions , psych
20
Q

Intrauterine Pregnancy

  • Fetal/Infant Nomenclature
  • GTPAL
  • Uterine growth
A

Abortion - elective or spontaneous < 20 wks GA or wt <500g

Premature Infant - 20-36 wks or 1000-2500g

Full Term infant - 37-42 wks GA or >2500g

Postmature infant >42 wks GA

GPTPAL

  • Gravida - # of pregnancies woman has had
  • T - total # of full term pregnancies - 37-42 wks
  • P - total # of preterm pregnancies (20-36 wks)
  • A - # of abortions
  • L - # of living childrent
  • Twins - one prgenancy but 2 live children

Uterine Growth

  • 12 wks at pubic symphsis
  • 20 wks at umbilicus
  • > 20 wks - 1cm for every wk gestation
  • 36 wks at xiphoid
21
Q

Intrauterine Pregnancy

  • Signs of pregnancy
  • Physical Exam
  • Lab changes
A

Diagnosis

  • Serum b-HcG - detect pregnancy as early as 5 days after conception
  • Urine b-HcG - detect a pregnancy 14 days after conception - incr Serum Progesterone

PE:

  • Increased basal body temp
  • Skin changes
    • Melasma/choasma - dark patches on face across bridge of nose or forehead
    • Linea Nigra - vertical line up abd
      • stimulation of melanocyte

Uterus changes

  • Ladin’s sign.- uterus softening after 6 wks
  • Hegar’s sign - uterine isthmus softening after 6-8 wks GA

Cervix changes

  • Goodell’s sign - cervical softening d/t increased vascularization - 4-5 wks GA
  • Chadwick’s sign - bluish coloration of cervic and vulva 8-12 wks

Lab changes

  • Cholesterol will increase
  • BUN and Cr will be decreased
22
Q

Intrauterine Pregnancy

first visit Prenatal labs

A
  • CBC
  • Blood type
  • Rh factor
  • Antibodies to blood group antigens
  • random glucose
  • Urine
  • Pap smear (if < 1 year since last)
  • Immunology
    • VDRL
    • Hep B
    • Rubella
  • As indicated
    • CF
    • Tay Sachs
    • Sickle Cell
  • Group B Strep
23
Q

Intrauterine Pregnancy

labs for PN visit

weight gain

A

Every Prenatal Visit

  • Maternal Weight
  • BP
  • Fundal Height
  • Fetal Size and Presenting part
  • Urine Dipstick for protein
  • glucose
  • ketones

Rec’d weight gain during pregnancy

  • 10-15 for overweight
  • 20-35 lb for reg weight
  • 40-45 lbs for underweight

Avoid

  • Smoking
  • ETOH
  • Drugs - teratogens
  • Unpasteurized food (apple cider, soft cheese) - listeria
  • Raw meat, seafood, deli meat - listeria
  • King mackerel, shark, swordfish, tuna, tilefish - mercury
  • Farm salon - PCBs
24
Q

Spontaneous Abortion

eti, sxs

A

Termination of a pregnancy < 20 wks = 15-20% of pregnancies

RF - smoking, infection, maternal systemic dz, immunologic parameters, drug use

SxS - variable, fundus of uterus may be boggy or tender

25
Q

Spontaneous Abortions

dx, tx

A

Early pregnancy bleeding and pain MUST r/o Ectopic

  • decreased b-HcG
    • should double q 48 hrs in viable preg
  • Transvaginal US - inappropriate development or intvl growth, poorly formed fetal pole, fetal demise
  • Blood type and Rh for Rh sensitization

Tx:

D&C

monitor B-HcG levels or US examinations

septic/infected abortion - complete evacuation of uterine contents, medical support, and abx

26
Q

Premature Rupture of Membranes (PROM)

A

Rupture of membranes at >/= 37 wks GA before contractions

Preterm PROM is < 37 wks GA

major risk - infection or cord prolapse

sxs

  • Sudden gush of clear or pale yellow fluid that occurs before 37 wks GA

Dx - need to confirm amniotic fluid

  • Speculum - fluid pooling in posterior fornix
  • Nitrazine test - blue d/t elevated pH >6.5 is positive
  • Microscopic examination - ferning crystalization of amniotic fluid

Tx based on GA

  • > 34 wks - induce labor
  • 32-34 wks - check lung maturity through fluid collection - induce
  • < 32 wks - stop contractions, start 2 doses of steroid injections, then deliver baby - give abx
27
Q

Fetal Distress

A

Non-Stress Test

  • Good - reactive NST > 2accelerations in 20 mins with increase FHR > 15bpm lasting 15 seconds
  • 2/20/15/15
  • Bad - nonreactive NST - no FHR accelerations or <15 bpm lasting < 15 secs, get contraction stress test

Contraction Stress Test

  • Good - Negative CST - no late decels in presence of 2 contractions in 10 mins
    • fetal well being, repeat CST as needed
  • Bad - Positive CST - repetitive late decels in presence of 2 contractions in 10 mins
    • worrisome esp if non reactive NST –> prompt delivery

APGAR - appearance, pulse, grimace, activity, respiration

  • score frm 1-10, > 7 is nl, 4-6 fairly low, < 3 critically low
  • test is done at 1 and 5 mins after birth
28
Q

Mastitis

A

Infection of breast from skin flora (MCC S aureus) d/t clogged milk ducts

Congestive (bilateral) vs Infectious (unilateral)

Sxs

  • cracked nipple
  • soreness/pain with breastfeeding - nipple trauma
  • unilateral erythema, tenderness, only 1 quadrant of breast affected
  • Fever/chills

Tx

dicloxacillin, cephalexin or erythromycin for staph

clinda as alternative

continue to breastfeed on infected side w/ warm heat QID

29
Q

Breast Abscess

A

Pocket of contained infection within the breast

Progression from mastitis - sxs same + localized mass and systemic signs of infection

MCC S. aureus

Tx:

  • I&D and anti-staph abx
  • Nafcillin/oxacillin IV or Cefazolin + Metronidazole
  • alternative is Vancomycin

​Stop breastfeeding on affected side - PUMP AND DUMP

30
Q

Ovarian Cysts

eti, types of OCs

A

Fluid filled sac w/in ovary

usu harmless and no sxs

  • bloating
  • lower abd pain
  • dyspareunia
  • LBP

Normal menstruation cycle (functional) or non-functional

Functional - 2-3cm, up to 10 cm, clear serous liquid, smooth internal lining

  • Follicular cyst MC - dominant follicule fails to rupture
  • Corpus luteum - dominant follicle rupture but closes again and doesn’t dissolve
  • Theca lutein cysts - overstimulation of HCG produced by placenta - only in pregnancy

Non functional cysts/neoplastic cysts - PCOS (amenorrhea, hirsutism), endometriomas (chocolate cysts), dermoid cysts (Teratomas), ovarian serous and mucinous cystadenoma

  • > 10cm, irregular borders, internal septations

Hx Follicular = asymptomatic, if larger = abd pain

corpus luteum - local pelvic pain, amenorrhea, or delayed menses

31
Q

Ovarian Cysts

sxs, dx, tx

A

Three main complications

  1. Hemorrhagic - MC w/ follicular and corpus luteal cysts
  2. Rupture - release contents in peritoneal cavity, freq after sex
  3. Torsion - ovary twists around suspensory ligament, cuts of supply to ovary (Risk if cyst > 5cm)

PE:

  • Ruptured - pain, low BP, abd or shoulder pain, tachy
  • torsion - waxing/waning pain, N/V, l-g fever
    • Abd and pelvic US - initial imaging of choice

Dx

  • Transvaginal US/abd
  • MRI if US is indeterminate for sx resection eval
  • Serum CA-125 - in post/menopausal women - r/o Ovarian cancer
  • US guided aspiration & histological analysis - definitive

Tx

  • < 5 cm - observation
  • Uncomplicated cyst rupture - hemodyn stable - expectant mgmt and NSAIDs
  • > 5cm - cyst removal by laparoscopy
  • Sx - symptomatic tumors, hemorrhaging severely, ovarian torsion

Emergency Medicine (13 decks)

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