OBGYN Emergencies Flashcards
Vaginal Bleeding:
- what types of questions do you want to ask in the Hx?
- PE
Hx Q:
-assess the amount of bleeding: # tampons/pads used, any clots?..size?
Pattern of periods:
- LMP (regularity of periods)
- Missed/late periods
SExual hx:
- # of partners
- use of condoms
Pain? where? quality? radiation?
PE:
- VS (HR and BP)
- Oral: mucosal hemorrhage, petechiae
- Abd: pain, masses, rebound tenderness
- pelvic exam: look for bleeding, signs of trauma, cervical motion tenderness, uterine size, masses, tenderness.
Vaginal Bleeding:
-tests
Test:
-hCG (symptomatic pts with hCG less than 1000mlU/mL are 4x more likely to have an ectopic pregnancy)
- trasnvaginal US
- CBC
- Type and cross if significant bleeding
- type and screen if not immediately needing blood transfusion
- coag tests if coagulopathy suspected
- STI testing (PDI)
Vaginal BLeeding:
- DDX based upon age of patients:
- -prepubertal
- -premenopausal nonpregnant
- -peri/post menopausal
- -pregnant 1st trimester
- -pregnant 2nd trimester
- -pregnant 3rd trimester
Prepubertal:
- vulvovaginitis
- FB
- trauma
- urethral prolapse
- sexual abuse (may have bruising, c/o pain)
- hormone secreting tumor
Premenopausal/nonpregnant:
- Ruptured ovarian cyst (if filled with blood may become unstable)
- ovarian torsion (usually need to be surgically removed)
- PID
- Dysfunctional uterine bleeding
- Uterine Leiomyoma
- Uterine Polyp
- Genital trauma 2ndray to sexual abuse
Peri/post menopausal:
- **Endometrial CA
- anti-coag medication
- hormone therapy
- coagulopathy
1st trimester:
- bleeding from implantation
- threatened, impending, or incomplete miscarriage
- ectopic pregnancy (abd pain, amenorrhea vaginal bleeding)
2nd & 3rd trimester:
- placenta previa
- placental abruption
- genital trauma 2ndry to abuse
Early and late signs of vaginal bleeding that is hemodynamically unstable?
Early: tachycardia and tachypnea
Late: hypotension, weak pulse, oliguria
-if you have two patients stabilize the mom first then the baby
Threatened Miscarriage:
- cramping?
- Cervix open/closed?
- US: fetal activity?
- management
Inevitable Miscarriage:
- cramping?
- bleeding?
- Cervix open/closed?
- US: fetal activity?
- management
Threatened:
- no cramping
- closed cervix
- fetal cardiac activity
- expectant management
Inevitable:
- cramping
- increased bleeding
- Open cervical os
- cardiac activity or fetal demise w/ US
- management expectant or surgical
Incomplete Miscarriage:
- definition
- sx
- PE findings
- US findings
- management
def: fetus is passed but placental tissue is retained.
sx: moderate to severe cramping, bleeding can be severe enough to cause hypovolemic shock
PE:
- cervical Os is open and gestational tissue may be present
- Uterus feels boggy on palpation
US: show tissue in the uterus
Management:
-D&C
Ectopic Pregnancy:
- risk factors
- presentation
- PE findings
- dx (H
risk factors
- previous ectopic pregnancy
- tubal surgery
- Hx PID
- women undergoing tx for infertility
Presentation:
- abdominal pain
- vaginal bleeding
- amenorrhea
- hypovolemic shock
PE:
- check hemodynamic status
- abd/pelvic tenderness
- adnexal mass
- may be unremarkable
Dx:
- transvaginal US (usually seen in fallopian tube)
- if stable and TVS is inconclusive serial hCG are followed. (they should drop)
T/F, TIf your patient has a +hCG and is hemodynamically unstable she is considered to have a ruptured ectopic pregnancy and needs immediate surgical intervention.
-if the patient is stable then treatment is with which medication?
True.
if the patient is stable then treatment with methotrexate can be considered with an OB consult.
Lower Genital Tract Bleeding:
- etiologies
- tests
Etiologies:
- vaginal lacerations, vervicitis
- growths, infections
- genital warts
- cervical polyps
Tests:
- chlamydia, gonorrhea, HPV
- vaginosis, yeast, trich
- syphillis, HIV, herpes
Ruptured Ovarian Cyst;
- sx
- work up
- management
Sx:
- *mild to mdoerate unilateral lower abdominal pain
- sx intensity varies with the type of fluid from cyst;
- -serous fluid: mild sx
- -blood; at risk of hemorrhage
- -sebaceous; quite irritating, can cause chemical peritonitits
work up:
- H&P
- Urine or serum hCG
- CBC
- UA
- STI
Management:
-surgery if necessary otherwise just reassurance
Preterm Labor:
- how many weeks gestation is this?
- management
Preterm labor is considered before 28wks gestation
Management:
- the goal is to stop pre-term labor with TOCOLYTICS to attempt to allow the feuts more time to develop.
- -Tocolytics: indomethacin*, nifedipine, terbutaline, mag sulfate
- corticosteroids are given to mother to aid in maturing of the lungs in the fetus.
- -corticosteroids are betamethasone or dexamethasone
Placenta Previa:
- classic presenting sign
- What PE technique is PROHIBITED in these pts?
- management
Classic presenting sx: painless vaginal bleeding
DO NOT do a vaginal exam with fingers or speculum!!! instead do an abdominal or transvaginal US
Management:
- if not briskly bleeding bedrest with monitoring.
- if baby less than 34weeks consult OB about giving corticosteroids
- if contracting consult about tocolytics (mag sulfate)
- if briskly bleeding; 2 large bore IVs, CBC, coagulation studies, type and cross match 4 units PRBC, maintain hgb greater than 10.
- -monitor fetal status, consult OB for possible emergent delivery.
- if complete placenta previa the mom will require C-section
Placental Abruption:
- risk factors
- presentation
- Tx
Risk factors: HTN, trauma, polyhydramnios, multiple gestation, smoking, cocaine use
Presentation:
- painful vaginal bleeding
- abd pain or contractions
- fetal distress
Tx:
- stabilize mom
- monitor fetus
- tocolytics w/ mag sulfate
- consult OB
Fetal Heart monitoring:
- what is normal fetal HR?
- what are good healthy signs?
- when are decelerations okay?
- what findings on heart monitoring indicate fetal distress?
- can strength of contractions be determined using this?
Fetal HR:
-120-160BPM
Healthy signs:
-variability and accelerations
Decelerations are ok to decrease slightly during a contraction BUT they must return to normal.
Fetal distress:
- lack of variability
- prolonged HR less than 120BPM
- Late decelerations
- sinusoidal pattern (SEVERE fetal distress)
NO, strength of contractions requires internal uterine monitoring.
Fetal Distress detected on Heart Tracings:
-what are our initial measures to correct this?
Initial measures:
- maternal administration of O2
- change maternal position (left decubitus)
- bolus w/ normal saline
Mild Preeclampsia:
- definition
- management
Severe Preeclampsia:
- definition
- management
Def:
- 2BP measurements 6hrs apart greater than 140/90
- proteinuria greater than 0.1g/L on urine dipstick or greater than 300mg protein 24hrs
Management:
- if pt is greater than 37wks = delivery
- 34-36wks can do expectant management
Severe Preeclampsia:
-definition: SBP greater than 160, DBP greater than 110, proteinurai greater than 5gm in 25hrs, **Signs of end organ damage (HA, vision loss, etc)
Management;
- mag sulfate (prevent seizures)
- Treat BP w/ labetalol, hydralazine
- Delivery (may require C section)
What are signs of magnesium sulfate toxicity?
SE of magnesium sulfate?
Do you continue magnesium sulfate admin after delivery?
loss of relfexes is first sign of hypermagnesemia
SE mag sulfate:
- w/ loading dose: diaphoresis, flushing d/t vasodilation & decrease in BP, N/V
- rare: pulmonary edema and chest pain
- *No significant SE on fetus
YES! continue mag sulfate admin for 48-72hrs postpartum b/c mom is still at risk for complications including seizures.
Ecclampsia:
- definition
- management
Definition:
-occurrence of one or more general tonic-clonic seizures or coma in a preeclamptic woman.
Managment
- protect maternal airway
- lower BP with hydralazine or labetolol
- prevent future seizures with mag sulfate
- persistent seizures: lorazepam(ativan) or diazepam (valium)
Death in Utero:
- presentation
- what needs to be documented in declaring this?
- management
- risk of keeping the baby inside the uterus
Presentation:
-mom usually c/o decreased fetal movement
Document: no fetal heart sounds and NO cardiac activity on US
Management: induce labor except if prior c-section then woman is at higher risk of uterine rupture.
Risks:
- coagulopathy the longer the fetus remains in teh uterus
- infection? (i think patt said this)
Do we delivery breech babies vaginally?
When delivering a breech baby what head position is critical for the baby?
Well ideally No, they require C-section, but sometimes there is no time for a c-section.
KEEP THE HEAD FLEXED by inserting a finger into the babys mouth. suprapubic pressure may also be applied to keep the head flexed.
Shoulder Dystocia:
-what maneuvers and measures are taken to delivery the baby?
Drain a full bladder
McRoberts: flex the maternal thighs back against the abd
Apply suprapubic pressure
Cut a generous episiotomy
Rubin: clinician places one hand in the vagina behind the posterior shoulder and rotates it anterior toward fetal face
get mom on all fours :( this is called “Gaskin all fours”
Acute Herpes Vulvovaginitis
- when is baby at highest risk for acquiring congenital herpes?
- if you have this do you require a c-section?
Baby is at highest risk of acquiring congenital herpes if the mother is infected with PRIMARY HSV-2 during the pregnancy
any pregnant woman who is in labor who has a hx of genital herpes should have a c section if:
- -she has active herpes lesions on or near the birth canal
- -any prodromal sx on or near the birth canal
