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Emergency Medicine EOR > Obstetrics and Gynecology > Flashcards

Obstetrics and Gynecology Flashcards

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1
Q

What is primary amenorrhea?

A

no menses by age 13 with an absence of secondary sexual characteristics; no menses by 15 with normal growth secondary sex

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2
Q

What are the causes of primary amenorrhea?

A

pregnancy, imperforate hymen, gonadal dysgenesis (turner’s syndrome), HPO axis abnormalities (anorexia, bulimia, weight loss, excessive exercise)

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3
Q

How is primary amenorrhea dx?

A

quantitative BHCG, FSH, prolactin, TSH, T3, free T4, estrogen, progesterone

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4
Q

What is secondary amenorrhea?

A

the absence of menses for 3 mo in women with previously normal menstruation or 6 mo in a women with a history of irregular cycles

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5
Q

What are the causes of secondary amenorrhea?

A

pregnancy, endometrial atrophy, premature ovarian failure, pituitary dysfunction, drug use, herbals, hormonal medications, stress, extreme weight changes, eating disorders, excessive exercise

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6
Q

How is secondary amenorrhea dx?

A

quant BHCG, TSH, prolactin if >200 CT of sella, progesterone challenge, FSH

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7
Q

What is the tx for amenorrhea?

A

treat underlying cause, use OCPs, cyclic progesterone 10 mg for 10 days

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8
Q

What is pelvic inflammatory disease?

A

infection that ascends from the cervix or vagina to involve the endometrium and/or fallopian tubes

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9
Q

What are the characteristics of pelivc inflammatory disease?

A
  • causative agents include gonorrhea and chlamydia
  • chandelier sign (cervical motion tenderness)
  • common symptoms include pelvic pain and fever, there may be vaginal discharge (cervicitis)
  • complications: infertility, ectopic pregnancy, tube-ovarian abscess (adnexal mass)
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10
Q

What are the clinical findings of pelvic inflammatory disease?

A

direct abdominal tenderness, cervical motion tenderness, and adnexal tenderness plus 1 or more of the following:

  • temperature >38 C
  • WBC count >10,000/mm3
  • pelvic abscess found by manual examination or ultrasonography
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11
Q

What is the outpatient tx of pelvic inflammatory disease?

A

ceftriaxone IM 250 mg once + PO doxycycline 100 mg BID x 14 d+/- PO flagyl 500 mg BID x 14 d

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12
Q

What is the inpatient tx of pelvic inflammatory disease?

A
  • severely ill or nausea and vomiting precludes outpatient management
  • consider hospitalization if the diagnosis is uncertain, ectopic and appendicitis cannot be rules out, pregnancy, pelvic abscess suspected, HIV positive, unable to follow or tolerate outpatient regimen or failed to respond to outpatient therapy
  • doxycycline + IV cefotetan or cefoxitin x 48 hours until the condition improves, then PO doxycycline 100 mg BID x 14 d
  • clindamycin + gentamicin daily, if normal renal function, x 48 h until the condition improves, then PO doxycycline 100 mg BID x 14
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13
Q

What is dysfunctional uterine bleeding?

A

defined as excessive uterine bleeding with no demonstrable organic cause

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14
Q

What is menorrhagia?

A

prolonged/heavy bleeding (>7 days or 80 mL); regular intervals

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15
Q

What is metrorrhagia?

A

variable amounts of bleeding at irregular, frequent intervals

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16
Q

What is menometrorrhagia?

A

more blood loss during menses and frequent and irregular bleeding between menses

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17
Q

What is polymenorrhea?

A

menses that occur more frequently (menses <21 days apart)

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18
Q

What is oligomenorrhea?

A

menses that occur less frequently (>35 days)

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19
Q

What are the causes of dysfunctional uterine bleeding?

A

Reproductive tract disease = pregnancy, gastational trophoblastic disease, uterine lesions, iatrogenic causes (IUDs, contraception, HRT, psychotropic agents)

  • uterine lesions: menorrhagia or metrorrhagia d/t increase in endometrial surface area/distortion of vasculature/having friable or inflamed surface = includes endometrial CA/sarcoma, endometrial hyperplasia, submucosal fibroid, enometrial polyps, endometritis, adenomyosis
  • systemic disease = blood dyscrasias (vWD, prothrombin deficiency, leukemia, severe sepsis), hypothyroidism, hyperthyroidism, cirrhosis
  • hypothyroidism assocaited with menorrhagia or metorrhagia; hyperthyroidism associated with oligomenorrhea and amenorrhea
  • cirrhosis can cause excess bleeding d/t low plts and less metabolization of estrogens
  • endocrine causes = anovulatory vs ovulatory DUB
  • anvolutatory:
  • continous production of estradiol-17 beta without corpus luteum formation and no progesterone release
  • unopposed estrogen = continous proliferation of endometrium which eventually outgrows its blood supply and sloughs of in an irregular unpredictable pattern
  • ovulatory:
  • mid-cycle spotting after LH surge
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20
Q

How is dysfunctional uterine bleeding dx?

A
  • rule out pregnancy
  • med reconciliation
  • PE = thyromegaly, hepatomegaly, GU infection, GI problems (hemorrhoids), pelvic structural abnormalities (polyps, fibroids)
  • labs = FSH, LH, prolactin, estradiol, testosterone, TSH, T3, T4, DHEAS, coags
  • eval of uterus = endometrial biopsy or hysteroscopy, pelvic US
  • uterine dilation and curettage (GOLD STANDARD): especially when done with hysteroscopy, uterine dilation, and curettage can be diagnostic and therapeutic
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21
Q

What is the tx for dysfunctional uterine bleeding?

A
  • structural problems can be corrected surgically = D and C (therapeutic and dx), hysteroscopy, endometrial ablation, hysterectomy
  • OCPs can regularize cycles
  • IV estrogen can be used acutely if pt is presenting with acute hemorrhage d/t DUB
  • NSAIDs reduced menstrual blood loss
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22
Q

What is pelvic pain/dysmenorrhea?

A

refers to uterine pain around the time of menses, which can either be primary or secondary
-commonly found in those who ovulate regularly; pain usually lasts 1-2 days and is relieved by NSAIDs and OCPs

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23
Q

What is pelvic pain/dysmenorrhea assocaited with?

A

associated with endometriosis: pain begins prior to menses

  • pain isn’t relieved by NSAIDs and OCPs
  • often have dyspareunia as well
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24
Q

What is primary dysmenorrhea?

A

begins w/in 6-12 mos of menarche

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25
Q

What is the patho of primary dysmenorrhea?

A

due to excess PG and leukotriene production at menstruation = increased uterine contraction

  • blood vessels are vasoconstrictor = decreased blood flow
  • Ischemia from contraction can cause pain
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26
Q

What are the sxs of primary dysmenorrhea?

A

severe cramp that start with menses and last 2-3 days (highest in the first day), lower abdominal pain that radiates to back thighs, h/a, nausea, diarrhea

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27
Q

What is the PE of primary dysmenorrhea?

A

normal

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28
Q

What is the tx for primary dysmenorrhea?

A

NSAIDs= first line, OCPs (prevent ovulation), menstrual suppression, surgical (endometrial resection)

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29
Q

What is secondary dysmenorrhea?

A

(pathologic cause)

  • painful menstruation caused by clinically identifiable cause
  • etiology: endometriosis, adenomyosis, polyps, fibroids, PID, IUD, tumors, adhesions, cervical stenosis/lesions, psych
  • pain with menstruation begins mid-cycle and increases in severity until end
  • common women age (20-40s)
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30
Q

What is the tx of secondary dysmenorrhea?

A

treat underlying cause

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31
Q

What is an ectopic pregnancy?

A

implantation of pregnancy somewhere other than the uterine cavity = 95% in the Fallopian tube (55% in the ampulla of the tube)

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32
Q

What are the classic features of an ectopic pregnancy?

A

abdominal pain, bleeding, and adnexal mass in a pregnant woman

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33
Q

What is the MC cause of an ectopic pregnancy?

A

occlusion of tube secondary to adhesions

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34
Q

What are the risk factors of an ectopic pregnancy?

A

history of previous ectopic, previous salpingitis (caused by PID), previous abdominal or tubal surgery, used of IUD, assisted reproduction, smoking

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35
Q

What is a ruptured ectopic pregnancy?

A

medical emergency

-severe abdominal or shoulder pain, peritonitis, tachycardia, syncope, orthostatic HTN

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36
Q

How is an ectopic pregnancy dx?

A
  • Beta HCG is >1,500, but no fetus in utero
  • serial increases of betaHCG are less than expected (should double every 2 days); get baseline BetaHCG and follow-up hormone levels in 48 hours - if they are sub optimally rising (not doubling) then it is likely an ectopic pregnancy
  • when betaHCG is >1,500 = should show evidence of developing intrauterine gestation on ultrasound = if not, suspect ectopic transvaginal US >90% sensitive (IUP visible by 5-6 weeks)
  • ultrasound = ring of fire sign: the ring of fire sign also known as ring of vascularity signifies a hypervascular lesion with peripheral vascularity on color or pulsed doppler examination of the adnexa due to low impedance high diastolic flow
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37
Q

What’s the tx for an ectopic pregnancy?

A

methotrexate = only if beta HCG <5,000, ectopic mass is <3.5 cm, no fetal heart tones, hemodynamically stable, no blood disorders, no pulmonary disease, no peptic ulcer, normal renal function, normal hepatic function, compliant pt that can return for follow up

  • administration fo methotrexate is the appropriate treatment for an ectopic pregnancy unless there are contraindications to use the drug
  • these contraindications include current breast-feeding, active pulmonary disease, immunodeficiency, or hypersensitivity to methotrexate
  • the drug is a folic acid antagonist that inhibits DNA replication
  • the effectiveness of administration is similar to surgical treatment without the risk of surgical complications
  • Indications for methotrexate therapy include a hemodynamically stable patient, hCG levels below 5,000 IU/L, mass <3.5 cm, no fetal cardiac activity, and the ability to comply with post-treatment follow-up
  • methotrexate can be administered intravenously, intramuscularly, or orally
  • It can also be injected into the ectopic pregnancy directly, although this route of administration is not commonly used
  • Intramuscular administration is the route of administration that is most commonly used for the treatment of ectopic pregnancy
  • surgical treatment: laparoscopy salpingostomy = emergent situations (rupture) or patient not meeting methotrexate criteria
  • follow-up testing = crucial
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38
Q

What is placenta abruption?

A

premature separation of all/section of otherwise normally implanted placenta from the uterine wall after 20 weeks of gestation resulting in hemorrhage

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39
Q

What are the characteristics of placenta abruption?

A
  • MC cause of third trimester bleeding
  • risk factors for placental abruption include trauma, smoking, hypertension, preeclampsia, and cocaine abuse
  • primary cause: unknown - maternal HTN, prior history of abruption, maternal cocaine use, external maternal trauma, rapid decompression of over distended uterus
  • presents as heavy painful vaginal bleeding in the 3rd trimester with severe abdominal pain and/or frequent strong contractions (30% have no symptoms)
  • physical exam: vaginal bleeding and firm tender uterus with small frequent contractions, 20% present with no bleeding (concealed hemorrhage)
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40
Q

How is placenta abruption dx?

A

the diagnosis is always clinical, ultrasound is minimally helpful but is usually ordered

  • ultrasound may show retroplacental blood collection
  • blood-stained amniotic fluid in the vagina
  • abruption signs evidence by fetal heart rate, uterine activity
  • decelerations may indicate fetal hypoxia, bradycardia
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41
Q

How is the tx for placenta abruption?

A

delivery of the fetus and placenta is the definitive treatment, blood type, crossmatch and coag studies as well as placement of large-bore IV line

  • emergent delivery = vaginal/cesarean, as indicated
  • corticosteroids as indicated to enhance fetal lung maturity
  • expectant management for small abruptions
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42
Q

What is endometriosis?

A

presence of endometrial tissue outside endometrial cavity - MC found in ovary and pelvis peritoneum

  • sometimes transported to the lymphatic system (retorgrade menstruation)
  • the severity of symptoms does not equate to the amount of endometriosis
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43
Q

What are the theories of DZ for endometriosis?

A
  • retrograde menstruation (most likely): endometrium floats back out of the Fallopian tubes onto ovary/into the cul-de-sac
  • hematogenous/lymphomatous spread
  • celomic metaplasia
  • can happen as a result of an obstructive anomaly (imperf. Hymen, transverse septum/longitudinal septum, cervicl anagenesis)- once the obstruction is removed, the endometriosis usually resolves
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44
Q

What are the risk factors of endometriosis?

A

early menarche, short cycles, heavy/prolonged cycles, early menarche, prolonged menses, Mullerian anomalies, family history, autoimmune history
-protective: multiparty, longer lactation, regular exercise

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45
Q

What are the sx of endometriosis?

A

The “THREE D’s” - dyspareunia, dyschezia (difficulty in defacating), and dysmenorrhea

  • cyclic pelvis pain peaking 1-2 days before the onset of menses
  • Infertility
  • many women are asymptomatic
  • the amount of endometriosis doesn’t correlate to pain (depth of implantation correlates better)
  • decrease in pain w/surgical excision/ablation/cauterization
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46
Q

What is the PE of endometriosis?

A

uterus is fixed and retoflexed

-tender nodularity of cul de sac and uterine ligaments

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47
Q

How is endometriosis dx?

A

pelvic laparoscopy and biopsy is the gold standard for diagnosis
-chocolate cysts are observed

48
Q

What is the tx of endometriosis?

A

medical or surgical

  • surgical: resect endometriosis
  • medical: NSAIDs, progestins, progestins, oral contraceptive therapy, danazol, NSAIDs, GnRH agonist (put in a state of pseudopregnancy)
  • can only give danazol for 6 months because of bone loss (can do longer if you do add-back therapy)
  • Increasing the consumption of long-chain omega-3 fatty acids can decrease a women’s risk of endometriosis
  • having multiple childbirths, extended periods of lactation, and the use of oral contraception may also decrease the risk
49
Q

What is placenta previa?

A

a condition in which the placenta lies very low in the uterus and covers all or part of cervix
-placenta previa happens in about 1 in 200 pregnancies

50
Q

What is complete previa?

A

placenta completely covers the internal os

51
Q

What is partial previa?

A

placenta covers a portion of the internal os

52
Q

What is marginal previa?

A

the edge of placenta reaches the margin of the os

53
Q

What is low-lying placenta?

A

implanted in the lower uterine segment in close proximity but no tending to the internal os

54
Q

What is vasa previa?

A

fetal vessel may lie over the cervix

55
Q

What is the presentation of placenta previa?

A

painless vaginal bleeding

  • usually occurs after 28 weeks of gestation
  • bleeding from placenta previa results from small disrputions in placental attachment during normal development and thinning of the lower uterine segment during third-trimester = may stimulate further uterine contractions = further placental separation and bleeding
  • fetal complications associated with previa: preterm delivery and its complications, preterm PROM, intrauterine growth restriction, malpresentation, vasa previa, congential abnormalities
56
Q

What are the risk factors of placenta previa?

A

prior c-section, multiple gestations, multiple induced abortions, advanced maternal age

57
Q

How is placenta previa dx?

A

ultrasound (transvaginal) - vaginal exam contraindicated = a digital exam can cause further separation
-sonography

58
Q

What is the tx of placenta previa?

A

strict pelvic rest (no intercourse) and modified bed rest, no vigorous exercise

  • blood transfusion may be necessary so get a type and screen if you discover previa via U/S
  • c-section is preferred delivery
  • give Rhogram if Rh-
  • some studies show that delivery between 34-37 weeks may be optimal
59
Q

What is non-stress testing?

A
  • GOOD - reactive NST - > 2 accelerations in 20 minutes, with increased fetal heart rate 15 bpm lasting > 15 seconds, indicated fetal well being
  • BAD - nonreactive NST - no fetal heart rate accelerations or <15 bmp lasting <15 seconds, get contraction stress test
60
Q

What is contraction stress test?

A

measures fetal response to stress at times of uterus contraction

  • GOOD - Negative CST - no late decelerations in the presence of 2 contractions in 10 minutes, indicates fetal well being, repeat CST as needed
  • BAD - Positive CST - repetitive late decelerations in the presence of 2 contractions in 10 minutes, worrisome especially if nonreactive NST, prompt delivery
61
Q

What is APGAR?

A

appearance, pulse, grimace, activity, respiration

  • score from 1-10 with > 7 norma, 4-6 fairly low, 3 and under critically low
  • test is done at 1 and 5 minutes after birth
62
Q

What is premature rupture of membranes?

A

clinical definition: the rupture of membranes at >37 weeks gestation prior to start of uterine contractions

  • preterm premature rupture of membranes (PPROM) describes PROM <37 weeks gestation
  • major risk = infection or cord prolapse
63
Q

What are the s/sx of premature rupture of membranes?

A

sudden “gush” of clear or pale yellow fluid from the vagina that occurs after 37 weeks of gestation

64
Q

What is premature rupture of membranes dx?

A
  • speculum - fluid pooling in the posterior fornix
  • nitrazine test - blue (due to elevated pH) determine if this is amniotic fluid - pH >7.1 means it is positive
  • microscope examination - ferning - take a specimen of fluid put it on a slide and let it air dry will see “fern pattern” crystallization of the amniotic fluid (crystallization of estrogen and amniotic fluid)
65
Q

What is the tx of premature rupture of membranes?

A
  • > 34 weeks - induce labor
  • 32-34 weeks collect fluid and check for lung maturity - then induce
  • <32 weeks stop contractions and start 2 doses of steroid injection then deliver the baby - give antibiotics
66
Q

What is an abortion?

A

(either elective or spontaneous) <20 weeks gestation or weigh <500 grams

67
Q

What is a premature infant?

A

20-36 weeks gestation or 1000 -25000 grams

68
Q

What is a full term infant?

A

after 37-42 weeks gestation or >2500 grams

69
Q

What is a postmature infant?

A

> 42 weeks gestation

70
Q

What is the abreviation of obstetrical history?

A

G_PTPAL

  • T: total number of full-term pregnancies (37-42 weeks)
  • P: total number of preterm pregnancies (20-36 weeks)
  • A: total number of abortions (elective or spontaneous occurring before 20 weeks)
  • L: total number of living children
    • twins count as ONE pregnancy, TWO live children
71
Q

When is fetal movement (quickening) felt at?

A
  • nulliparas: 18-20 weeks

- multiparas: 14-16 weeks

72
Q

What are the signs of pregnancy?

A
  • Chadwick’s sign: bluish discoloration of vagina and cervix
  • Increased basal body temperature
  • skin changes:
  • melasma/chloasma (dark patches on the face across the bridge of the nose or forehead
  • linea nigra: vertical line up the abdomen
  • caused by stimulation of melanocyte
  • Hegar’s sign: softening between the fundus and cervix
73
Q

What is the uterine growth stages?

A
  • 12 weeks at the symphysis pubis
  • 20 weeks at the umbilicus
  • after 20 weeks 1 cm for every week gestation
74
Q

What is the range for the heart rate of the baby?

A

120-160

-will be visbile on the US at 6 weeks gestation

75
Q

What are the important lab changes of pregnancy?

A
  • cholesterol with INCREASE and this is normal if elevated just repeat at the 6-week postpartum visit
  • BUN and Creatinine will be DECREASED
76
Q

What are the first visit prenatal labs?

A

CBC, blood type, RH factor, antibodies to blood group antigens, random glucose, VDRL (RPR), hepatitis B, rubella, urine, Pap smear (if less than 1 year since last), group b streptococcus, as indicated: sickle cell trait, cystic fibrosis, tay-sachs

77
Q

What is done at every prenatal visit?

A

maternal weight, blood pressure, fundal height, fetal size and presenting part, urine dipstick for protein, glucose, ketones

78
Q

What is the recommended weight gain during pregnancy?

A
  • 20-35 lbs: avery weigh women
  • 40-45 lbs: underweight women
  • 10-15 lbs: overweight women
79
Q

What is the nutrition during pregnancy?

A

pregnant intake = increase in calories should be 300 kcal/day + folic acid (0.4 mg/day), iron (30 mg/day)

80
Q

What are the things to avoid during pregnancy?

A

smoking, ETOH, drugs - teratogens, unpasteurized foods (apple cider, soft cheese) - listeria, raw meat, seafood - listeria, Deli meat - listeria, king mackerel, shark, swordfish, tuna, tilefish-mercury, farm salon -PCBs

81
Q

What is a spontaneous abortion?

A

termination of a pregnancy before 20 weeks - occurs in 15-20% of pregnancies

82
Q

What are the risk factors of spontaneous abortion?

A

smoking, infection, maternal systemic disease, immunologic parameters, drug use

83
Q

What are the signs and symptoms of spontaneous abortion?

A

bleeding = variable, fundus of uterus may be boggy or tender

84
Q

How is a spontaneous abortion dx?

A

diagnose by decrease BetaHG and classification based on ultrasound findings

  • transvaginal ultrasonography is the cornerstone of the evaluation of bleeding in early pregnancy
  • the US demonstrates inappropriate development or interval growth, poorly formed/unformed fetal pole, fetal demise
  • the beta HG should double every 48 hours in a variable intrauterine pregnancy
  • blood type and Rh status necessary tests to preclude Rh sensitization in mother
85
Q

What is the tx of spontaneous abortion?

A

traditionally managed by D and C only monitor progress with B-hCG levels or ultrasound examination

  • Immunoglobulin administered to Rh-negative women
  • septic/infected abortion requires complete evacuation of uterine contents, medical support, abx
86
Q

What is a threatened abortion?

A

abdominal pain or bleeding in the first 20 weeks of gestation

  • closed cervical os
  • no passage of fetal tissue
87
Q

What is an inevitable abortion?

A

abdominal pain or bleeding in the first 20 weeks of gestation

  • open cervical os
  • no passage of fetal tissue
88
Q

What is an incomplete abortion?

A

abdominal pain or bleeding in the first 20 weeks of gestation

  • open cervical os
  • yes passage of fetal tissue (some products of conception remain in uterus)
89
Q

What is an complete abortion?

A

abdominal pain or bleeding in the first 20 weeks of gestation

  • closed cervical os
  • complete passage of fetal parts and placenta and contacted uterus
90
Q

What is a septic abortion?

A

infection of uterus during miscarriage, fever, and chills

  • usually due to Staph aureus
  • open cervical os with purulent cervical drainage and uterine tenderness
  • none or may be incomplete passage of fetal tissue
91
Q

What is mastitis?

A

a regional infection of the breast from skin flora or oral flora of breastfeeding baby - organisms enter erosion or cracked nipple; the main cause is clogged milk ducts

  • occurs mainly in breastfeeding women
  • usually caused by nipple trauma
  • unilaterl erythema, tenderness, usually one quadrant of the breast affected, fever and chills
  • congestive (bilateral) vs. infectious (unilateral)
  • usually caused by S. auresu
92
Q

What is the tx for mastitis?

A

if infectious treat with dicloxacillin, cephalexin, or erythromycin for staph alternate is clindamycin
-continue to breastfeed on the affected side along with warm heat 4 times per day

93
Q

What is a breast abscess?

A

a pocket of contained infection within the breast

  • a progression from mastitis - symptoms are the same with the addition of localized mass and systemic signs of infection
  • staphylococcus aureus is the most common cause
94
Q

How is a breast abscess tx?

A

I&D and anti-staph antibiotics

  • regimen: nafcillin/oxacillin IV or cefazolin PLUS metronidazole
  • alternative is vancomycin
  • stop breastfeeding on the affected side - pump and dump
95
Q

What are the ddx of vaginal discharge?

A

yeast infection, BV, HPV, trichonmoniasis, herpes, cervicitis, foreign body (tampon), sexually transmitted infections (STIs), such as chlamydia or gonorrhea, various sex practices, vaginal medicines/douching, menopause, vaginal discharge, an absence of menstruation, anxiety

96
Q

What is an ovarian cyst?

A

an ovarian cyst is a fluid-filled sac within the ovary

  • the majority of cysts are harmless and cause no symptoms
  • occasionally they may produce bloating, lower abdominal pain, dyspareunia, or lower back pain
  • ovarian cysts may be classified according to whether they are a variant of the normal menstrual cycle (functional) or non-functional
  • follicular cysts are the most coomon
97
Q

What are the characteristics of functional cysts?

A

(3 types): normal physiologic functioning of ovaries = follicular (MC) and corpus luteum; 2-3 cm can get as big as 10 cm, clear serous liquid, smooth internal lining

  • follicular cyst (the most common type): a dominant follicle fails to rupture
  • corpus luteum: dominant follicle ruptures but closes again and doesn’t dissolve
  • theca lutein cysts: overstimulation of HCG produced by placenta so only seen in pregnancy
98
Q

What are non-functional cysts/neoplastic cysts?

A

PCOS (amenorrhea, hirsutism), endometriomas (chocolate cysts), dermoid cysts (teratoma), ovarian serous and mutinous cystadeoma, etc.
->10 cm, irregular borders, internal septations

99
Q

What are the complcations of ovarian cysts?

A
  • hemorrhagic: more common with follicular and corpus luteal cysts
  • rupture: release contents into peritoneal cavity, frequently after sexual intercourse
  • torsion: ovary twists around suspensory ligament, cuts of blood supply to the ovary (risk if the cyst is >5 cm)
100
Q

What is the hx of a patient with ovarian cysts?

A

follicular tend to be asymptomatic, larger = pelvic pain; corpus luteum = local pelvic pain, amenorrhea, or delayed menses

101
Q

What is the PE of ovarian cysts?

A

ruptured = pain, low blood pressure, abdominal or shoulder pain, tachycardia; torsion = waxing and waning pain, n/v, low-grade fever

  • abdominal and pelvic ultrasound is the first imaging study of choice for suspected ovarian torsion because it is less expensive than and has similar diagnostic performance as computed tomography (CT) and magnetic resonance imaging (MRI)
  • definitive diagnosis is direct visualization of a tossed ovary during surgery, and prom operative evaluation is the mainstay of treatment to preserve ovarian function
102
Q

How is ovarian cyst dx?

A

transvaginal ultrasound/abdominal

  • MRI: if ultrasound indeterminate for surgical resection evaluation
  • labs: serum CA-125 (in menopausal, postmenopausal individuals) = assists in ruling out ovarian cancer
  • histologic analysis via ultrasound-guided aspiration (definitive)
103
Q

What is the tx of ovarian cyst?

A

treatment is based on type and size

  • < 5 cm observation is the mainstay (function, endometriomas, serous and mutinous adenomas)
  • uncomplicated cyst rupture (hemodynamically stable): expectant management and NSAIDs
  • > 5 cm cyst is removed by laparoscopy
  • surgery indicated if benign but symptomatic tumors, malignant tumors, cysts that are hemorrhagic severely, and ovarian torsion
104
Q

What is bacterial vaginitis?

A

lack of lactobacilli = low hydrogen peroxide = high pH (>4.5); infection is polymicrobial (mostly gardnerella Vaginalis)
-sxs: thin discharge, fish odor

105
Q

How is bacterial vaginitis dx?

A

milky vaginal discharge, pH >4.5, amine “whiff” test (fishy odor), clue cells (gram-negative)
-AMSEL criteria: thin, white homogeneous discharge, presence of clue cells in microscopic exam (striped epithelial cells), pH >4.5, fishy odor - must have 3/4

106
Q

What is the tx for bacterial vaginitis?

A

metronidazole (PO or intravaginally) OR clindamycin = recurrence is common d/t biofilm production - may need prolonged tx (6 mos.)

107
Q

What is candidiasis?

A

infectious of the vaginal tract with candida (MC is albicans)

  • sxs: itching/burning, dyspareunia, thick white discharge, beefy red vaginal mucosa
  • diabetes mellitus is a predisposing factor for recurrent vulvovaginal candidiasis since hyperglycemia enhances the ability of Candida alicans to bind to vaginal epithelial cells
108
Q

How is candidiasis dx?

A

wet mount = KOH and saline + microscopy; pH <4.5 (normal) BD affirm = DNA test; yeast cs if recurrent (look for different type of yeast)

109
Q

What is the tx for candidiasis?

A

fluconazole (150 mg PO x 1) - if it’s really bad, can give another dose 72 hours later, vaginal cream (miconazole, terconaxole, clotrimazole, etc) - 7 day course typically works better

110
Q

What is trichomonas?

A

caused by parasitic protozoan trichomonas vaginalis; can affect fertility so we want it treated well
-sxs: men are usually asymptomatic; females: itching, burning, post-coital bleeding, dysuria, frothy white/grey discharge

111
Q

How is trichomonas dx?

A

saline wet mount a must look at very quickly (parasites die fast); pH>/= 4.5; BD affirm, strawberry cervix on spec exam (only present ~1-% of time but is pathogomonic

112
Q

What is the tx for trichomonas?

A

metronidazole (PO only)
-partner: tx warrants full STI screening, pt should be retested in 2 weeks - 3 los. to ensure successful tx (“test of cure”)

113
Q

What is atrophic vaginitis?

A
  • Def: atrophy of vaginal and vulvar tissue d/t hypoestrogenic state (often seen in menopause)
  • Sxs: dryness, burning, irritation, low lubrication, pain/discomfort w/sex, urinary urgency, dysuria, recurrent UTIs
114
Q

What is the PE of Atrophic vaginitis?

A

fragile tissue, fissures, petechiae, labia minora resorption, loss of moisture and rug and elasticity, prominent meatus, urethral eversion or prolapse

115
Q

How is atrophic vaginitis dx?

A

clinical

116
Q

What is the tx for atrophic vaginitis?

A

first-line therapy for symptomatic relief of vulvovaginal atrophy is with non-hormonal vaginal moisturizers and lubricants

  • If therapy does not result in symptom relief, low-dose vaginal estrogen (insert, ring, cream) therapy may be used if the woman has no contraindications (estrogen-dependent malignancy)
  • sexual activity and/or use vaginal dilators can help maintain healthy vaginal epithelium
  • prescribing a vaginal ring that contains 2 mg of estradiol to be placed once every 3 months is an appropriate initial intervention for patients with symptoms of post-menopausal vaginal atrophy
  • a daily intravaginal estradiol tablet is also effective

Emergency Medicine EOR (12 decks)

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