vaginal bleeding Flashcards
2-3 mo pregnant women complaining of severe abdominal pain and bleeding BP70/30 HR130 RR22 O298% POC glu 80 ETA 4-6 mins
any woman that comes in with abdominal pain and bleeding need ectopic on ddx
belly full of blood on ULS with + pregnancy test
fluid collects in morrison’s pouch any trauma pt or hypotensive pt will see this space
need type and cross need a surgeon and operating room
Most ectopics happen in the
ampulla
scarring form STDs cause the fetus to get stuck
blood work up in a pt with ectopic
not especially helpful
Blood WBC 8K, Hgb 11.9; Urine WBC 10-20 + LE
in a UA we are looking for undiagnosed UTI not helpful for ectopic
CBC +/- chemistry (if in case pt requires methotrexate later),
UA (check for infxn like undetected pyelo or STI – associated with preterm labor). A lot of preterm labor deliveries we see can be traced back to an infection
how does the cervix differ from the ULS
- Cervix cant respond to active bleeding – if it is ripped in any way, you will bleed to death (like if you have a pregnancy there)
no hemostasis in the cevix
what are the ectopics we miss
The ectopics that we miss are in the cervical area
fimbriae in the ovary – they are hard to detect b/c on US they are sitting next to a lot of other structures
Ectopics hiding near the uterus will present with
More difficult to diagnose - both can appear intrauterine.
More likely to cause catastrophic bleeding.
iHigher rates in ART patients.
Cornual Ectopic
close to the insertion of the uterine artery
RF for cervical ectopic
prior instrumentation, fibroids, IUDs, IVF, uterine structural abnormalities (Asherman’s Syndrome, DES)
Heterotopic Pregnancy
one is in the uterus and one is not
i. 1 in 4,000 pregnancies
ii. 1 in 100 pregnancies in patients using assisted reproductive technology
endocaveterial ULS
always start with the transabdominal view
2 large bore IV
type and cross
OB on board
ULS pitfalls
i. Make sure you are oriented correctly!
ii. Find the uterine cavity.
iii. Find the endocervical canal.
iv. Always look in the adnexa and ovaries.
Always scan trans-abd AND trans vaginal
When in doubt, get a formal study!
Threatened miscarriage
just have bleeding
closed OS
pain, OS may or may not be closed, bleeding, some tissue left behind
Incomplete miscarriage
labs on pregnant ptds
CDC type and screen
STD
need to know if there is incompatibility
don’t want mom to build a response
Quantitative beta hCG
Primarily used to trend an early pregnancy.ii. Indicates when we should see an IUP.
above 7500 -abd uLS
5000-transvaginal
if you have a completely early uterus with a Low HcG –> suspicious .
hcg for
iii. Ectopic pregnancies have been reported from 5-200,000 mIU.
with super high suspect molar pregnancies or multiple gestations
threatened miscarriage
workup
Address the possibility of ectopic pregnancy, and include the patient in this discussion.
Standard labs include CBC, CMP, UA, STI testing, Rh status, and quantitative hCG for trending purposes.
iii. Ultrasound.
iv. 48-hour follow-up either in the ED or with an OB provider.
v. Strict return precautions.
what can you assess in a patient coming 30+ weeks pregnant with blleding and pain
gestational age
abruption
looking a
anything outside a labor and delivery suite is precipitous delivery
two placental catastrophes
previa= over the cervix usually painless
abruption= part of the placenta has separated away from the uterine wall
classic abruption and sxs and dx tests
uterine cramping or pain with bleeding. Can occur from sheer forces as well
ULS not very sensitive for abruption
- CBC, type/crossmatch
- Coagulation profile
- Renal function studies
maternal wellness and fetal variability on fetal heart rate strips
RF for abruption
- MCC HTN
- Maternal trauma
- AMA
- Multiparity
- Smoking
- Cocaine use
- Previous abruptions
can go into DIC
what is the major problem with cord prolapse
deprieving oxygen and blood to the fetus
As uterus is contracting, there are decelerations which means the cord is being squeezed which means there are times baby is not getting O2 so there is a lack of circulation
need to elevate the presenting part
tx of cord prolapse
a. Elevate the foot off the cord and put pt in trendelenberg and take pt to the OR
Infusing the bladder with saline - although not as helpful if a presenting part is visible.
how do you know is the cord isn’t in danger
success with pulsations in the cord
you do not want to pull the baby being delivered unitl
- DO NOT PULL until the umbilicus is delivered.
should be delivered
Infant should deliver face down.
premi more likely to be breeched
presentation of shoulder dystocia
Buddha like faces – very plethoric, can appear purplish
“Turtle sign”
if the head comes out and back in
what could indicate a possible shoulder dystocia
Fetal macrosomia- is used to describe a newborn who’s significantly larger than average.
Precipitous delivery (less than 3 hours)
how to resolve should dystocia
NO fundal pressure/hold pushing until repositioned.
knees to chest in the mom
Want suprapubic pressure and turn the baby to dislodge the shoulder
c section preferred
a. McRobert’s Maneuver
b. Suprapubic pressure
c. Delivering the posterior shoulder
d. Rubin, Woods Corkscrew
e. Zavenelli Maneuver
what are we worried about in houlder dystocia
Worry about brachial plexus injury
Post-Partum Care
for devilry of the umbilical cord
Do not pull on the umbilical cord.
B/c it detaches and then the placenta stays up there. Can put you at risk for PPH
Postpartum Hemorrhage
atony of the uterus ( occurs when the uterus fails to contract after the delivery of the baby)
- Greater than 500 cc blood.
- Leading cause of obstetric death worldwide. In the US, second after VTE.
nipple stimulation will cause uterine contraction
Manual Interventions
Resuscitating PPH
Fundal massage (stimulates the uterus to contract down), explore for lacerations, manual uterine exploration for retained products
nipple stimulation will cause uterine contraction
medical interventions FOr PPH
Oxytocin, methylergonovine (ergot alkaloid), misoprostil —> will cause vasoconstriction
Resuscitation with fluids and blood.
TXA (Tranexamic acid) now second-line.
1. Used for DUB and also used in PPH
makes you clot which isn’t ideal
non pregnant cause of bleeding
i. Fibroids
vii. Infection
iii. Systemic disease
iv. Cancer
v. Dysfunctional uterine bleeding
vii. Look for symptomatic anemia.
viii. Consider evaluation for systemic illness.
perimenopause
fibroids
easy to detect on ULS
painful and heavy periods
contraception that can cause bleeding
a. Intrauterine device
i. Spotting and bleeding a known complication.
ii. Still check for pregnancy!
b. Hormonal therapies
i. Medroxyprogesterone
ii. Oral contraceptives
iii. Still check for pregnancy!
assessment needs to cover
a. Pregnancy status: negative
b. Hemoglobin level: not anemic
c. Status of the os: closed and no lesions
d. Size of the uterus: no fibroids
e. Skin: warm, dry, without bruising
f. Mucosa: no petechiae or bleeding
g. Discharge instructions: follow-up and return precautions.
Vaginal bleeding summary
Vaginal bleeding is an ectopic until you prove it is not!
Look for ABNORMAL VITAL SIGNS!
c. Screen for vaginal trauma and intimate partner violence.
d. Think about systemic disease.
e. Educate your patient to ensure safe follow-up.
screening for systemic disease in a female bleesing
CBC with smear, PT and PTT
Adolescents with menorrhagia: von Willebrand’s Disease
Secondary immune thrombocytopenias
SLE, antiphospholipid syndrome, thyroid disease
Viral associated thrombocytopenias:
HIV, Hep C, CMV
ITP: diagnosis of exclusion
when is estimating the gestational age inaccurate with fundal heigh and LMO
Multiple gestations
how else can you estimate gestation age?
ULS
how do you measure a BPD
Biparietal diameter
Measure perpendicular to the falx through that thalamus. Outer edge to inner edge of skull
pathogens in pyeo pregnancy
E.coli, Klebisiella, Group B strep.
increased risk in pregnancy
what diseases are we worried about in pregnancy
STI
PYELO
PNA
what does ALARA
ALARA: as low as reasonably achievable.
With respect to imaging
Risk highest in the first trimester and least in the third.
Higher rates of dissemination with this type of PNA in pregnancy
coccidyomycosis
Higher rates of morbidity and mortality; complications to the fetus with this type of pNA in pregnancy
varicella
High rates of respiratory failure with this type of PNA in pregnancyt
Influenza
what do you need to know about the increase risk of appy in pregnancy
Perforation rates increase with trimester.
risk of perf incraeases with trimester and increases risk to the fetus
imaginign ULS and MRI first
what test should be done to assess potential trauma to the fetus
Kleihauer–Betke
measures fetal hgb in mothers blood
new onset hypertension excessive uterine size for dates very elevated hCG levels abnormal ULS preeclampsia prior to 20 weeks
molar pregnancy
evaluation of a premature rupture of the membrane
PROM
iii. Nitrazine Paper: amniotic fluid has a pH of 6.5/7 or higher.
and ferning pattern on smear
Ferning: arborization of salt crystals in amniotic fluid.
when would a cervical exam be contraindicated
CONTRAINDICATED if you suspect placenta previa.
RF for Peripartum Cardiomyopathy
hypertension
preeclampsia
multiple gestations, advanced maternal age, African descent
use of prolonged tocolytics
sxs of preipartum cardiomyopathy
Peripartum Cardiomyopathy
causes of
preipartum cardiomyopathy
Causes include autimiimune, virally mediated
cytokine inflammatry repsonse
stress of pregnancy, genetics, nutrition, myocite apoptosis, elevated prolactin levels
approach to pregnant pt with dyspnea
Scrutinize the blood pressure, heart rate, and O2 sat.
Look for DVT.
Scan for PE if indicated.
Look for signs of heart failure.
Three medication for managing preeclampsia
: labetalol, nifedipine, hydralazine.
management of preterm labor
Tocolytics: Still given but not proven!
Calcium channel blockers now popular.
Do not use more than one agent
Corticosteroids: Proven! Give them!
Dexamethasone or betamethasone.
Fetal lung maturity.
Antibiotics: Proven, but only with ruptured membranes.
Increase the latency period in PPROM.
pelvic pain in female ddx
PID, ovarian cysts, torsion, endometriosis
Renal stones, renal infections
Appendicitis, diverticulitis, hernia
RF for ectopic pregnancy (6)
- Current intrauterine contraception (IUD)
- Hx of ectopic pregnancy, utero exposure to diethylstilbestrol
- Hx genital infxn, including PID, chlamydia, gonorrhea
- Hx of tubal surgery i.e. tubal ligation
- IVF, infertility
- Smoking
ddx of ectopic pregnancy
- Acute appendicitis
- Miscarriage
- Ovarian torsion
- PID
- Ruptured corpus luteum cyst or follicle
- Tubo-ovarian abscess
- Urinary calculi
presentation of ectopic
- Vaginal bleeding (only in 2/3 of pts!)
- Abdominal pain
- Normal or slightly enlarges uterus
- Cervical motion tenderness
- Hypotension/syncope
- Palpable adnexal mass
mngmt of ectopic
- No evidence of tubal rupture
- Minimal pain or bleeding
- Starting B-hCG <1,000 and falling
- Ectopic or adnexal mass less than 3cm or not detected
- No embryonic heartbeat
- Then:
a. Admit or discharge & follow serial hCGs
b. Diagnostic laparoscopy
c. Presumptive methotrexate
Painless, bright red bleeding in 2nd or 3rd semester
what are you worried about
Placenta Previa
DON’T do a digital or speculum exam
iv. STAT abdominal U/S
v. Call OB stat for possible C/S
pt comes in with chief complain of pain in 2nd or 3rd trimester and vaginal bleeding
on PE she has a Tender uterus
and Hypertonic, hyperactive uterine contractions
Premature separation of a normally implanted placenta from the uterine wall
ii. Often misdiagnosed at preterm labor
Placental Abruption ddx
placenta previa
preterm labor
complication of placental abruption
- Maternal death from hemorrhage or DIC
- Fetal death, fetal distress
- Fetomaternal transfusion
- Amniotic fluid embolism
- Hypotension
rf for placenta abruption
- MCC HTN
- Maternal trauma
- AMA
- Multiparity
- Smoking
- Cocaine use
- Previous abruptions
management of placental abruption
- Crystalloids to maintain volume status & FFP for coagulopathy
- Emergency OB consult whenever suspected!
- Stat U/S for fetal viability emergency delivery
- Rhogam, tetanus
Management of 1st trimester bleeding
Quantitative B-hcg >1800-2000
no sac on ULS
ectopic or SAB
U/S shows a gestational sac
a. Follow for threatened abortion
b. Consider subchorionic hemorrhage
hematoma b/w chorion & uterine wall
Bright endometrial stripe suggests on evaluation of 1st trimester bleeding
SAB
Gestation sac >2cm should have a
embryo
Embryo > 5mm crown rump should have a
Heart beat
if fetal heart beat present in mother with 1st trimester bleeding
- <35yo mother 2% risk of miscarriage
- > 35yo mother 16% risk of miscarriage
pt stable
Follow serial quantitative B-hcg q 48hrs
Confirm quant B-hcg double in 48hrs
Confirm IUP when B-hcg >1800-2000
CC of SAB
i. MCC chromosomal abnormalities (50-60%)
ii. AMA
iii. Prior poor OB hx SABS, fetal demise, multiple gestations, uterine s/x
iv. Concurrent medical d/o thyroid, DM, HTN, coagulopathies, P4 deficiency, SLE
v. Maternal infxn HIV, syphilis, TORCH, GC/CT, UTI, vaginitis
vi. Exposures-> heavy metals, chemicals, tobacco, EToH, caffeine (>200mg/d)
vii. Meds antidepressants: paroxetine, venlafaxine
MCC of bleeding during 1st trimester
SAB
HELLP syndrome
- Hemolysis
- Elevated Liver Enzymes
- Low Platelet count
(Often no HTN +/- proteinuria )
diagnoses of HELLP
CLINICAL
get
CBC, CMP, LFTs
presentation of HELLP
N/V, viral like, generalized malaise
Epigastric pain, HA
** any pregnant woman who presents w/ malaise or viral type illness in 3rd trimester should be eval w/ labs asap!
pe of HELLP
RUQ pain & tenderness rupture of liver capsule= hematoma
TX of HELLPO
- Prompt delivery of baby!
- Magnesium sulfate –> decrease risk of seizures
- Blood transfusions –> anemia
- DIC –> fresh frozen plasma
- Anti-HTN –> i.e. labetalol, hydralazine, nifedipine
Causes of PID
i. Salpingitis, endometriosis, tubo-ovarian abscess, pelvic peritonitis
ii. Neisseria gonorrhea, chlamydia trachomatis (may have been asymptomatic)
iii. Untreated cervicitis
RF of PID
i. Multiple sex partners
ii. Unprotected intercourse
iii. Hx of STIs
iv. Frequent vaginal douching
v. Younger age
clinical findings with PID
i. Lower abdominal pain
ii. abnml vaginal discharge
iii. vaginal bleeding
iv. post-coital bleeding
v. dyspareunia
vi. irritative voiding sxs
vii. malaise, N/V
PID PE
i. Lower abd TTP, abd guarding/rebound (peritonitis)
ii. CMT, uterine/adnexal TTP, adnexal mass or fullness (TOA)
iii. RUQ tenderness and jaundice
labs for suspected PID
i. hcG–>ectopic, SAB
ii. saline/KOH wet mounts–> trich
iii. endocervical swabs –> GC/CT, HIV, HEP
iv. CBC, ESR, CRP, liver panel
parenteral tx for PID
cefotetan or cefoxitin + doxycycline
Clindamycin or gentamycin
Ofloxacin or levofloxacin w/wo metronidazole
Oral/outpt
cefotetan or cefoxitin + probenecid + doxycycline w/wo metronidazole
alternative to doxy for PID
a. Azithromycin alternative to doxy
viollin strings is a classic appearance for
fitz hugh curtis syndrome
MC cystic growth in vagina
Bartholin Gland Cyst/Abscess
tx for Bartholin Gland Cyst/Abscess
depends on size, pain, infxn
i. Home tx
ii. I&D, word catheter placement
iii. Abx if cellulitis is present
iv. Marsupialization if recurrent
PID vs appy
PID: pain is NOT migratory
PID: pain is bilateral
PID: NOT associated with nausea and vomiting
Sudden onset of severe unilateral pelvic pain or dull aching pain w/ sharp exacerbations
and vomiting
torsion
get formal U/S to look at flow
ii. Pt w/ ovarian mass
iii. Pt w/ pelvic adhesions
tx of torsin
Adnexal torsion is a SURGICAL EMERGENCY
OR immedeatly
Superficial cellulitis of breast tissue that results in breast pain, swelling warmth, erythema, malaise, fever, chills
Mastitis/Breast Abscess
which populations do we usually see mastitis with
Often in first few wks of breastfeeding
Usually affects lactating women
Caused by a blocked milk duct that didn’t empty during nursing
Stap aureus infxn
RF for mastitis
i. Breast feeding
ii. Sore or cracked nipples
iii. Breastfeeding only one position
iv. Wearing tight fitting bra
v. Fatigue
vi. Previous hx of mastitis
tx for mastitis if no response to anbxs
U/S if no response to supportive care or abx (mastitis vs abscess)
systemic emptying, anti-inflammatories, abx
Continue breast feeding!!
what should be on your tray for ED delivery
2 large hemostats
scissors
cord clamp
towels
syringe for cord gas
association between hypothermia and mortality
acidosis, respiratory distress, NEC, intraventricular hemorrhage
The smaller you are, the faster you lose heat. BIG problem less than 30 weeks
A ruptured cyst can causes abnormal vital signs and an acute abdomen in sudden unilateral pain think
e. A ruptured cyst can causes abnormal vital signs and an acute abdomen.
Cysts that are >8 cm, multiloculated, or solid are concerning for malignancy
chronic hypertension in pregnancy defined as
Defined HTN present before 20th wk of pregnancy or present before pregnancy
ii. Mild HTN: > 140-180/90-100
iii. Severe HTN: >180/100
iv. Major risk factor: development of preeclampsia or eclampsia later in pregnancy
preeclampsia
Preeclampsia is characterized by hypertension, greater than 140/90 mmHg, on two occasions at least 4 hours apart and proteinuria ≥300 mg in 24 hours in patients
at 20 weeks’ gestation until 4 to 6 weeks after delivery.
in the absence of proteinuria in a otherwise preeclampsic woman what can indicate this dx
In the absence of proteinuria, thrombocytopenia with platelet count less than 100,000,
elevation of liver enzymes twice normal,
new renal insufficiency with a creatinine of 1.1 or a doubling of serum creatinine,
pulmonary edema,
or new-onset mental status disturbances or visual disturbances can be used to make the diagnosis of preeclampsia.
what are some sxs of Preeclampsia
- Facial edema, pulmonary edema, Ascites
a. Unresponsive to rest in supine position - BP > 160/110
- Progressive renal insufficiency (Cr >1.1)
- Cerebral or visual disturbances –> HA, scotomata
- Epigastric or RUQ pain
- Evidence of hepatic dysfunction–>transaminases doubled
- Thrombocytopenia
- Rapid weight gain (2lbs/wk)
- Hyperreflexia or clonus at ankle –>worrisome!
Risks for preeclampsia
- Placental abruption
- ARF
- Cerebral hemorrhage
- Hepatic failure or rupture
- Pulmonary edema
- DIC
- Progression to eclampsia (one of four leading causes of maternal death)
labs with preeclampsia
- CBC
- Platelets –> thrombocytopenia
- PT, PTT–> coagulopathy
- LFTS –> hepatocellular dysfunction
- Serum Cr/ CrCl –>decreased renal function
- 24hr urine –>protein
in a CBC if you see increased HCT on a pt with preeclampsia what are you worried about
increased Hct signals indicate worsening vasoconstriction & intravascular volume
what is eclampsia
i. Presence of convulsions/ grand mal seizures in a woman w/ preeclampsia NOT explained by a neuro d/o
when is eclampsia most commonly seen
ii. Most cases occur w/I 24hrs of delivery
what are the complications with eclampsia
- Musculoskeletal injury
- Hypoxia
- Aspiration
tx of eclampsia
- Urgent OBGYN consult!
- Usually self-limited
a. Not dangerous unless >20min
b. Avoid delivery of baby - Tongue blade, gentle restraints, airway, IV access, foley catheter, EKG
- Tx directed to initiation of Mg sulfate to prevent further studies
