OBGYN Flashcards
(148 cards)
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
■ A vaginal mass is seen with uterine inversion.
■ Vaginal bleeding despite good uterine tone and size is likely due to retaine products.
Infertility
Ectopic pr
Chronic pelvic pain
Fitz-Hugh-Curtis synd (perihepatitis)
Hospital alternative: Clindamycin + gentamicin
OP: Ceftriaxone (250 mg) + doxycycline (100 mg po bid x 14 days) +/- metronidazole
nonbarrier contraception
3 forms:
❏ Ulipristal acetate: progesterone receptor modulator,
❏ Levonorgestrel: Progestogen- progesterone receptor agonist
❏ OCP: Combination of progestin and estrogen, “Yuzpe method”
IUD: Copper vs Mirena (not used as emergency contraception)
- Ovarian mass ≥ 5 cm
- Reproductive age
- Pregnancy
- Ovulation induction
- Prior torsion
- Prior pelvis surgery (tubal ligation)
- doxy + cefoxitin, cefotetan or
- amp-sulbactam or
- clindamycin + gentamicin
Leg elevation,
-Presence of multiple gestation
-Is Fluid clear / presence of meconium staining
-Vaginal bleeding
-Any additional risk factors in pregnancy (ie AMPLE- including prenatal care, HIV/Hepatitis)
-GA<24w
-BW<500g
-T13/18
Active management refers to standardized steps taken in every delivery to decrease the risk of post partum hemorrhage and should include:
oxytocin 10IU IM (or 20-40IU/1L NS @150ml/h or 5-10IU IV bolus) after delivery of the anterior shoulder
fundal massage.
Other advanced therapies may be considered in those at high risk or with demonstrated bleeding
- >500ml/24h
- 10% drop in the hematocrit
- a need for transfusion of packed red blood cells
- volume loss that causes symptoms of hypovolemia.
-Active mgmt 3rd stage
-Two-handed uterine massage
-Pharm: oxytocin, ergots, PGs
-Packing, embolization, hysterectomy
-Repair lacerations
-Uterine digital exploration
-Manual placental extraction
-Curettage
-Hysterectomy
-Manual/curettage
-Embolization, hyst
-Blood products, reverse coagulopathy
-""Discriminatory zone"": 1,500-2,000
-Yolk sac: 2,500
-Upper ""discriminatory zone"": 3,000
-Fetal pole: 5,000
-Fetal heart motion: 17,000"
RESP: Diaphragmatic elevation -> decreased FRC. Tube thoracostomy in T3->2 spaces higher
susceptible to penetrating trauma >T1
-Flow-cytometry
-Placental abruption
-Fetal injury
-Preterm labour
-Kleihaur-Betke
-U/S
positive test?
-Any fetal distress is considered positive (100% NPV)
-Late decelerations, variable decels, complex variable decels
- Lack of variability (these are signs of fetal distress)
-If > 3 contractions in one hour (watch for 24 hrs more)
-If > 12-13 contractions per hour: high risk for abruption
Variable | no relation | intermittent cord compression | if persistent: delivery
Late | after contraction | uteroplacental insufficiency | deliver ASAP
bleeding. Please use a response ONLY ONCE
-TxA: Thrombophilia
-OCP: Thrombophilia, migraines, smoker, HTN, CA, cirrhosis, valvulare heart disease
* Note: other advanced options include: IUD, Danazol, Desmopressin, and Clomiphene, but are typically NOT appropriate to ED management.
-Ectopic fetal pole
-Free uid in cul-de sac/pelvis
-Adnexal mass* without IUP
-Empty uterus with Bhcg >3000 on TVUS or >6000 on TAUS
Indeterminate: Lack of the Findings diagnostic of intrauterine pregnancy:
--""Double"" gestational sac
--Intrauterine fetal pole or yolk sac
--Intrauterine fetal heart activity
pregnancy
-FHR present
-Hemodynamic instability
-Decreasing Hb
-Sonographic evidence of rupture
-Infection (choriaminoitis, Bacterial vaginosis, GBS)
-Trauma
-Incompetent Cervix
-Pre-term labor
-Cigarette Smoking
–Obtaining FHR as vital sign
–Pain control
–Right hip wedge or other offloading to IVC
–Chest tube placement 3rd or 4th intercostal space
–Administration of Rhogam
–Abdominal CT
–Fetal monitoring via non stress testing x min 4h
–Admission to ICU with consult to ObGyn
–Large bore IV access
–Blood products / MTP
–Oxytocin
–TXA
–Misoprostol
–Consider Carboprost / Ergot
–Speculum / PV exam
–Disposition to Gyne for OR or to IR for embolization
- What are some short term management strategies to control the bleeding?
–Oral contraceptive
- Higher estrogen more effective, more risk of VTE
- May take continuously with one cycle q 3 mo
- May use in patients with IUD for extra control J
–Tranexamic acid po
- Ex: Cyclokapron 500mg 2-3 tab po TID – QID prn heavy bleeding for 3 – 5 days.
- What is one thing you must do to prevent recurrence of PID in this patient?
- 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?
–Short term – 48-72 hour re-assess to ensure improving
–Long-term – negative test of cure typically not required for chlamydia or gonorrhea, do test for cure in pregnancy
Ascending genital tract infection usually STI
- Endometritis
- Parametritis
- Salpingitis
- Oopheritis
- TOA
- Peritonitis
- Chlamydia:
–Axithromycin 1g po once (safe in pregnancy)
–Doxycycline 100mg po BID x 7d
- Gonorrhea:
–Ceftriaxone 250mg IM once + Azithro 1g po once
–Cefixime 800mg po once + Azithro 1g po once
–Azithromycin 2g po once
–May replace Azithro with Doxy 100mg BID x 7d if macrolide allergy
–Cephalosporins and azithro safe in pregnancy
Must identify 3 structures:
Miscarriage
Gest trophoblastic tumor
Implantation bleeding
postcoital bleeding
Infections:
Condylomata accuminata
Chlamydia
Gonorrhea
PID
Hemorrhoids
–Absence of embryo with heartbeat 7–13 days after a scan that showed a gestational sac without a yolk sac
–Absence of embryo with heartbeat 7–10 days after a scan that showed a gestational sac with a yolk sac
–Absence of embryo ≥6 wk after last menstrual period
Management of Early Pregnancy Loss
- Expectant management
- Medical management with misoprostol
- Surgical management with suction curettage
- Note: Spontaneous abortion is medically common, and its emotional impact is often underestimated. Ensure patient has appropriate emotional support +/- conselling prior to discharge.
Misoprostol 800 mcg pv, may repeat in 48 hrs if no result.
Ibuprofen for pain
RhoGAM within 72 hrs in Rh(-)
US in 7-14 days to document complete expulsion (or serial BHCG)
Counsel re: what is too much bleeding? Soaking 2 maxi pads per hours for 2 consecutive hours – if this occurs return to ED
If misoprstol fails, patient may opt for expectant or surgical management
Hge
Infection
Severe anemia
Patient preference
Multiple ED visits
Hx not compatible with exam
Vague historian
Any inj during pregnancy
Abn/odd partner behavior
Name 8 risk factors for intimate partner violence
–Young age
–Low SES / economic stress
–Low academic achievement or low IQ
–Not married or relationship instability
–Unemployed
–Drug/alcohol use disorder
–Unplanned pregnancy
–Social isolation
–Personal history of depression
–Previous suicide attempt
–Witnessing IPV in parents as a child
Gest troph tumors
HEG
Gest trophoblastic tumor
Gestational trophoblastic disease, What investigation could you order to confirm your diagnosis?
–bHCG confirms diagnosis if greater than 100 000
–Lab tests for work up GTN: Cr, liver enzymes, TSH, +/- testosterone level
hyperemesis gravidarum from typical nausea and vomiting of pregnancy
– Dehydration
– HypoK
– Other safe alternatives if Diclectin ineffective: • Add ginger, Gravol
– If ongoing nausea, consider:
• Metoclopramide 5 to 10mg po or IM q8h
• Prochlorperazine 5 to 10mg po/PR/IM q 6-8h
– Ondansetron has some evidence of cardiac malformation, consider only if benefit outweighs risk
bleeding greater than 20 weeks
– Uterine rupture
– Placenta previa
– Vasa previa
– Preterm labour
– Repeat ultrasound to determine if ongoing placenta previa
• Medications
– RhoGAM 300mcg IM
– Steroids for fetal lung maturity
• Betamethasone 12mg IM q24h x 2 doses
• OR Dexamethasone 6mg IM q12h x 4 doses
• Give at GA 240 – 346 for women at risk for preterm birth within next 7d, in
consult w OBGyn
• Some patients eligible for outpatient management, if
hemodynamically stable, reliable and live close to hospital
– A decision for the obstetrician
rupture of membranes? (PPROM)
– Genital tract infection in pregnancy
• Ex: Bacterial vaginosis, chlamydia
– UTI
– Antipartum bleeding in first trimester
– Polyhydramnios
– Trauma
– Preterm labour
– Cervical insufficency / previous LEEP
– Nitrazine changing from yellow to blue
– Ferning pattern on microscopy
– Immunoassay (ex: Amnisure)
– Transfer to ObGyn for admission
– Avoid pv exam to limit infection risk
– Screen for UTI, STI and GBS, treat if present
• Urine culture, GC chlamydia swab, Group B strep swab
– Steroids for fetal lung maturity
• Betamethasone 12mg IM q24h x 2 dose for GA 240 – 346
– Antepartum antibiotics
• Ampicillin 2g IV q6h AND Erythromycin 250mg IV q6h x48h
THEN Amoxil 250mg po q8h AND Erythro 333mg po q8h x 5d (total 7d)
• OR Erythromycin 250mg po q6h x 10d
– ?tocolysis with nifedipine or indomethacin
• →controversial, discuss with ObGyn if indicated
airway more challenging.
- Aspiration
- Decreased respiratory reserve
- Airway edema
- Belly in the way of laryngoscope blade
- Harder to bag
- LLD position
pregnancy that you must consider in
abdominal trauma.
– Preterm labor
– PPROM
– Uterine rupture
– Lack of variability
– Late decelerations, variable decels, complex variable decels
home after 4 hours of monitoring?
– <3 contractions per hour
– Fibrinogen – low (although could be normal)
– PT – increased
– PTT– increased
– D-dimer - increased
which pregnancy increases risk? What is your leading diagnosis?
– Cerebral venous sinus thrombosis
– Subarrachnoid hemorrage
– Carotid or vertebral artery dissection
– Pituitary apoplexy
– Chronic hypertension
– Pregestational diabetes
– Systemic lupus erythematosus (SLE)
– Antiphospholipid antibody syndrome
– Pre-pregnancy overweight or obesity
– Multifetal pregnancy
– Nulliparity or first pregnancy with new partner
– Fx of pre-eclampsia in first degree relative
– Known fetal growth restriction
– Previous pregnancy w IUGR or stillbirth
– Advanced maternal age > 35 yoa and esp. > 40 yoa
– Use of assisted reproduction technology
– (Note: Smokers at LOWER risk of pre-eclampsia)
– Subarachnoid hemorrhage
– Hypoglycemia
– Cerebral venous thrombosis
– Toxins
– EtOH withdrawl
• Decreased RR < 12
• Urine output < 100ml in 4h
• Bradycardia
– Announce the problem and Ask for help
– LIFT/hyperflex Legs (McRobert’s maneuver)
– ANTERIOR shoulder disimpaction (Suprapubic pressure)
– ROTATION (Woods maneuver / “corkscrew” maneuver)
– MANUAL removal posterior arm
– EPISIOTOMY
– ROLL over onto “all fours”
– Pulse
– Grimace
– Activity
– Respiration
– UTI / pyleonephritis
– Wound infection
– Septic pelvic thrombophlebitis
– Pulmonary embolism
– Mastitis
– Uterine tenderness
– Purulent lochia
endometritis?
– E. coli
– Streptococcus agalactiae
– Staphylococcus aueus
– Group A strep
– Clindamycin 900mg IV q8h + Gentamycin 5mg/kg iv daily
• Outpatient:
– Amoxi-clav 875/125mg po BID x 14 days
– Amoxicillin 500mg and Metronidazole po TID x 14 days
– Clindamycin 600mg po q6h x 7 to 14 days
• Most infections are mild and respond well to Abx
• If ongoing fever, consider surgical site abscess requiring drainage,
retained products or alternate etiology such as septic phlebitis.
– Marital conflict
– Single marital status
– Young age <25 yrs
– Fx postpartum depression
– Intimate partner violence
– Unintended pregnancy
– Breastfeeding difficulty
– Sleep deprivation
– Childcare stress such as inconsolable crying
– Onset occurs before delivery in about 50% of cases
– Self doubt about ability to care for infant
– Lack of interest in infant’s activities
– Use of alcohol / illicit drugs
– Nonadherence to postnatal care
– Frequent non-routine visits with family physician
Reportable STDs in Canada
- Chlamydia
- Gonorrhea
- Syphilis
- Chancroid
- HIV/AIDS
- Hep B
