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Flashcards in OBGYN Emergencies Deck (34):
1

APPROACH TO VAGINAL BLEEDING IN THE ER

What is the first thing we assess?

Assess the hemodynamic state of the patient

2

APPROACH TO VAGINAL BLEEDING IN THE ER
Assess the hemodynamic state of the patient:

If not hemodynamically stable, proceed how? 3

1. begin appropriate measures for fluid resuscitation and stabilization
2. Immediately determine if the patient is pregnant
3. Emergently refer to OB/GYN service for possible OR intervention

3

APPROACH TO VAGINAL BLEEDING IN THE ER
Assess the hemodynamic state of the patient:

If hemodynamically stable?

If hemodynamically stable:
1. Determine if the patient is pregnant
2. Determine the amount and length of time of vaginal bleeding
3. Do a complete pelvic exam (UNLESS- PLacenta previa! Have to do an US if they are pregnant in the third trimester

4

APPROACH TO VAGINAL BLEEDING--HX
4

1. Assess the amount of bleeding:

2. Pattern of periods:

3. Sexual history:


4. If Pain—where?—quality?—radiation?

5

What questions should you ask for with:
1. Assess the amount of bleeding? 2

2. Pattern of periods? 2

3. Sexual history? 2

1. Number of pads/tampons used
2. Any clots—size

3. LMP—regularity of periods
4. Missed/Late periods—possibility of pregnancy

5. Number of partners
6. Use of condoms to assess risk of STI/PID

6

APPROACH TO VAGINAL BLEEDING--PE
5

1. Vital signs
2. Looking for mucosal hemorrhage, petechiae- HELLP, DIC/TTP
3. Signs of PCOS
4. Abdominal exam:
5. Pelvic Exam

7

APPROACH TO VAGINAL BLEEDING--PE
1. Abdominal Exam possible findings? 2

2. Pelvic Exam possible finsings? 3

Abdominal exam:
1. Pain, masses
2. Rebound tenderness

Pelvic exam:
1. Looking for source of bleeding, signs of trauma
2. Cervical motion tenderness
3. Uterine size, contour, masses and tenderness

8

APPROACH TO VAGINAL BLEEDING--TESTS
6

1. Qualitative and sometimes quantitative hCG test:


2. CBC

3. Type and cross if significant bleeding
4. Type and screen if not immediately needing blood transfusion

5. Coag tests if coagulopathy suspected

6. STIs tests if suspected infection (PID)

9

Qualitative and sometimes quantitative hCG test:
1. Symptomatic patients with a hCG of what are 4 x more likely to have an ectopic pregnancy?
2. TVUS can determine an intrauterine pregnancy at hCG levels of _______ mIU/mL or above?

1. less than 1000 mIU/mL
2. 1500

10

APPROACH TO VAGINAL BLEEDING CONT.

Differential Diagnosis—Based on patient age:
Prepubertal patient?

1. Vulvovaginitis
2. Foreign body
3. Trauma
4. Urethral prolapse
5. Sexual abuse
6. Hormone secreting tumor

11

What would be evidence for the following in a prepubertal pt with vaginal bleeding:
1. Vulvovaginitis?
2. Foreign body?
3. Trauma?
4. Urethral prolapse?
5. Sexual abuse?

1. —bloody vaginal discharge/pruritis
2. —bloody vaginal discharge/foul smelling
3. —varied presentation—history is important
4. —can visualize on exam
5. —blood from sexual trauma, may have bruising, c/o pain--MUST have careful approach and may involve collecting evidence

12

APPROACH TO VAGINAL BLEEDING
Premenopausal nonpregnant pt?
7

1. Ruptured ovarian cyst**
2. Ovarian torsion**
3. PID—decision to treat as outpatient or inpatient
4. Dysfunctional uterine bleeding:
5. Uterine leiomyoma
6. Uterine polyp
7. Genital trauma secondary to sexual abuse

13

Dysfunctional uterine bleeding in a premenopausal nonpregnant pt may be caused by?

1. May be caused by endometrial cancer in a patient as young as 35YO

Treatment for DUB

14

APPROACH TO VAGINAL BLEEDING

Peri-/Post-Menopausal patient:
5

1. Primary concern is endometrial cancer

2. Anti-coagulant medication
3. Hormonal therapy
4. Other medications
5. Coagulopathy

15

Peri-/Post-Menopausal patient:
Primary concern is endometrial cancer: How should we proceed with management? 2

1. DO NOT start on OCPs!
2. Refer for appropriate evaluation and diagnosis

16

APPROACH TO THE PREGNANT PATIENT: Vaginal Bleeding
1. First trimester? 3
2. Second and third trimester? 3
3. Early postpartum?

1. First trimester:
-Bleeding from implantation
-Threatened, impending or incomplete miscarriage
-Ectopic pregnancy: abdominal pain, amenorrhea, vaginal bleeding**

2. Second and third trimesters:
-Placenta previa
-Placental abruption
-Genital trauma secondary to abuse (?)

3. Early post-partum—post-partum hemorrhage

17

GENERAL TREATMENT CONSIDERATIONS

Remember the ABC's!
You have 2 (or more) patients: stabilize mom first and then the baby(s)

1. REMEMBER general measures? 3

2. With vaginal bleed: Early signs? 2 Late signs? 3

3. Women who are Rh neg need _______ after any bleeding episode!!!

Remember the ABC's!
You have 2 (or more) patients: stabilize mom first and then the baby(s)

1. REMEMBER general measures:
-O2
-lateral displacement of the -uterus
-IV fluids

2. With vaginal bleed:
Early signs of hemodynamic compromise are
-tachycardia
-tachypnea
Late:
-hypotension,
-weak pulse
-oliguria

3. Rhogam

18

VAGINAL BLEEDING IN EARLY PREGNANCY
Etiologies? 4

Evaluation? 4

1. Etiologies
-Ectopic pregnancy
-Threatened, impending, incomplete miscarriage
-Physiologic (i.e. Implantation of the pregnancy
-Cervical, vaginal or uterine pathology

2. Evaluation
-History: amount of bleeding, passed clots or tissue, pain?
-Physical: hemodynamic status
-Ultrasound
-Labs: hCG, CBC, UA, cultures as indicated

19

MISCARRIAGE
1. Presentation of a threatened miscarriage? 5

2. Inevitable miscarriage? 5

1. Threatened Miscarriage
-No cramping
-Closed cervix
-US: + fetal cardiac activity
-90-96% will go on to term
-Expectant management

2. Inevitable Miscarriage
-+ cramping
-Increased bleeding
-US: – cardiac activity or fetal demise
-Open cervical os
-Management expectant or surgical

20

INCOMPLETE MISCARRIAGE
1. Definition?
2. Symptoms? 2
3. On exam? 2
4. US?
5. Management?

1. Definition: the fetus is passed, but placental tissue is retained

2. SYMPTOMS:
-Moderate to severe cramping
-Bleeding—bleeding can be severe enough to cause hypovolemic shock

3. On exam:
-The cervical os is open & gestational tissue may be present
-Uterus feels “boggy” on palpation

4. US shows tissue in uterus

5. Surgery is usually necessary to remove retained tissue

21

ECTOPIC PREGNANCY
1. Incidence?
2. Hx: look for risk factors?
3. Presentation? 4

1. Incidence: 1 in every 100 pregnancies in the United States

2. Hx: look for risk factors:
-Previous ectopic pregnancy
-Tubal surgery
-History of PID
-Women undergoing treatment for infertility

3. Presentation:
-Abdominal pain(most common symptom)
-Vaginal bleeding
-Amenorrhea
-Hypovolemic shock

22

Differential Diagnosis

7

1. Urinary tract infection or kidney stones
2. Appendicitis, diverticulitis
3. Ovarian torsion, neoplasm, ruptured cyst
4. Endometriosis, PID, endometritis
5. Implantation of the pregnancy
6. Threatened, inevitable or incomplete miscarriage
7. Cervical, vaginal or uterine pathology

23

ECTOPIC PREGNANCY
1. PE? 4

2. Transvaginal US? 3

1. Physical Exam:
-Check hemodynamic status
-May reveal abdominal or pelvic tenderness
-May find adnexal mass
-May be unremarkable

2. Transvaginal US:
-Most helpful to determine if intrauterine pregnancy (IUP) is present
-An IUP should be seen if serum hCG > 2000mlU/ml
-If it’s an ectopic pregnancy it’s usually seen in a fallopian tube (97%)
-If the TVS is inconclusive and the patient is stable serial quantitative hCG's are followed

24

MORE ON ECTOPIC PREGNANCY!

1. If the patient presents with what she is considered to have a ruptured ectopic pregnancy & needs immediate surgical intervention? 2

2. If the patient is stable then treatment with what can be considered with an OB consult?

1.
-(has a +hCG)
-is hemodynamically unstable

2. methotrexate

25

LOWER GENITAL TRACT CAUSES
1. PE?
2. Test? 9
3. Etiologies? 6

4. What do we have to test if infection is a concern?

1. Usually obvious on exam

2. Test: (when indicated)
-chlamydia,
-gonorrhea,
-HPV
-vaginosis,
-yeast,
-trich
-syphillis,
-HIV,
-herpes

3. Etiologies
-Vaginal lacerations,
-cervicitis
-Growths,
-infections
-Genital warts,
-cervical polyps

4. Remember if infection is a concern test and treat partner(s)‏

26

RUPTURED OVARIAN CYST
1. Common occurance in women in what ahe of women?

2. Usually present with what kind of pain?

3. Symptom intensity varies with type of fluid from cyst? 3

1. Common occurrence in women in their reproductive years

2. Usually present with mild to moderate unilateral lower abdominal pain

3. Symptom intensity varies with type of fluid from cyst:
-Serous fluid—not very irritating: symptoms mild
-Blood—more irritating: can be at risk for hemorrhage
-Sebaceous material [from dermoid cyst]—quite irritating: can cause chemical peritonitis

27

RUPTURED OVARIAN CYST—WORK-UP
5

TX?

1. Thorough Hx and PE

2. Urine or serum hCG to r/o ectopic

3. CBC—look for decreased Hgb or platelets?

4. UA

5. If indicated cultures to r/o STIs

MANAGEMENT
BC

28

ANTEPARTUM COMPLICATIONS
2

1. Pre-term labor
2. Placenta previa/abruption

29

Pre-term labor
1. What is it?
2. If it occurs before the 28th week then it is referred to as:

3. The goal is to STOP pre-term labor with

4. If pre-term labor starts what are given to the mother to aide in maturing the lungs of the fetus?

1. Labor that occurs before 28th week of gestation

2. extreme preterm labor
3. tocolytics to attempt to allow the fetus more time to develop

4. ante-natal corticosteroids

30

ANTENATAL CORTICOSTEROIDS
1. Mechanism?
2. Two regimens?

1. Mechanism: enhances maturational lung architecture and induces lung enzymes which results in biochemical maturation

2. Two regimens: -betamethasone 12mg IM 2 doses 24 hrs apart
-dexamethasone 6mg IM 4 doses 12 hrs apart

31

PLACENTA PREVIA
1. Classic symptoms? 1
2. Do not do a what?
3. Do an ? to dx placenta previa & R/O placental abruption or other etiologies of bleeding?
4. About 33% have initial bleeding episode at what gestation & are at > risk of what?

1. “Classic”: painless vaginal bleeding, although some women may have contractions

2. DO NOT do a pelvic exam
As long as the patient is hemodynamically stable

3. TVUS



4. less than 20 wks, preterm birth

32

MANAGEMENT OF PP
1. Confirm dx?
2. If acutely bleeding determine hemodynamic status: How should we do this? 4
3. Maintain maternal hgb of?
4. When should we give plts?
5. Monitor what?

1. Confirm diagnosis

2. If acutely bleeding determine hemodynamic status:
-2 large bore IV's
-Foley for following urine output(goal 30cc/hr)
-CBC, coagulation studies (can develop DIC)
-Type and cross match 4 units pRBC's

3. Maintain maternal hgb >10,
4. if plt less than 100,000

33

MANAGEMENT OF PP STABLE PT
1. If patient has minimal bleeding or bleeding stops or hemodynamically stable how should we proceed?

2. If baby what wks gestation consult with OB about giving antenatal steroids?

3. If contracting consult about what?

4. If not in facility where what is available consider transfer? 2

1. monitor mom & baby


2. less than 34

3. tocolysis probably mag sulfate

4.
-immediate c-section
-neonatal capabilities

34

PLACENTAL ABRUPTION
1. Risk factors? 6
2. Presentation? 3
3. Differential? 5
4. Tx? 4

1. Risk factors:
-HTN,
-trauma,
-polyhydramnios,
-multiple gestation,
-smoking,
-cocaine use

2. Presentation:
-uterine bleeding(concealed 20%),
-abdominal pain or contractions,
-fetal distress

3. Differential:
-PP,
-uterine rupture,
-labor,
-cervical or vaginal trauma

4. Tx:
-Stabilize mother,
-monitor fetus,
-tocolysis with mag sulfate,
-consult with OB & neonatal services