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369 Cards in this Set
- Front
- Back
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What shorthand notation are used to indicate a woman's past obstetrical history
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G - gravidity - total number of pregnancies, past and current, normal and abnormal, regardless of outcome
P - parity - total number of births regardless of outcome further subdivided into T - term P - preterm <38wks A - abortus <20wks L - number of children currently alive Many use the simpler GPA notation where P includes all pregnancies carried beyond 20 wks |
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What percentage of women presenting to the ED with abdo pain or vaginal bleeding who claim there is no chance that they are pregnant, have positive pregnancy tests?
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11.5%
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What percentage of adolescents, found to be pregnant on an ED visit, deny being sexually active?
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10%
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WHat are common early signs and symptoms of pregnancy?
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Cessation of menses, anorexia, nausea, easy fatiguability, urinary frequency, breast tenderness and swelling
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At how many weeks gestation do pregnant women normally detect fetal movements?
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16-20 weeks
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How can you calculate a pregnant women's estimated date of delivery?
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Naegel's rule - LMP +7days minus 3 months or use a pregnancy wheel
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What is the supine hypotension syndrome?
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May occur in the second half of pregnancy when the patient is in the supine position: the gravid uterus can compress the abdominal aorta and inferior vena cava leading to maternal hypotension. It is relieved by turning the patient on her left side or placing a wedge under the right hip
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What is considered pathologic hypertension in pregnancy?
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Pathologic hypertension of pregnancy is defined as a sustained rise of 30mmHg systolic or 15mmHg diastolic over baseline values on at least 2 occasions, 6 hours or more apart.
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At what gestational age can the fetal heart be detected with a fetal doppler?
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8-10 weeks
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What sounds can be heard when auscultating the pregnancy women's abdomen with the fetal doppler?
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fetal heart beat
fetal movements maternal pulse umbilical cord souffle (blood rushing through umbilical arteries at the same rate as the fetal heart beat) uterine souffle (soft blowing sound at the same rate as maternal pulse, function of blood flow through dilated uterine vessels) |
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HOw big is the gravid uterus at different stages of pregnancy?
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6-8 weeks - size of an orange
12 weeks - fundus at the level of the pubic symphysis 16-20 weeks - fundus at the umbilicus 36-38 weeks - fundus at the xiphoid >38 weeks - descends a little as the head engages in the pelvis |
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Where does human chorionic gonadotropin come from and what is it for?
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It is secreted by the embryo; its principle function is to maintain the corpus luteum until the placenta is sufficiently developed to take over production of progesterone
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What level of hCG can be detected by most point of care urine pregnancy test? When in pregnancy dose this become detectable?
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25-50iU/L, usually detectable by the third day after missed menses
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WHy is the test called "beta" HCG?
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The test measures the beta subunit, which is specific to hCG. THe alpha subunit is the same as the alpha subunit of FSH, LH and thyrotropin. A fragment of the beta subunit is what is filtered into the urine by the kidney.
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What are causes of false positive and false negative urine beta HCG tests?
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False positive
-first trimester abortion -exogenous administration of hcg to induce ovulation -post menopausal women have baseline levels of hcg but you would have to have a very sensitive assay to pick this up (cut off for normal in this population is 14iU/L) -certain cancers can secrete it (testicular, bladder, uterine, lung, liver, pancreas, stomach) False negative -early pregnancy (hcg below the threshold for detection) this could happen if the wrong LMP date is used or if ovulation was delayed -dilute urine |
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What is the expected rate of rise of bHCG in a normal pregnancy? What should you suspect if the rate of rise is either faster or slower than expected?
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-The rate of rise is quite variable even among normal pregnancies but the average doubling time is around 2 days (1.8 days-3 days), peaking at around 8 weeks
-a slower than expected rise suggests a non-viable pregnancy, particularly an ectopic pregnancy or spontaneous abortion -a faster than expected rise suggests multiple gestation, molar pregnancy or chromosomal abnormalities |
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For how long does the beta HCG remain elevated after abortion? What should you suspect if it remains elevated for a longer period of time?
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-Levels of hCG may take as long as 60 days to return to zero after an abortion
-persistent elevation of HCG suggests incomplete abortion, twin pregnancy with only one fetus removed or ectopic pregnancy |
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What dose of in utero radiation has bee shown to double the risk of childhood cancer in the offspring of female radiologists?
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1000mrad (doubles the risk 0.07% to 0.16%)
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What is considered an acceptable upper limit for in utero radiation exposure from medically necessary tests?
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5000mrad
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How much fetal radiation exposure (in mrads) comes from the following tests: CXR, Chest CT, Abdo CT with and without contrast, CT head, VQ scan?
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Plain CXR with abdo shield (<1)
Chest CT with abdo shield (<10) Abdo CT with and without contrast 2000 and 1000 head CT <10 V/Q scan <50 |
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What usually happens to the migraines of a patient who becomes pregnant?
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60-70% improve significantly
4-8% get worse |
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How should migraines be managed in pregnant women?
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-avoid potential triggers and use nonpharmacologic therapies (relaxation and biofeedback)
-acetaminophen ASA and NSAIDS can be used for short periods but should be avoided in the 3rd trimester -for severe attacks chlorpromazine, dimenhydrinate and diphenhydramine can be used; metoclopramide would be used only in the third trimester -if prophylaxis is needed, beta blockers are preferred and should be discontinued at least 2 weeks prior to delivery narcotics and dexamethasone or prednisone can be used for refractory cases (neurology 1999; 53: S26-28 |
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What symptoms and signs should trigger a cardiac evaluation in a pregnant woman?
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progressive orthopnea, dyspnea severe enough to limit activity, paroxysmal nocturnal dyspnea, syncope during or immediately after exertion, hemoptysis and chest pain, cyanosis, clubbing, pulmonary rales, pulmonary hypertension
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How much more common are thromboembolic events in pregnant compared to non-pregnant women?
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Five times more common (highest risk before 15 weeks)
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How would you investigate a pregnant women for possible pulmonary embolism?
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-D-dimer is less specific and should not be used for high probability cases
-leg dopplers, if available, are a good first test since there is no radiation involved and if a DVT is found then the treatment is the same and PE can be presumed -classically a perfusion scna has been considered the best test for ruling out PE in pregnancy, with a ventilation scan added only if perfusion defects are noted. however given the poor sensitivity of this test and the fact that newer generation CT scans expose the fetus to very small amounts of radiation, attitudes may be shifting toward considering CT scan to be the modality of choice |
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What travel restrictions exist for patients with a normal pregnancy?
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-airline travel beyond 35 -37 weeks should be only short trips and require a doctor's note
-patients should avoid prolonged immobilization - counsel them to walk every 2 hours |
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Who is at risk for adnexal torsion?
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-Can occur at any age but the majority occur in women of reproductive age
-50-80% of cases are associated with an ovarian tumour, usually benign neoplasm or a cyst -pregnant women are at risk because of corpus luteum cysts, and in particular women who have undergone ovarian hyper stimulation because of the expanded ovarian volume -patients with history of pelvic surgery (especially tubal ligation) are at risk because of adhesions |
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Describe the presentation of adnexal torsion?
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-classically present with sudden onset, severe, unilateral lower abdominal pain that worsens intermittently over man yours along with nausea and vomiting
-some patients complain only of mild pain with a more prolonged time course and about 25% experience bilateral pain -there may be a history of prior episodes due to spontaneously resolving torsion -onset is often during exercise or after a sudden movement -fever may occur as a late finding when the ovary becomes necrotic -on exam a unilateral tender adnexal mass is often felt but the absence of this finding does not exclude the diagnosis; even tenderness may be absent in 30 % of patients |
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How is the diagnosis of adnexal torsion confirmed?
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Most importantly the first step is to rule out ectopic pregnancy - 20% of patients with adnexal torsion are pregnant
-US may reveal enlargement of the ovary, or a mass and an abnormal position relative to the uterus - and free fluid -doppler US findings are inconstant - surgically proven cases may have documented blood flow because the ovary has a dual blood supply from both ovarian and uterine arteries; also the torsion may be intermittent. Overall sensitivity is 50% -CT scan is the best initial study if the presentation suggests renal colic or appendicitis. CT may show fallopian tube thickening, smooth wall thickening of the associated adnexal mass, ascites, and uterine deviation to the twisted side. -MRI is not usually ordered but may show findings similar to those on CT -diagnostic laparoscopy is the gold standard in patients with high clinical suspicion but negative imaging results. |
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What is the treatment for adnexal torsion?
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immediate surgery. Best chance of salvage if taken to the OR within 8 hours of onset of symptoms
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What are 2 useful categories of STDs?
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-genital ulcers (+/- adenopathy)
-non ulcerative |
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Which ulcerative lesions are not painful?
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syphillis
lymphogranuloma venereum |
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Which ulcerative lesions are painful?
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herpes
chancroid |
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Which ulcerative lesions have unilateral lymphadenopathy?
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chancroid
lymphogranuloma venereum |
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Which herpes simplex virus most commonly causes genital herpes?
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HSV-2
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Why does HSV play a role in HIV?
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herpetic lesions increase the risk of acquisition and transmission of HIV
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What are potential complications of HSV?
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-sacral radiculopathy
-urinary retention -perineal sensory changes -aseptic meningitis -transverse myelitis |
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What is the recommended diagnostic test for HSV infection?
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viral culture
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What is the value of antivirals in HSV?
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-they decrease the duration of symptoms of primary infection
-may abort recurrences -decrease viral shedding |
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What is the treatment for a Bartholins cyst?
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I and D with Word catheter placement
sitz baths |
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What is the treatment for a Bartholins abscess?
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I and D
Word catheter placement culture (for STD) antibiotics if cellulitis |
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What organism causes syphillis?
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treponema pallidum
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Describe primary syphilis?
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Painless papule which ulcerates and becomes a chancre (a single lesion with a sharply demarcated border and a clean base. It resolves spontaneously
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Describe secondary syphilis?
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Most commonly results in a total body rash - macular spreading from the trunk outwards. It may affect the palms and soles. There are mucous patches present. There may be condyloma lata in the genital region, and there are constitutional symptoms present
It resolves spontaneously |
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How can latent syphilis be identified?
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Laboratory testing
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Describe tertiary syphilis?
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Latent period of 3-4 years
Predominantly involves the cardiovascular and nervous systems. May present with thoracic aortic aneurysm, meningitis, peripheral neuropathy or gummatous lesions of the mucous membranes. |
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What is the only means of rapidly identifying syphilis?
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Darkfield microscopy of scrapings from primary and secondary lesions
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What are the 2 types of serologic tests for syphilis?
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non-treponemal -> VDRL and RPR
treponemal -> FTA-ABS |
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When and how are serologic tests for syphilis used?
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In secondary or greater stages (it may be negative in primary)
Begin with non-treponemal test as a screening tool (this test is also used to follow response to treatment Treponemal tests are used for confirmation |
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What is the treatment of syphilis?
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-primary and secondary - 1 x 2.4million U penicillin G benzathine IM
-tertiary and latent: same as above q1week x 3 This is a reportable disease |
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What is lymphogranuloma venereum?
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A chronic STD caused by chlamydia trachomatis
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Who gets lymphogranuloma venereum?
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-people from tropical countries
-local outbreaks ie. men who have sex with men |
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Describe the evolution of lymphogranuloma venererum?
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small painless genital lesions -> lesion diseappears, involvement of lymphatic channels -> breakdown into multiple draining sinus' or hard inguinal mass
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What is the treatment of lymphogranuloma venereum?
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doxycycline 100mgPO BID x 21 days
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What causes chancroid?
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Haemophilus ducreyi (gram negative bacteria)
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What characterizes chancroid?
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Multiple painful ulcerative lesions and inguinal bubo (large painful, fluctuant lymphadenopathy)
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What is often confused with chancroid?
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Herpes - often treat and test for HSV, then when there is no improvement and the test is negative people consider chancroid
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What are criteria for the presumptive diagnosis of chacroid?
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-one or more painful genital ulcers
-no evidence of treponema palladium on dark field microscopy or serologic testing -clinical appearance of chancroid -negative HSV testing |
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What is important about testing for chacroid?
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It is very difficult and a special medium is needed
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What is the treatment for chancroid?
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1x azithromycin 1gPO
or 1x 250mg ceftriaxone IM or Cipro 500mg PO BID x 3d or erythromycin 500mg PO TID x 7d |
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Should the bubo's of chacroid be drained?
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No, typically they resolve with antibiotics
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What causes granuloma inguinale?
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Klebsiella granulomatis (a gram negative rod)
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Describe the evolution of granuloma inguinale.
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Chronic progressive painless ulcerative lesions irregular, clean based granulomatous ulcers that are very vascular (beefy red appearance) which eventually mutilate the genitalia. They may cause elephantiasis
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What is the treatment for granuloma inguinale?
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doxycycline 100mgPO BID x 3 weeks or until the lesions heal. The patient may relapse in 6-18 months.
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Which types of HPV cause visible warts?
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HPV types 6 and 11
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What are patient administered treatments for condyloma accuminata?
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podofilox
imiquimod |
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What are provider administered treatments for HPV?
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-podophyllin
trichloro/dichloroacetic acid -cryotherapy -surgical excision |
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What causes chlamydia?
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Chlamydia trachomatis, an obligate intracellular anaerobe
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How should you test for chlamydia?
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Nucleic acid amplification get (endocervical for females and urine for men)
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What is the treatment for chlamydia?
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1g azithromycin Po x 1 or 100mg PO BID doxycyline x 7 days
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How long should patients abstain from intercourse after treatment for chlamydia?
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7 days post treatment completion
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What characterizes non gonococcal urethritis?
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Urethral discharge
Urethral pruritus Dysuria |
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What organisms may cause non-gonococcal urethritis?
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c-trachomatis
ureaplasma mycoplasma |
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What are the manifestations of disseminated gonococcal infection?
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arthritis-dermatitis
-fever and chills -arthritis-arthralgia -tenosynovitis -rash (pustular acral skin lesions) |
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What are problems with gonorrhea culture in the ED?
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They should be plated immediately or stored at 35-36 decrees carbon dioxide enriched atmosphere
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What do we use instead of cultures for gonorrhoea?
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nucleic acid amplification if symptomatic
female - endocervical male - urethral |
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Which sites of gonorrhoea require culture?
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-oropharynx
-synovial fluid -csf -anorectal -anything used for legal proceedings |
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What is the treatment for gonorrhoea?
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cefixime 400mg PO x 1
or ceftriaxone 125mg IM (2010 guidelines 250mg IM) |
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What organism causes trichomoniasis?
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trichomonas vaginalis
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What are presenting signs and symptoms of trichomoniasis?
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dysuria
malodorous yellow-green discharge vulvar irritation/itching |
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How can trichomoniasis be diagnosed?
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wet mount (60-70% sensitive)
culture (not timely) |
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What is the treatment for trichomoniasis
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Metronidazole 2g Po x 1
or tinidazole 2g PO x 1 or topical (less efficacious) or metronidazole 500mg PO BID x 7d |
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What is the treatment for trichomoniasis in pregnant females?
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metronidazole 500mg PO BID x 7d
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How do you diagnose candidiasis?
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wet mount with KOH prep
culture (though candida may be part of the normal flora) |
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What is the treatment for candidiasis?
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fluconazole 150mg PO x 1
(or OTC preps - which may cause dermatitis) |
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What defines a complicated candidal vaginitis?
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>/= to 4 episodes/year
occurs in patients with complicated medical problems (DM, immunosuppression) |
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What is the treatment for complicated candidal vaginitis?
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7-14d topical or 150mg PO fluconazole x 3 (d 1,4 and 7)
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What is the treatment of vulvovaginal candidiasis in Hiv + patients?
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Treatment is the same as in uncomplicated
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What can be used to treat vulvovaginal candidiasis in pregnancy?
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Only topical azoles (fluconazole PO is contraindicated)
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Should you treat sexual partners in candidiasis? trichomoniasis? BV?
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candidiasis - No
trichomoniasis - yes BV - No |
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What are the Amsel criteria for diagnosis of BV?
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At least 3 out of 4
-thin white homogeneous discharge -clue cells on microscopy -pH of vaginal secretions >/=4.5 -fishy odor to discharge before or after the addition of 10% KOH "whiff test" |
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Is culture isolation of gardnerella vaginalis useful in diagnosing BV?
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No, it can be found in 50% of healthy women
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What is the treatment of BV?
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metronidazole 500mg PO BID x 7d
or metronidazole intravaginal or clindamycin intravaginal |
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How should BV be treated in pregnant patients?
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flagyl 500mg PO BID x 7d
or 250mg PO TID x 7d or Clinda 300mg PO BID x 7d (should not treat with topical) |
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What is atrophic vaginitis?
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Vaginal discomfort related to decreased circulating estrogen. Treatment is for/o candida and give topical estrogen cream
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What are the treatments for scabies?
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5% permethrin cream
or ivermectin or 1% lindane |
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When should lindane not be used?
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infants
pregnancy |
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How do you treat pubic lice?
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1% permethrin cream
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What is the microbiology of PID?
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polymicrobial
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Is PID always sexually transmitted?
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No, and the diagnosis does not imply partner infidelity
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Which patients should be empirically treated for PID?
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Sexually active young females with lower abdo pain if any:
CMT adnexal tenderness uterine tenderness |
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What is inpatient treatment for PID?
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cefoxitin 2g IV q 6
and doxycycline 100mg IV BID (continue for 10-14 days) |
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What is outpatient treatment for PID?
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ceftriaxone 250mg IM x 1
doxycycline 100mg PO BID x 10-14d +/- flagyl 500mg PO BID x 14d |
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What is gravidity?
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The number of pregnancies normal and abnormal that a person has had
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What is parity?
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The total number of times a person has given birth
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What is considered a term infant?
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38wks-42 weeks
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What is an embryo?
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conceptus - 8weeks
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What is a fetus?
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>8weeks
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How do you calculated the due date?
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Nagele's rule
add 7 days to the 1st day of the last menstrual period and subtract 3 months |
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What changes in vital signs are seen in pregnancy?
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HR increases by 10-15bpm
blood pressure changes |
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Where is the uterine funds at various stages of pregnancy?
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12 weeks - symphysis pubis
16-20 weeks - umbilicus 36-38 weeks - xiphoid |
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What is the sensitivity level of urine pregnancy?
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25-50mIU/mL
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What sensitivity level is needed to detect pregnancy on the day of missed menses?
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12.5mIU/mL
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When is the fetus most vulnerable to the teratogenic effects of radiation?
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8-15 weeks post conception
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What are potential causes of HA in pregnancy?
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-muscle contraction HA
-brain tumour (pituitary, prolactin secreting, other) -cerebral venous thrombosis -SAH -pseudotumor cerebri |
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What is meralgia paresthetica?
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Painful dysesthesia along the lateral aspect of the thigh (secondary to entrapment of the purely sensory portion of the lateral femoral cutaneous nerve)
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What type of vaccine is contraindicated in pregnancy?
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live attenuated virus vaccine
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What vitamins should be taken in pregnancy?
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maybe iron
folate 1mg q days (start 1 month before conception) |
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What is the recommended weight gain in pregnancy?
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10-12 kg
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What are the major causes of miscarriage?
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uterine malformations
chromosomal abnormalities |
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What is the definition of threatened miscarriage?
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uterine bleeding but cervical os closed
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How do you diagnose a completed miscarriage?
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-D and C with pathological confirmation
-Empty uterus on US after documented IUP -reversion to a negative pregnancy result |
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What is the sonographic discriminatory zone?
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TA - 6500 mIU/mL (EDE 3000 mIU/mL)
TV - 3000 mIU/mL (EDE 1500 mIU/mL) |
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What are sonographic criteria for abnormal pregnancy on TVUS?
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beta HCG >3000mIU/mL and no gestational sac
13mm gestational sac with no yolk sac 5mm crown rump length and no FHR no FHR after 10-12 weeks gestation |
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What is the dose of Anti-D immunoglobulin?
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50ug in 1st trimester
300ug after 1st trimester |
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What % of pregnancies are ectopic?
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2%
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What is the rate of heterotopic pregnancy in the normal population? in assisted reproduction?
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Normal 1:4000
Assisted 4% |
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What are RF for ectopic pregnancy?
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Tubal ligation
PID smoking advanced age prior spontaneous abortion medically induced abortion history of infertility IUD |
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What are criteria for medical treatment of ectopic?
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-tubal mass <4cm diameter
-no fetal cardiac activity -no US evidence of rupture (usually beta HCG <5000mIU/mL |
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What is a teratogen?
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Any chemical, environmental, pharmacologic or mechanical agent that can disrupt development of the conceptus
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What is a Class A teratogenic risk?
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Controlled studies have shown no risk
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What is a Class B teratogenic risk?
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No evidence of risk exists for humans. Animal studies have been done which show risk or are negative but no human studies
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What is a Class C teratogenic risk?
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Use may engender risk for fetus. Human studies have not been done, animal studies are positive or lacking. Benefit may outweigh the risks
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What is a Class D teratogenic risk?
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Positive evidence of risk is based on post-marketing data potential or benefit may outweigh the harm
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What is a teratogen?
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Any chemical, environmental, pharmacologic or mechanical agent that can disrupt development of the conceptus
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What is a Class A teratogenic risk?
|
Controlled studies have shown no risk
|
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What is a Class B teratogenic risk?
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No evidence of risk exists for humans. Animal studies have been done which show risk or are negative but no human studies
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What is a Class C teratogenic risk?
|
Use may engender risk for fetus. Human studies have not been done, animal studies are positive or lacking. Benefit may outweigh the risks
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What is a Class D teratogenic risk?
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Positive evidence of risk is based on post-marketing data potential or benefit may outweigh the harm
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What is Class X teratogenic risk?
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Drug is contraindicated in pregnancy
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When is the fetus most vulnerable to toxins?
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During organogenesis d21-56
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Over what period does the CNS develop?
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10-17weeks
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Can APAP be given to lactating females?
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Yes, a small amount goes to the fetus and is taken care of by sulfhydration
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Can ASA be used in pregnancy?
|
Yes, there is a slight increase in risk of gastroschisis if used in the 1st trimester
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When can NSAIDs be used?
|
2nd trimester
|
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Can NSAIDs be used in lactation?
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Yes, short courses
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Can opiates be used in lactation?
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Yes, they are poorly concentrated in the milk
|
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Which antibiotics are safe in pregnancy?
|
1st to 4th generation penecillins
1s to 4th generation cephalosporins macrolides sulfonamies (in 2nd trimester and during lactation) nitrofurantoin (not in the 3rd trimester because of hemolytic anemia) chloramphenicol is safe except around term and with lactation Vancomycin Clindamycin |
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Which antibiotics should be avoided in pregnancy?
|
Aminoglycosides (nephrotoxic and ototoxic)
Tetracycline (acute fatty liver of pregnancy and chelates calcium) Fluoroquinolones Probably linezolid |
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Which macrolide is preferred in lactating females?
|
Azithromycin ( it does not concentrate in the breast milk)
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Can metronidazole be used in pregnancy?
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Yes, but it is avoided in the 1st trimester because it can be mutagenic
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What anti fungal med is the 1st choice in pregnancy?
|
nystatin
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What is the first line treatment of TB in pregnancy?
|
rifampin and INH (ethambutol is also safe)
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When should acyclovir be used in pregnancy?
|
-disseminated HSV
-viral encephalitis -varicella pneumonia -1st episode of genital herpes during pregnancy |
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Which antivirals are probably harmful?
|
Acyclovir and valacyclovir are probably ok
Famciclovir- associate with CV anomalies, hepatotoxicity and death |
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Which anti-influenza drug should you used in pregnancy?
|
Oseltamivir appears to be safe in pregnancy
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Should warfarin be used in pregnancy? in lactation?
|
No
Yes, except breast fed premies |
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What are possible side effects of heparin in pregnancy?
|
Maternal osteopenia and immune mediated thrombocytopenia
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Can LMWH be used in pregnancy?
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Yes
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|
Can thrombolytics be given to pregnant females?
|
They can be used successfully in females with life-threatening pulmonary embolism or mi
|
|
|
Which anticonvulsant is associated with the most frequent adverse effects on pregnancy and the fetus?
|
valproic acid
|
|
|
Can adenosine be used in pregnancy?
|
Yes, safely
|
|
|
Should amiodarone be used in pregnancy?
|
No, unless refractory cases of supra ventricular and ventricular tachycardias (it can cause congenital goitre, hyper and hypo thyroidism)
|
|
|
Which antiarrhythmatics are considered safe during pregnancy and lactation?
|
Procainamide
Lidocaine (except near term) digoxin disopyramide quinidine |
|
|
Discuss vasopressors in pregnancy?
|
They offer a maternal benefit that far outweighs the possible deleterious effects on the fetus
|
|
|
What are 1st line agents for HTN in pregnancy?
|
Beta blockers
|
|
|
Which anti emetics can be used in pregnancy?
|
Metoclopramide
Promethazine Chlorperazine Perphenazine Ondansetron |
|
|
What does ketamine do to the uterus?
|
It has an oxytocic effect and can result in uterine tetany
|
|
|
Can proposal be used in pregnancy?
|
Yes, but it may cause neonatal CNS and respiratory depression
|
|
|
Can etomidate be used in pregnancy?
|
Yes, but it may reduce serum cortisol in newborns
|
|
|
Which paralyzing agents should be used in pregnancy?
|
Succinylcholine or rocuronium or vecuronium
|
|
|
Can activated charcoal be used in pregnancy?
|
Probably yes, although there are no published studies
|
|
|
Who is at risk for adnexal torsion?
|
It can occur at any age but the majority of cases are in women of reproductive age
50-80% of cases are associated with an ovarian tumour usually a benign neoplasm or a cyst Pregnant women are at risk because of corpus luteum cysts and in particular women who have undergone ovarian hyper stimulation because of expanded ovarian volume Patients with history of pelvic surgery (especially tubal ligation) are at risk because of adhesions |
|
|
Describe the presentation of adnexal torsion
|
Classically presents with sudden onset, severe, unilateral lower abdo pain that worsens intermittently over many hours along with nausea and vomiting
Some patients complain only of mild pain with a more prolonged time course and about 25% experience bilateral pain There may be a history of prior episodes due to spontaneously resolving torsion Onset is often during exercise or after a sudden movement Fever may occur as a late finding On exam, a unilateral, tender adnexal mass is often felt, but the absence of this finding does not exclude the diagnosis; even tenderness may be absent Note that the presentation is often subtle and the diagnosis is missed on the first visit in half of patients |
|
|
How is the diagnosis of adnexal torsion confirmed?
|
Most importantly the first step is to rule out ectopic pregnancy
Ultrasound may reveal enlargement of the ovary or a mass and an abnormal position relative to the uterus and free fluid Doppler US findings are inconsistent - overall sensitivity is still only about 50% CT scan is the best initial study if the presentation suggests renal colic or appendicitis. CT may show fallopian tube thickening, smoot wall thickening of the associated adnexal mass, ascites and uterine deviation. Overall the sensitivity of US is much higher than CT Diagnostic laparoscopy is the gold standard in patients with high clinical suspicion but negative imaging results |
|
|
What is the treatment for adnexal torsion?
|
immediate surgery. Best chance of salvage if taken to the OR within 8 hours of onset of symptoms
|
|
|
Describe the different types of functional ovation cysts?
|
Follicular cysts
most common, develop normally in the first half of the menstrual cycle pathologic if >2.5cm thin walled, filled with clear fluid may rupture but rarely cause hemorrhage usually resolve within 4-8 weeks, if not, should be followed up by gyne to exclude neoplasm Corpus luteum cyst after ovulation, the follicular remnants form a corpus luteum which produces progesterone, in the absence of pregnancy it's lifespan is 14days, failure of dissolution may result in a cyst which is usually blood filled. Can cause dull unilateral pain and my be complicated by rupture which causes acute pain and possibly massive blood loss. Unruptured can be treated conservatively; severe pain or bleeding may mandate operative treatment Theca lutein cysts least common cause by hypertrophy of the theca intern layer of the corpus lutuem in response to excessive bHCG. Usually bilateral and result in massive ovarian enlargement. most resolve spontaneously |
|
|
When assessing an ovarian cyst what ultrasound findings suggest malignancy?
|
internal septation, solid elements, internal echoes, daughter cysts, thickened wall and large amounts of ascitic or free fluid
|
|
|
What diagnoses should be suspected in patients who present with vaginal bleeding before the age of menarche or after menopause?
|
-before menarche: trauma (sexual abuse), or structural lesion
-12 months after menopause, suspect endometrial malignancy |
|
|
What is considered an abnormal menstrual cycle?
|
cycle <21 days or >35 days
flow <2 days or >7days |
|
|
How often do patients with heavy menstrual bleeding turn out to have an underlying coagulation disorder and when should this be suspected?
|
~10%
mostly von Willebrands Family history of bleeding disorder, prolonged history of heavy menses, excessive bleeding with surgery or dental procedures, easy bruising |
|
|
List risk factors for endometrial CA?
|
-diabetes
-anovulatory cycles -obesity -nulliparity -age older than 35 years |
|
|
Given the differential diagnosis of anovulatory bleeding in non pregnant patients?
|
-medication/iatrogenic
OCP IUD anticoagulants steroids antipsychotics thyroid hormone replacement -Systemic disease PCOS thyroid disease Cushings disease hypothalamic suppresion (weight loss, exercise) coagulopathies liver or renal disease genital tract pathology fibroids cervicitis endometritis adenomyosis malignancy trauma FB |
|
|
What physical exam signs suggests PCOS?
|
obesity
acne hirsutism acanthosis nigricans (hyperpigmentation in skin folds, neck, groin or axilla) |
|
|
How often does pelvic ultrasound imaging reveal the cause of abnormal uterine bleeding in non-pregnant patients?
|
60%
(mostly fibroids) |
|
|
What is your approach to treatment in patients with abnormal uterine bleeding with no specific aetiology?
|
Mild DUB: iron supplementation and NSAIDs
Moderate DUB: combination oral contraceptive pills beginning with 2-4 pills of 35-50micrograms of estrogen per day in divided doses and tapering down Severe DUB: stabilization and transfusoin as needed. Premarin 25mg IV q 4-6 hours until bleeding stops. D&C prn Transexamic acid can be used (not in patients with thrombosis) Note that high dose estrogen is contraindicated in patients with prior history of thrombosis or estrogen responsive cancer -side effects are mainly vomiting and nausea |
|
|
What are options for post-coital contraception?
|
Yuzpe: can use several different combination pills, most commonly Ovral 2 tables followed by 2 tabs 12 hours later (0.5mg norgestrel and 50 mg ethinyl esrtradiol per tablet)
Paln B - levonorgestrel in a dose of 0.75mg given twice, 12 hours apart of in a single 1.5mg dose (plan B is more effective and better tolerated) Should be administered ASAP - up to 12 0hours. Usually contraindications to contraceptives do not apply because of the short duration of therapy. Also, it does not pose a risk to an established pregnancy. Should use contraception for the rest of the cycle. |
|
|
What are most cases of ovarian torsion associated with?
|
Ovarian tumor, cyst or PCOS
|
|
|
Why is complete arterial obstruction of the adnexa rare?
|
Because of dual blood supply (ovarian and uterine arteries)
|
|
|
What is the most common finding of adnexal torsion on US?
|
Ovary enlargement
|
|
|
What is clinical suspicion for torsion is high but imaging negative?
|
Could still be torsion
|
|
|
What is the most common gyne mass?
|
Ovarian cyst
|
|
|
When is a follicular cyst pathologic?
|
If >2.5cm
|
|
|
Why are patients who deliver in the ED at higher risk for perinatal morbidity and mortality than those who present to the case room?
|
ED patients often have unexpected complications: antepartum hemorrhage, PROM, eclampsia, premature labor, abruptio placentae, precipitous delivery, malpresentation and umbilical cord emergencies
ED patients have little or no prenatal care: immigrants without access, patients with drug or alcohol problems, victims of intimate partner violence, women in denial of pregnancy |
|
|
How do you distinguish "true" from "false" labour?
|
Braxton Hicks contractions (false labour) are irregular, generally painless (or mildly uncomfortable) and do not increase in frequency or intensity (generally no more than 1-2 per hour often relieved by ambulation or change in position) They do not lead to effacement or dilation of the cervix or rupture of membranes
True labor contractions are usually painful and are of increasing frequency, duration and strength leading to effacement and dilation of the cervix |
|
|
At what gestational age does the fetus become viable (potentially able to survive outside the uterus)?
|
24 weeks
|
|
|
What is "bloody show" and what conditions must it be differentiated from?
|
Expulsion of the cervical mucus plug at the onset of labour (dark red vaginal bleeding mixed with mucous) Bleeding of larger volume or bright red bleeding may suggest a more serious cause such as abruptio, placenta pre via or vasa previa (in which case vaginal exam is contraindicated until US has confirmed the location of the placenta)
|
|
|
What are the stages of labour?
|
Stage 1 cervical effacement and dilation (ends with cervix fully dilated and effaced)
latent phase = slow cervical dilation active phase = rapid dilation begins once the cervix is 3-4 cm dilated Stage 2 = fully dilated cervix to delivery of baby Stage 3 from delivery of baby to delivery of placenta Stage 4 uterine contraction |
|
|
In vertex presentations, how can you tell in which direction the fetus is facing?
|
Feel for the fontanelles. The anterior fontanelle (which should be positioned posteriorly in an occiput anterior presentation) has four sutures radiating from it, whereas the posterior fontanelle has three. You should carefully examine the lateral margins fro fingers or facial parts that indicate compound or brow presentations
|
|
|
Describe the reassuring fetal heart tracing in labour?
|
-baseline HR 120-160bpm
-beat to beat variability (oscillation of the FHR around the baseline in amplitude of 5-10bpm) -the presence of at least 2 accelerations, each lasting for 15 or more seconds above baseline and peaking at 15 or more bpm in a 20 minute period is reassuring -acceleration triggered by stimulating the fetal scalp -early decelerations |
|
|
What are the three type of decelerations seen on fetal monitor tracings and how should they be interpreted?
|
-early decelerations have their onset coinciding with the start of a contraction and a slow return to baseline that coincides with the end of the contraption (mirror image of the contraction the the recording strip) Caused by vagal stimulation as the fetal head is compressed during uterine contraction. Not associated with fetal distress
-Late decelerations are symmetric falls in the heart rate beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. Associated with uteroplacental insufficiency, this pattern is non reassuring and further evaluation (e.g. with fetal scalp pH) is warranted. When persistent and associated with decreased beat to beat variability this patter is ominous -variable decelerations are an acute fall in the heart rate with a rapid downslope and variable recovery phase; they do not bear a constant relationship to uterine contractions. Caused by compression of the umbilical cord. Attempt to shift weight off the umbilical cord by changing positions. Generally associated with positive outcomes, but if persistent and associated with loss of beat to beat variability is considered ominous |
|
|
What are other non reassuring fetal monitor tracings?
|
Fetal tachycardia (baseline HR 160; severe when >180) Suggests chorioamnionitis or when HR is >200 (fetal tachydysrhythmias
-Fetal bradycardia 100-120bpm with normal variability is not associated with fetal distress. FHR<100bpm suggests congenital abnormalities. Severe prolonged bradycardia of 80bpm that lasts for 3 minutes or longer is ominous and often fatal. sinusoidal tracing - also an ominous finding |
|
|
What parameters should be assessed by US in a patient in labor in the ED?
|
Number of fetuses, fetal viability, lie, presentation and placental location.
|
|
|
What equipment and personnel should be ready if an ED delivery is expected.
|
Personnel: at least one nurse for the mother and one for the infant plus a circulating nurse; obstetrician and neonatologist (if available)
-radiant warmer should be preheated -neonatal resuscitation adjunct: towels, scissors, umbilical clamps, bulb suction, airway management, ET tubes, suctioning equipment for meconium) equipment to achieve and umbilical line |
|
|
Describe how to proceed with the second stage of labour in the Ed?
|
-position mother in the dorsal lithotomy
-have an IV -use sterile gloves to assess -coach the mother to push in a controlled coordinated way with contraction -when the fetal head is crowning, instruct mother not to push but pant -perform the modified Ritgen maneuver - towel covered hand is at the perineum -when the head is delivered, the head should be allowed to rotate to face the mother's thigh. Check the neck for cord and slip it over the head or double clamp and cut. deliver the anterior shoulder by gentle downward triton on the head and chin followed by upward pressure to deliver the posterior shoulder. place baby on mom's abdomen. Clamp and cut the cord wrap the baby in towels and move to warmer. Dry, stimulate, suction, record apgar at 1,5 an 10 minutes. |
|
|
What are available options for maternal pain control during delivery in the ED?
|
nitrous oxide
narcotics regional anesthesia |
|
|
What are the signs of placental separation in the third stage of labour?
|
the uterus becomes firmer
umbilical cord lengthens 5-10 cm there is a sudden gush of blood |
|
|
How long is it supposed to take for the placenta to separate?
|
Usually 5-10 minutes
after 18minutes risk of PPH exists After 30 min risk of PPH increases 6x |
|
|
Why is it important to be patient during the third stage of labour?
|
You could end up causing uterine inversion which can cause severe PPH
|
|
|
What are your options for managing the third stage of labour?
|
-expectant
-active managemnet (give oxytocin and controlled gentle traction on the clamped cord) |
|
|
What is the normal architecture of the umbilical cord?
|
two umbilical arteries on either side of a single umbilical vein
|
|
|
What do you with the placenta once it is delivered?
|
Examine it for abnormalities
|
|
|
What are contraindications to tocolysis?
|
acute vaginal bleeding
fetal distress lethal fetal anomaly chorioamnionitis preeclampsia or eclampsia sepsis DIC Relative chronic HTN cardiopulmonary disease stable placenta previa cervical dilation >5cm placental abruption |
|
|
What are commonly used tocolytic agents?
|
MgSO4 4-6g IV
Terbutaline 5-10mg PO q4-6 Ritodrine 10mg PO q2-4 Isoxsuprine |
|
|
What is the failure rate of tocolysis?
|
25%
|
|
|
What is the definition of premature rupture of membranes and preterm premature rupture of membranes?
|
PROM - rupture of amnionic and chorionic membranes before the onset of labour
PPROM - same except before 37 weeks |
|
|
HOw should you manage the patient who presents with a history suggestive of PROM or PPROM?
|
no digital exam
sterile speculum (look for pooling, test with nitrazine and look for ferning) obtain cultures for GBS, chlamydia and gonorrhea -institute fetal monitoring request an ultrasound consult OB |
|
|
List RF for chorioamnionitis?
|
Prolonged labour, PROM, excessive vaginal examinations and recent amniocentesis
|
|
|
what are clinical signs suggestive of chorioamnionitis?
|
Maternal - uterine tenderness, tachycardia, fever, malodorous vaginal discharge, leucocytosis
Fetal - decreased activity, abnormal BPP, tachycardia, non reassuring tracing |
|
|
How should the stable patient with suspected chorio be managed?
|
sterile speculum to obtain cultures
antibiotics (ampi/genta) fetal monitoring admission to OB tocolytis are contraindicated |
|
|
What are the causes of dystocia?
|
Dystocia - abnormal labour progression
-fetopelvic disproportion (passage) -fetal size or presentation problem (passenger) inadequate expulsive forces |
|
|
Why is breech delivery problematic?
|
buttocks and legs do not provide sufficient wedge
umbilical prolapse because presenting part does not completely occlude if head is hyperextended there is significant risk for SCI with vaginal delivery |
|
|
How can a breech presentation be recognized in a patine with labour?
|
tactile vaginal exam
ultrasound |
|
|
How do you deliver a frank breech?
|
episiotomy recommended
allow delivery to proceed spontaneously until umbilicus appears at the introitus -do not apply traction prior to umbilicus being delivered and do not rupture the membranes -When the umbilicus is deliver gently pull 10-15cm of cord down -hold the baby by the bony pelvis and apply gentle downward traction -when the tip of the anterior scapula comes into view sweep the anterior arm across the chest and out -deliver the opposite arm Deliver the head by the mariceau maneuver - one hand enters the introitus and a finger is firmly applied to the occiput. The other hand is placed posteriorly with two fingers placed on the maxilla Assisstant applies suprapubic pressure the head should remain in flexion at all times |
|
|
What are the complications of shoulder dystocia?
|
Fetal - asphyxia, traumatic brachial plexus and humeral and clavicle fractures
Maternal - vaginal, perineal, anal sphincter tears and urinary incontinnece |
|
|
What are clinical findings of shoulder dystocia?
|
Inability to deliver either shoulder
fetal head retracts towards the maternal perineum arrested delivery fetal shoulder are on a vertical axis |
|
|
What time interval is considered critical from delivery of the head to delivery of the body?
|
beyond 6-8 minutes there is a significant risk of asphyxia and CNS injury
|
|
|
What sequence of maneuvers can be employed when confronted with a shoulder dystocia (HELPER)
|
H - call for Help
E -empty the bladder /generous episiotomy L - flex the legs and the hips and knees (McRoberts) P - apply pressure suprapubically E - enter the vagina Rubin - push the most accessible shoulder toward the fetal chest Wood's corkscrew - rotation of the fetus up to 180 degrees by pushing the most accessible shoulder to the chest R - remove the posterior arm - introduce a hand along the posterior aspect of the posterior shoulder and identify the fetal arm. pull the arm out of the birth canal across the face delivering the posterior shoulder |
|
|
What is umbilical cord prolapse?
|
Occurs when the umbilical cord precedes the fetal presenting part or the presenting part does not fill the birth canal completely. Most are unexpected and develop during the second stage of labor.
|
|
|
What conditions are associated with increased risk of cord prolapse?
|
fetal mal presentation
prematurity polyhydramnios high presenting part long cord iatrogenic rupture of membranes when the presenting part is too high |
|
|
How is umbilical cord prolapse diagnosed?
|
Visual inspection, palpation of the cord or both (hint is a sudden deep variable or persistent bradycardia on the monitor)
|
|
|
What response is indicated when an umbilical cord prolapse is identified?
|
Get Help
assess babies condition by measuring the pulsations elevated the presenting part out of the pelvis and forcibly push up on the baby. Place a foley in the bladder and install 500-750 cc of saline tocolysis and deep trendelenberg ALSO manual suggests do not attempt the futile tactic of replacing the cord in the uterus |
|
|
What is the definition of PPH?
|
>500cc. Primary within the first 24 hours, secondary occurs from 24 hours to 6 weeks after delivery
|
|
|
What is the differential diagnosis of PPH?
|
The 4 T's
Tone (uterine atony) Trauma (lacerations) Tissue (retained products of conception) Thrombin (coagulopathies) |
|
|
What factors predispose to uterine atony?
|
Overdistention of the uterus
prolonged labor chorioamnionitis tocolytics GA with halogenated compounds |
|
|
What is the approach to managing PPH?
|
IV fluids and blood (2 large bore IVs)
institute treatment immediately massage uterus give oxytocin 40units in 1LNS at 250cc/hr or 20units IM (do not give oxytocin directly) -if no response give ergonovine 0.2mgIM Third line treatment is prostaglandin F2 (Hemabate) 0.25-1mg IM or intramyometrially |
|
|
How can you diagnose retained placental tissue as the cause of PPH?
|
suspect if any defect in the placenta or excessive traction on the placenta
US - empty or fluid filled uterus provides a high NPV |
|
|
How can remnant placental tissue be removed?
|
usually done manually by digital uterine exploration with blunt dissection of the fragments away from the myometrium.
Stop the oxytocin drip to do this. If the fragments cannot be removed they are likely invasive (placenta increta, accrete or percreta) and this needs to be treated by OB by curettage or hysterectomy |
|
|
What are the downsides of using uterine packing to decrease PPH
|
Opponents point out that an atonic uterus can accommodate a large volume of packing and blood without effective tamponade. It also may increase the risk of postpartum infection. There is also risk of perforation. Because dilation and curettage and hysterectomy sometimes are not available to the EP, the importance of uterine packing as an option is increased. THis is a temporizing measure
|
|
|
Describe the clinical presentation of uterine inversion
|
RF include forceful traction on the UC
Sudden onset severe abdo pain with exam demonstrating tenderness and absence of the uterine corpus which is potentially visible in the cervical os or bulging profuse bleeding and hemodynamic instability |
|
|
How is uterine inversion managed?
|
if placenta adherent - do not remove
-hold all uterotonic agents -push fundus toward the mothers umbilicus - if this fails, use sedation and tocolyties to relax the cervical ring -when the uterus is repositioned, restart oxytocin continue firm manual pressure until uterine contraction |
|
|
How is uterine rupture diagnosed and treated?
|
usually VBAC especially it classic or Tshaped incision
intrapartum bleeding pain prolong fetal heart rate decelerations needs immediate c-section within 30mintes |
|
|
What are clinical manifestations of postpartum endometritis?
|
2nd to 3rd day postpartum
foul smelling lochia elevated wbc fever abdo pain search for retained products of conception treat with antibiotics (clinda/genta or 3rd generation cephalosporin) obtain vaginal culture usually need admission because of risk of sepsis |
|
|
Describe the presentation of postpartum cardiomyopathy
|
Sudden onset cardiomyopathy days to weeks after delivery in healthy women with no prior cardiac disease
symptoms range from mild fatigue to acute pulmonary edema. Often unrecognized in its milder form |
|
|
List risk factors and describe the clinical presentation of postpartum depression.
|
Risk factors include previously diagnosed depression and neuroticism, inadequate spousal support, adverse socioeconomic factors, recent life stressors, and emergency delivery
symptoms are the same as other MDD: depressed mood, anhedonia, loss of appetite, insomnia, fatigue, decreased concentration, feelings of guilt and worthlessness and suicidal ideation. Most do not have vegetative signs or symptoms may present as suicide attempt symptoms peak at 10-12 weeks postpartum but some cases are only diagnosed up to a year postpartum |
|
|
When is tocolysis contraindicated?
|
The mother feels the urge to push
The head is crowning |
|
|
What is a Braxton-Hicks contraction?
|
Muscle activity not associated with cervical effacement or dilation
|
|
|
What are contraindications to vaginal exam in the 3rd trimester?
|
placenta previa
placental abruption |
|
|
What is the 1st stage of labour?
|
Begins with cervical dilation and ends with a completely dilated and fully effaced cervix
|
|
|
What are the latent and active phases of the 1st stage of labour?
|
latent <3cm
active >3cm |
|
|
What are the stages of labour?
|
Stage 1 - cervical
Stage 2 - fetal expulsion Stage 3 - placenta expulsion Stage 4 - uterine contraction |
|
|
What tests confirm future of membranes?
|
-ferning (on microscopy)
-nitrazine (pH>6) |
|
|
What are signs of methotrexate failure?
|
decreased hemoglobin
unstable vital signs significant pelvic fluid |
|
|
What is the difference between a complete hydatiform mole and an incomplete mole?
|
complete hydatiform mole ->absence of fetal tissue
incomplete mole-> fetal tissue and focal trophoblastic hyperplasia |
|
|
What causes vaginal bleeding after the 1st trimester?
|
placenta previa
placental abruption premature labour vaginal and cervical lesions GU infection hemerrhoids |
|
|
What are clinical features of abrupt?
|
-vaginal bleeding (often dark)
-uterine tenderness -uterine irritability or contractions |
|
|
What are features of molar pregnancy>
|
-nausea and vomiting
-+/- vaginal bleeding passage of hydatid vesicles (like grapes) |
|
|
What is the role of US in the diagnosis of placental abruption?
|
It is not sensitive because fresh blood has the same echogenicity as placental tissue
|
|
|
What is the risk of fetal distress and death in abruptio?
|
~15%
|
|
|
What does placental separation put the mother at risk of?
|
amniotic fluid embolus
|
|
|
What causes maternal death in placental abruption?
|
-exsanguination
-coagulopathy |
|
|
What is often confused with placental abruption?
|
early labour
|
|
|
What increases the risk of placenta previa?
|
-increased maternal age
-multiparity -smoking -prior c-section |
|
|
What tests should be ordered in patients with 2nd and 3rd trimester bleeds?
|
-cbc
-coags/INR -fibrinogen (<300mg/dL is concerning for consumption) -D-dimer |
|
|
What is the definition of gestational hypertension?
|
A new blood pressure reading >/= 140/90mmHg
|
|
|
How do you diagnose pre-eclampsa?
|
gestational HTN
and proteinuria >300mg/24hours |
|
|
How do you diagnose eclampsia?
|
pre-eclampsia and seizures
|
|
|
What is pre-eclampsa
|
A vasospastic disease of unknown cause unique to pregnancy
|
|
|
Is edema used as a criteria to diagnose pre-eclampsa?
|
No, because pregnancy is normally associated with increased ECF
|
|
|
What may be present in pre-eclampsia?
|
Kidney changes
thrombocytopenia increased LFTs Liver tenderness HA or visual disturbances |
|
|
What is HELLP syndrome?
|
A severe form of preeclampsia seen in 5-10% of cases
Hemolysis elevated LFTs low platelets (<100,000) |
|
|
Which patients with pre-eclampsia require admission?
|
sustained HTN above 140/90
signs of severe pre-eclampsia |
|
|
What is the definition of severe pre-eclampsia?
|
HTN >160/110mmHg
epigastric or liver tenderness visual disturbance or severe HA |
|
|
What is the management of severe pre-eclampsia or eclampsia
|
MgSo4 - to control seizures
control HTN if DBP >105mmHg initial labs - cbc/plat/LFT/BUN/Cr monitor urine output <25cc/hr limit IV fluid +/- CT head initiate steps to delivery |
|
|
What is the dose of MgSO4?
|
6g IV loading
then 2g IV/hr monitor for loss of reflexes and respiratory depression |
|
|
How do you reverse the adverse effects of hypermagnesemia?
|
calcium gluconate
|
|
|
What meds are used to treat HTN in pre-eclampsia/eclampsia?
|
hydralazine 5mgIV
or nimodipine or labetalol |
|
|
What is amniotic fluid embolus?
|
The release of amniotic fluid into the maternal circulation during intense uterine contractions or manipulation or areas of placental separation, triggers an anaphylactoid type reaction
|
|
|
What is the management of AFE?
|
-oxygen
-support of ventilation and oxygenation with intubation -fluid resuscitation -inotropic CV support -anticipate and manage consumptive coagulopathy |
|
|
When is Rhogam given to Rh negative females?
|
~28weeks
|
|
|
What is the t1/2 of Rhogam?
|
24 days
|
|
|
Why is the Kleihauer-Betke test no longer used?
|
difficult
not immediately available detects 5cc fetal blood (0.1cc needed to sensitize) |
|
|
What does 300ug of Rhogam cover?
|
15cc fetal rbcs
or 30cc of whole blood |
|
|
Which blood tests must be interpreted carefully in pregnancy?
|
wbc are increased
amylase may be increased ALP is increased |
|
|
What is the differential diagnoses of RUQ pain in pregnancy?
|
cholelithiasis/cholecystitis
pyelonephritis appendicitis hepatitis fatty liver infiltration pregnancy induced HTN spontaneous intrahepatic bleeding |
|
|
Which pregnant patients require surgical management of GBD?
|
-obstructive jaundice
-gallstone pancreatitis -sepsis -failure of conservative management |
|
|
What is the most common cause of liver disease in pregnancy?
|
hepatitis
|
|
|
What is acute fatty liver of pregnancy?
|
A cause of hepatic failure which may complicate labour and cause fetal mortality in the 3rd trimester of pregnancy
|
|
|
What features of liver disease in pregnancy are less typical for pregnancy induced HTN?
|
-jaundice
-increased aminotransferase -rapid progression, coags, hypoglycemia |
|
|
What is the management of AFL of pregnancy?
|
-stabilization
-fluid and clotting factor repletion -confirm diagnoses by liver biopsy -rapid delivery |
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What is intrahepatic cholestasis of pregnancy?
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It is a rare syndrome
occurs in the 3rd trimester cholestasis and dilated canaliculi in the biliary tree |
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What is the most common presentation of intrahepatic cholestasis of pregnancy?
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pruritus (+/- mild jaundice)
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What is hyperemesis gravid arum?
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nausea and vomiting that cases starvation metabolism, weight loss, dehydration, prolonged ketonemia and ketonuria
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What is the treatment of hyperemesis?
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IV hydration
antiemetics +/- enteral nutrition |
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When is the risk of thromboembolism highest in pregnancy?
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in the puerperium
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When is the risk of thromboembolism highest in pregnancy?
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in the puerperium
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Which patients with lower GU symptoms in pregnancy are treated?
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Lower UT signs and symptoms or asymptomatic bacteruria
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What is the treatment of UTI in pregnancy?
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Cephalosporin
Nitrofurantoin Sulfonamides (not in the 3rd trimester) 7-10 days |
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What are the risks associated with Bacterial Vaginosis
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Chorioamnionitis
Subclinical PID PROM Prematurity Postpartum endometritis |
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What is the treatment of BV in pregnancy?
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Flagyl 7days PO
or clindamycin 7days PO not intravaginally |
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What is the treatment of candidal vaginitis in pregnancy?
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vaginal azoles x 7days
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Why is the clinical diagnosis of chlamydia different in pregnancy?
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Because cervical mucus is usually cloudy and contains wbc
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What is the treatment of chlamydia in pregnancy?
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1g azithromycin x 1 PO
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Discuss PID in pregnancy?
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Extremely rare in pregnancy and does not occur after the 1st trimester
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What is chorioamnionitis?
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Infection or inflammation of the placenta and fetal membranes
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How is chorio diagnosed?
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Fever
Maternal and fetal tachycardia Uterine tenderness >16 weeks |
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What are the risks of corticosteroids in pregnancy?
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Minimally increased risk of cleft deformities, IUGR, risk of GDM and HTN
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How can you differentiate between false and true labor?
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False
Braxton Hicks contractions (brief and irregular) No cervical changes Membranes intact True Cyclic uterine contractions of increasing strength, frequency and duration Cervical changes begin Membranes will rupture |
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What is bloody show?
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Slight bleeding associated with expulsion of cervical mucus plug
Reliable indicator of the onset of true labor |
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What is a reactive/reassuring fetal heart tracing (nonstress test)?
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Baseline HR 120-160 with at least 2 accelerations >15bpm lasting >15secs
Baseline FHR must be maintained for 15 mins in absence of contractions Variability can be beat to beat or long term over intervals of >/=1min |
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What causes decreased variability?
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Fetal acidemia and hypoxia
Certain drugs: analgesics, sedative hypnotics, phenothiazines, alcohol |
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What is the cause of early decelerations?
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Head compression
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What is the cause of variable decelerations?
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Umbilical cord compression
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What is the cause of late decelerations?
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Uteroplacental insufficiency (70% have suboptimal outcomes)
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During what stage of labour is hemorrhage most likely?
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Uterine contraction (stage 4)
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Describe Leopold's maneuver's and their meaning?
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Leopols'd maneuvers are performed in the first stage of labor to confirm the lie of the fetus
A - the first Leopold maneuver reveals what fetal part occupies the fundus B - the second Leopold maneuver reveals the position of the fetal back C - the third Leopold maneuver reveals what fetal part lies over the pelvic inlet D - the fourth Leopold maneuver reveals the position of the cephalic prominence |
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Describe the 5 components of the pelvic exam pregnancy?
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Sterile procedure
Effacement Dilation Position (relationship of fetal presenting part to birth canal - typically occiput anterior) Station(relationship of presenting fetal part to maternal ischial spines) Presentation |
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What is the preferred episiotomy location?
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Mediolateral incision
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In what situations should an episiotomy be done?
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Shoulder dystocia
Breech delivery |
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Which adjuncts to Normal labor and delivery are useful in the ED?
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-NPO and IV hydration status (allow for venous access and decrease the risk of aspiration)
-Nitrous oxide analgesia (self administered, minimal fetal side effects and noninvasive -Ultrasonobgraphy -Ritgen maneuver (decreases birth trauma) |
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What are the indications for third trimester ultrasonography
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Determine the number of fetuses
Establish fetal presentation Identify fetal heart motion Locate placenta Measure amniotic fluid Determine gestational age Survey fetal anatomy Diagnose cord prolapse Diagnose third trimester bleeding Rule out abruption |
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What are the effects of barbituates on labor?
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in anesthetic doses they can stop labor
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What are the effects of alcohol on labor?
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Decrease oxytocin release
Smooth muscle relaxant |
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What are the effects of cocaine on labor?
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Increased prematurity
Placental infarction |
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What are the effects of caffeine on labour?
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increased duration of labor
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What are the effects of narcotic on labour?
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Increased latent phase, slow dilatation
(minimal effect once in active labour) |
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What are the effects of atropine and scopolamine on labor?
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Lower segment relaxation
Decreased frequency of contractions |
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What are the effects of halothane on labor?
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Strong inhibition of labor
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What are the effects of nitroglycerin on labor?
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Profound uterine relaxation
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What is the modified Ritgen maneuver?
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Use one gloved hand to stretch the perineum and exert pressure on the chin of the fetus and the other hand puts pressure on the occiput superiorly, guiding the head into slight extension
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What equipment is necessary during an emergency delivery?
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Gyne bed with sheets
IV and NS running cleansing solution and gauze sterile gloves and jelly Sterile towels and drapes hemostats and suture equipment Neonatal airway equipment Umbilical cord clamp Scissors or scalpel Radiant warmer Bassin for the placenta Oxytocin 10-40 units in 1L of IV solution at a rate sufficient to control uterine atony |
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Define preterm labor
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Uterine contractions with cervical changes before 37 weeks gestation
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What are risk factors for preterm labor?
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Demographic and psychosocial
Extremes of age LSES Tobacco use cocaine abuse prolonged standing (occupation) Psychosocial stressors Reproductive and Gynecologic Prior preterm delivery Diethylstilbestrol exposure Multiple gestations Anatomic endometrial cavity anomalies Cervical incompetence Low pregnancy weight gain First-trimester vaginal bleeding Placental abruption or previa Surgical Prior reproductive organ surgery Prior paraendometrial surgery other than GU Infectious Urinary tract infections Nonuterine infections Genital tract infections (BV) |
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What is the management of preterm labour
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-clarify that the patient is in preterm labour (fetal monitor)
-work up: UA, cvc, fetal monitor, pelvic US -Ob/gyn consult -When possible transfer to perinatal centre -if viable fetus and healthy mother attempt to prolong gestation, tocolysis, bedrest, hydration (Labour is considered an unstable condition and precludes transfer out of hospital) |
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When should preterm labour not be prolonged?
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Intrauterine demise
Major congenital abnormalities Eclampsia PROM |
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What medications may be used as tocolytics and how long do they prolong pregnancy?
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Beta mimetics (terbulatine and ritodrine)
MgSO4 NSAIDS (indomethacin and sulindac) CCB (nifedipine or nicardipine) They prevent imminent delivery in 75-80% of patients for 48-72hours |
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What are contraindications to tocolysis?
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Absolute
Acute vaginal bleeding Fetal distress (not tachycardia alone) Lethal fetal anomaly Chorioamnionitis Preeclampsia or eclampsia Sepsis Disseminated intravascular coagulopathy Relative Chronic hypertension Cardiopulmonary disease Stable placenta previa Cervical dilation >5cm Placental abruption |
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What is the definition of PROM?
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Rupture of the amniotic and chorionic membranes before the onset of labor
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How do you assess a patient for PROM?
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-do not perform a digital exam
-perform sterile speculum exam to confirm -check for prolapsed cord and abnormal fetal presentation -If >36 wks, fetal pulmonary maturity is likely -if immature fetus (24-31 wks) corticosteroids can accelerate pulmonary maturation, but in PROM can also increase risk of infection |
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What antibiotics should be given in PROM?
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Preterm PROM: IV penicillin and erythromycin
PROM: Rx only if GBS +ve or unknown |
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What bedside test can be done in suspected PROM?
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-speculum exam: direct observation of amniotic fluid coming out of cervical canal or pooling
-nitrazine paper: amniotic fluid pH 7.0-7.3 turns the paper blue. Normal vaginal secretions turn the paper blue -ferning: fluid from the posterior vaginal fornix is swabbed only a glass slide and allowed to dry -smear combustion: amniotic fluid turns white and crystallizes |
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What are risk factors for the development of chorioamnionitis?
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Prolonged labor
Premature rupture of membranes (PROM) Excessive vaginal examinations Recent amniocentesis |
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What is the presentation of chorioamnionitis?
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Maternal signs and symptoms
-PROM -Uterine tenderness -fever -tachycardia -malodorous vaginal discharge -leukocytosis Fetal signs and symptoms -decreased activity -abnormal biophysical profile -fetal tachycardia -decreased variability of FHR |
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What is the treatment of chorioamnionitis?
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Ampi/genta IV
Add clindamycin or metronidazole if undergoing c-section |
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What is the most common malpresentation?
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Breech (4%)
Then shoulder dystocia face presentation brow presentation |
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What are indications for c-section?
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labour arrest
umbilical cord prolapse |
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What are the etiologic categories of dystocia?
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Labour fails to progress when
1) passage problem (pelvic architecture) 2) passenger (fetal size or presentation problems) 3) power (uterine force inadequate) |
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What are the different types of breech presentations?
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Frank breech
Complete breech Incomplete breech |
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What is a frank breech?
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hips flexed and knees extended
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What is complete breech?
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hips and knees flexed
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What is an incomplete breech?
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incomplete hip flexion, single or double footling
increased incidence of prolapsed cord (15-18%) |
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What is the Mauriceau maneuver?
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Use of fetal oral aperture to flex the fetal neck and draw in the chin
This is intended to avoid hyperextension of the neck which can cause spinal cord injuries in the baby |
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How do you manage a breech delivery?
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Episiotomy
maternal knee flexion and sweep out babies legs Pull out 10-15cm loop of cord after umbilibus clears the perineum Hold infant using bony pelvis Keep face and abdomen away from symphysis and using rotation to deliver the more accessible arm Mauriceau maneuver |
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What should be avoided in breech delivery?
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-Inappropriate transfer with delivery en route
-Misdiagnosis of cervical dilation, iatrogenic rupture of membranes, moving patients and leaving them unmonitored -traction of the fetus during delivery -grasping fetus by the waist causing abdominal organ damage -arm entrapment over head -neck hyperextension |
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What are risk factors for shoulder dystocia?
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Maternal
DM obesity prolonged 2nd stage of labor Fetal macrosomia postmaturity erythroblastosis fetalis |
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What is the management of shoulder dystocia?
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HELPER
Help (obstetrics, neonatology, anesthesia) Episiotomy (generous size, also drain bladder) Legs flexed (McRoberts maneuver) Pressure (suprapubic pressure to deliver the anterior shoulder, posterior shoulder pressure via episiotomy to facilitate posterior shoulder retreat) Enter vagina (Rubin maneuver - push most accessible shoulder towards the chest resulting in hunched back and decreased bisacromial diameter or Wood's corkscrew - rotate the fetus 180 decrees) Remove posterior arm (splint, sweep, grasp and pull to extension the posterior arm) |
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What is the shoulder position in a normal delivery?
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As the fetal head rotates, the shoulders assume an oblique position and enter the pelvis one at a time
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What is the shoulder position in shoulder dystocia?
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Both shoulders attempt to clear the pelvis simultaneously forcing the bisacromial diabmeter into the opening
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When does cord prolapse occur?
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-When the umbilical cord precedes the fetal presenting part
-When the presenting part does not fill the birth canal completely (breech) |
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What is the management of cord prolapse when a c-section is available?
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Mother knee to chest position
Trendelenburg position Instruct mother not to push Digitally lift presenting part off the cord Place a foley and instill 500-750cc of saline into the bladder C-section ASAP |
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What is the management of cord prolapse if c-section is unavailable?
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Funic reduction (manual replacement of the cord into the uterus and rapid vaginal delivery
knee to chest trendelenberg instruct mother not to push push the cord gently above the presenting part |
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What is postpartum hemorrhage?
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Hemorrhage >500cc
Primary: within first 24 hours Secondary: 24h to 6wks after delivery |
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What is the differential for primary post partum hemorrhage?
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Tone -> uterine atony
Trauma -> maternal birth trauma Tissue -> retained placental tissue Thrombin ->coagulopathies -> always assess for DIC |
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What is the treatment for PPH?
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Uterine massage and oxytocin
Suturing of birth trauma site Manual removal of placenta remnants Blood products for DIC Other treatment: uterine packing, pelvic embolization, uterotonic agents (oxytocin, ergot alkaloids, prostaglandins), hysterectomy, recombinant factor VIIa |
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What are the different types of tears that occur during delivery?
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First degree tear: perineal skin and vaginal mucous membranes
Second degree tear: through skin, fascia and muscles Third degree tears: skin, mucous membranes, perineal body and anal sphincter (should be repaired by Ob/gyn) Fourth degree: extend through all layers including the rectal mucosa. Also associated with tears in the region of the urethra -> should be repaired by Ob/gyn |
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Describe amniotic fluid embolism
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Spread of amniotic fluid through the maternal vasculature which activates a procoagulant or anaphylactic cascade
Sudden onset dyspnea, hypoxia, AMS, seizure, hemodynamic collapse, DIC |
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Describe postpartum endometritis
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Usually develops 2nd or 3rd day post partum
Gram positive cocci or gram negative coliforms Rx Clinda and aminoglycodies; alternatively 2nd or 3rd generation cephalosporin |
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Describe postpartum cardiomyopathy?
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onset days to weeks after delivery
require O2, diuretics, vasodilators Cardiac function returns to normal in 1/2 of patients over 6 months |
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Describe postpartum depression
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peaks at 10-12 weeks postpartum although some delayed up to 1 year
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