Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
207 Cards in this Set
- Front
- Back
|
What must be ruled out in any reproductive-age women presenting with acute pelvic s/sxs? (abd/pelvic pain or unexplained hypovolemia)
|
ectopic pregnancy
|
|
|
Pt hx clues of ectopic pregnancy include
|
hx of abnormal bleeding, fever, pain, or amenorrhea
hx of prior ectopic or acute salpingitis |
|
|
Lab value used to check for ectopic pregnancy includes
|
urine HCG (pos very early)
serum quant if in doubt |
|
|
What is used to r/o ectopic pregnancy?
|
u/s to check for IUP
|
|
|
If u/s is non-dx in suspected ectopic, what should be done?
|
laparoscopy
|
|
|
many pts with acute appendicitis have CC of
|
abd pain, nausea, vomiting
|
|
|
Fever is a _____ finding in acute appendicitis except
|
late
when ruptured |
|
|
Labs used in the ddx of acute appendicitis include
|
CBC (increased wbc)
U/A (leukocytes) |
|
|
Xray findings of acute appendicitis may demonstrate
|
free air under diaphragm when flat and upright
|
|
|
Ovarian causes of acute pelvic sxs include
|
ovarian cyst or torsion of adnexa
|
|
|
Factors diagnostic of ovarian causes of pelvic pain include
|
u/s
CBC w/ elevated WBC negative hCG |
|
|
Causes of severe acute pelvic pain include
|
PID
acute salpingitis acute endometritis peritonitis rupture endometrioma |
|
|
Etiology of pain in a ruptur eendometrioma includes
|
rupture of chocolate cysts and production of toxic rxn
|
|
|
In regards to endometriosis, the most pain is caused by
|
least severe disease
|
|
|
definitive dx of endometriosis is
|
seeing endometrial glands/stroma in other tissues (cannot dx endometriosis w/o histology)
|
|
|
Other causes of acute pelvic pain include
|
Sexual assault/pelvic trauma
ureteral colic |
|
|
S/Sxs of ureteral colic include
|
spastic pain secondary to obstruction from stone or clot
elicit peritoneal signs |
|
|
Acute pelvic pain can also be 2ary to
|
threatened or inevitable abortion
incomplete abortion or septic abortion |
|
|
Uncommon cause of acute pelvic pain with a IUP is
|
heterotropic pregnancy (combined IUP and ectopic)
|
|
|
heterotopic pregnancy is dx by ____ and tx with _____
|
u/s
laparoscopic abortion |
|
|
Causes of pelvic pain other than ectopic pregnancy, abortion, stones, trauma, salpingitis, etc
|
UTI esp cystitis
ruptured corpus luteum cyst |
|
|
Causes of acute pelvic pain in post-menopausal women
|
GI and urinary tract most common
Degenerating myoma |
|
|
Hx diagnostic of degenerating myoma in post-menopausal pt with pelvic pain is
|
fibroids
|
|
|
What mus tbe ruled out in post-menopausal pts presenting with acute pelvic pain?
|
adnexal pathology
|
|
|
Conception is defined as
|
Period from LNMP to 2 weeks
|
|
|
Abortion defined as
|
2 - 21 weekes
|
|
|
Fetal Death defined as
|
22 weeks +
|
|
|
Infant death defined as
|
delivery to 1 year
|
|
|
Premature fetus defined as
|
wt 1000 - 2400 g
|
|
|
mature fetus defined as
|
wt 2400-4000 g
|
|
|
Postmature fetus defined as
|
42 weeks or 4000g+
|
|
|
Pregnancy is diagnosed by
|
LNMP and positive HCG
amenorrhea |
|
|
Sxs of pregnancy are variable and may include
|
amenorrhea
nausea/vomiting breast tenderness and enlargement urinary tract sxs |
|
|
quickening occurs at
|
14-20 weeks gestation
|
|
|
Signs of pregnancy include
|
Chadwick's sign
hegars sign Pelvic, joint and ligament relaxation arthralgia esp in pubic symphysis abdominal enlargement |
|
|
Chadwick's sign is
|
vascular congestion of the cervix (appears blue or purple)
|
|
|
Hegar's sign is
|
softening of uterine isthmus making it compressible, 6-8 weeks
|
|
|
"Belly" measurement in pregnancy is done by
|
measuring from top of symphysis to fundus
|
|
|
Abdominal measurement in pregnancy always done in
|
CM
|
|
|
Fundus stops enlarging/raising at
|
37-38 weeks (or cm?)
|
|
|
urine hCG tests are positive
|
around 2 weeks post conception
|
|
|
FHT are heard as early as
|
10 weeks
|
|
|
Fetal movement is felt around
|
18-20 weeks
|
|
|
Pregnancy can be detected by sonography by
|
5 weeks
|
|
|
Braxton-Hicks contractions can be felt at
|
28 weeks +
|
|
|
Serum pregnancy tests are positive around
|
8 days after conception
|
|
|
Goal of prenatal care is to
|
recognize high risk pregnancy
|
|
|
Pregnancy is complicated in about
|
5-20% of cases
|
|
|
What should be done at the first PRENATAL visit
|
ID risk factors
make dx and establish EDC (delivery date) HX of previous pregnancies HX of current pregnancy Medical hx including blood transfusions, allergies, infections Family hx (diabetis, twins) Complete physical exam Size of uterus (helps with gest age) Evaluate bony pelvis for adequate diameter to accomodate fetus Check cervical length (should be firm and 2-3 cms) |
|
|
Diagonal conjugate is ____ and should be ____
|
distance b/t symphysis and sacrum
10-11cm |
|
|
Lab studies to get at first prenatal visit include
|
Hemoglobin, Hct, Blood type, Rh, syphilis, Hep B, HIV
Screen for neural tube defects, Trisomy 18, 21 with quad test at 15-20 wks OFFER genetic testing to pts over age 35 ; CVS or amnio Dipstick UA for glucose and protein |
|
|
Genetic testing should be offered to all pregnant pts over
|
35
|
|
|
Test that should be performed at 35-37 wks gestation
|
Group B strep
|
|
|
PPD for pts
|
in endemic areas
|
|
|
F/U appointments should be
|
q 4 wks until 32 weeks then q 2 weeks until 36 weeks then weekly
|
|
|
What should be done at every f/u appt?
|
Check wt gain, fetal growth, BP, FHR, UA for protein and glucose
|
|
|
Nl wt gain in the pregnant pt is
|
25-35 lbs
|
|
|
_____ can be a sign of fetal well being
|
maternal well being
|
|
|
subtle changes in _____ may give clue to early fetal compromise
|
maternal BP
|
|
|
____ should both be monitored closely and should be _____ and _____
|
wt gain and FH
gain is 25-35 lbs FH increases ~ 1cm/wk past 20 weeks |
|
|
FHR at f/u appts in pregnancy pts should be monitored for
|
accels, decels, irregular rates
nl is 120-160 bpm |
|
|
___ should be noted in pregnant pts at f/u appts with _____ in late pregnancy normal
|
edema
dependent edema in late pregnancy |
|
|
Early signs of preeclampsia include
|
upper-body edema with elevated BP
facial edema |
|
|
fetal size and position should be checked at
|
26-28 wks
|
|
|
Persistant abnormal lie may indicate ______ and should be evaluated with ____
|
problem with placenta, pelvis, uterus, or fetal size
u/s |
|
|
In preparing for labor, the pt should be evaluated if
|
regular contractions q5-10min
ruptured membranes vaginal bleeding decreased fetal movement signs of pre-eclampsia (facial swelling, rapid wt gain) chills and fever severe abdominal or back pain (placental separation if in upper quadrant) any other medical problems |
|
|
Common complaints during pregnancy include
|
Ptyalism (excessive salivation)
Pica (eating clay) Polyuria Vaginal infections varicose veins back/pelvic pain leg cramps |
|
|
Leg cramps in pregnancy should be tx with
|
increase Ca carbonate or citrate
decrease cal phos |
|
|
Breast soreness in pregnancy can be tx with
|
24 hr bra or ice packs
|
|
|
hand discomfort in pregnancy related to
|
carpal tunnel d/t swelling
|
|
|
Pts should be instructed to
|
stop smoking
stop ALL alcohol (dose for FAS is not known) |
|
|
If a pregnant pts desires exercise, they should
|
maintain pre-pregnancy levels
|
|
|
Dental and peridontal infections may
|
contribute to preterm labor
|
|
|
Most common cause of PID
|
acute salpingitis secondary to gonoccocal or chlamydial infection
|
|
|
PID is
|
acute, subacute or chronic infection of tubes, ovaries, and adjacent tissues
|
|
|
Most PID infections are
|
bacterial
|
|
|
3 pathways of PID infection
|
Up vagina and through endometrium into tubes
lymphatic spread via endometrium hematogenous spread |
|
|
Most common pathway of infection in PID
|
Up vagina and through endometrium into F tubes and ovaries (typical with gonorrhea)
|
|
|
Dx criteria for PID
|
Lower ABD tenderness
adnexal tenderness CMT And at least one of Oral temp > 101F Abnormal cervical and vaginal discharge Elevated ESR Elevated C-reactive protein Positive gonorrhea or trachomatis culture |
|
|
Acute salpingitis dx by
|
sudden onset FOLLOWING MENSES
heavy vaginal discharge (+/-) generalized abd/pelvic tenderness Plus one or more of Temp > 101F leukocytosis > 10,000 inflammatory mass on exam or u/s |
|
|
Labs indicative of acute salpingitis
|
Purulent material on culdocentesis or laparoscopy
Elevated ESR Gram negative diplococci |
|
|
Blood finding in culdocentesis can indicate _____ as well as _____
|
ruptured ectopic
acute salpingitis |
|
|
Culdocentesis + for blood most likely indicates a ruptured ectopic in
|
young, healthy pt of reproductive age
|
|
|
S/Sxs of PID/acute salpingitis
|
Pelvic pain
purulent discharge fever |
|
|
Labs of acute salpingitis
|
Leukocytosis > 10,000 with left shift (increased immature WBCs)
Fluid from culdocentesis positive |
|
|
Imaging studies used in the dx of PID/AS
|
Abdnominal xray (to r/o other things)
vaginal u/s |
|
|
Study diagnosis of PID/AcSalp
|
vaginal u/s
|
|
|
DDx of PID/AcSalp
|
appendix
ectopic ruptured corpus luteum diverticulitis adnexal torsion endometriosis acute UTI Colitis |
|
|
Complications of PID/Acute Salpingitis include
|
Peritonitis
Pelvic thrombophlebitis abscess formation adnexal destruction w/ infertility intestinal adhesions and obstruction |
|
|
Common complication of PID
|
peritonitis
|
|
|
Prevention of PID complications is best done by
|
early recognition and tx of minimal dz
|
|
|
Tx of PID started when?
|
As soon as presumptive dx is made
|
|
|
Tx of PID/AcSap includes
|
Most respond to out patient antibiotics
|
|
|
Hospital tx for PID/Acute Salp is reserved for
|
Severe cases or uncertain dx, or a patient with abscess
Pt with temp greater than 102.2F Pt with marked abdominal guarding or rebound tenderness Pt who does not respond to outpatient therapy |
|
|
Outpatient therapy for PID includes
|
antibiotics
analgesics bed rest removal of IUD if present |
|
|
Hospital tx of PID includes
|
bed rest
IV antibiotics surgical exploration possible |
|
|
Prognosis of PID is
|
related to prompt tx with adequate meds
|
|
|
A bout of PID may
|
cause infertility in 12-18%
increase risk for ectopic pregnancy |
|
|
What should be done if a PID pt compalins of infertility after tx?
|
hysterosalpingogram of tubes to check for patency
|
|
|
Additional cause of PID includes
|
toxic shock syndrome
|
|
|
sxs of TSS
|
fever, rash, desquamation of palms and soles of feet, shock
|
|
|
Signs of TSS include
|
acutely ill pt with temp 102+, GI sxs, pain, shock
Pt hx of menstruation and tampon use |
|
|
Rash of TSS resembles
|
sunburn on face, trunk, and proximal extremities
|
|
|
Tx of TSS is _____ and requires
|
aggressive
fluids, antibiotics, steroids, blood products |
|
|
Mortality rate of TSS is
|
3-6%
|
|
|
Indications for C-section
|
Previous C-section
Breech Dystocia Fetal distress Other |
|
|
Reasons for increase in c-section include
|
Age
Obesity Fewer operative deliveries Breech presentation Fetal monitoring (increases knowledge of distressed fetus) Increased inductions esp in nulliparas increased litigation risk |
|
|
M&M is increased in c-section due to
|
infection, hemorrhage, thromboembolism
|
|
|
Elective C-sec is
|
not medically justified
|
|
|
Two types of abdominal incision in C-sec
|
vertical
low transverse (more cosmetic) |
|
|
Uterine incisions in C-section include
|
Classical (vertical)
Low Transverse |
|
|
Which uterine incision type is rarely used in C-sec and why?
|
classical
cuts through lots of muscle which can weaken it and cause uterine rupture in subsequent pregnancies |
|
|
C-section procedure
|
Separate and push bladder down
Incise serosa and myometrium 2cm Pull apart Deliver fetus Sew it up |
|
|
Indications for classical incision include
|
difficulty in exposing or entering lower uterine segment
transverse lie of large fetus Cases of placenta previa with anterior implantation Non-thinned lower uterine segment with small fetus Massive maternal obesity |
|
|
Post-op care of C-sec pts includes
|
IV fluids
Prevention of infection with single dose of B-lactam Prevention of hemorrhage with IV oxytocin |
|
|
Prevention of infection in C-sec pts post-operatively is done with
|
B-lactam
|
|
|
Post-op management includes
|
Cath removel in 12 hrs
Solid foods 8 hrs Ambulate 24 hrs |
|
|
Wound care in C-sec pts
|
Staples removed 3-4 days postop, or 7 days in obese pts
|
|
|
Patients may return home after a C-sec on
|
3rd or 4th day post-op
|
|
|
Obstetric emergencies include
|
incomplete abortion
ectopic pregnancy hypertensive crisis DVT placental abruption placental previa cord prolapse post-partum hemorrhage pulmonary embolism |
|
|
Incomplete abortion may cause _____ and requires _____
|
profound blood loss
emergency surgery |
|
|
Most episodes of DVT in pregnant pts is confined to the
|
deep venous system of the lower extremities
|
|
|
90% of DVTs involve the
|
left leg
|
|
|
Classic sxs of DVT are
|
abrupt onset of pain and edema of the leg and thigh
positive homan's sign (painful passive dorsiflexion of the foot) sometimes noted |
|
|
Most frequently used method to dx DVT and positive findings
|
compression ultrasonography
+ findings are noncompressability of the vein and typical clot pattern |
|
|
Standard dx test of DVT
|
contrast venography
|
|
|
A normal venous u/s does not always r/o _______ in pregnant pts since the clot frequently arises in the _____
|
pulmonary embolism
iliac veins |
|
|
____ is most helpful in the dx of pelvic vein thrombosis, including iliac vein thrombosis
|
MRI
|
|
|
Tx of DVT includes
|
Heparin while pt pregnant
Warfarin 6-12 wks AFTER DELIVERY |
|
|
Untreated eclampsia can result in
|
maternal stroke
blindness subcapsular hematoma of the liver DIC |
|
|
Fetal M&M in eclampsia is due to
|
uteroplacental insufficiency
|
|
|
Tx of eclampsia involves
|
MgSO4 bolus plus continous infusion
Antihypertensives Deliver |
|
|
____ cures eclampsia
|
delivery
|
|
|
____ should be avoided in the tx of eclampsia
|
diuretics
|
|
|
Placental abruption defined as
|
separation of placenta before birth
|
|
|
Placental abruption most often evident by
|
vaginal bleeding
|
|
|
Concealed abruption is
|
Pt with nl pregnancy but no longer feels fetal movement
fetal demise at 38 wks |
|
|
Greatest risk factor of placental abruption is
|
prior abruption
|
|
|
risk factors of placental abruption include
|
increased age and parity
preeclampsia preterm ruptured membranes smoking prior abruption |
|
|
S/Sxs of placental abruption include
|
vaginal bleeding (most common)
uterine tenderness or BP fetal distress preterm labor tetanic contractions (irritation from blood) hypertonus dead fetus |
|
|
Tx of placental abruption at term with a living fetus involves
|
C-sec
|
|
|
Placenta previa defined as
|
part of placenta detaches from uterus
|
|
|
Most common cause of perinatal death in placenta previa is
|
preterm delivery
|
|
|
Clinical sign of placenta previa is
|
painless vaginal bleeding in 2nd trimester
|
|
|
An important thing to remembe rwith pts presenting with bleeding in mid-trimester or later is
|
NEVER DO A CERVICAL EXAM
|
|
|
Tx of placenta previa
|
C-sec
|
|
|
Prolapse cord is a true emergency and tx/management consists of
|
placing pt in knee-chest position
pushing presenting part up and away from cord C-sec |
|
|
When doing an amniotomy, it is important to
|
always check for the cord
|
|
|
Post-partum hemorrhage is
|
excessive bleeding from placental implantation site (event, not a dx)
|
|
|
Tx of uterine atony in PPH is done by
|
rapid infusion of oxytocin
|
|
|
If oxytocin is insufficient in managing PPH, what should be used?
|
methylergonovine 0.2mg IM
PGF2-alpha 0.25 mg IM if ergonovine unresponsive Surgery if all are unresponsive |
|
|
If oxytocin fails to stop PPH ...
|
Uterine massage
get help add IV, oxytocin w/ blood Blood transfusion explore cavity and retrieve missing placenta piece inspect vag/cervix for tears Insert foley to monitor urine output |
|
|
____ requires immediate attention as shock can be profound and bleeding extensive
|
uterine inversion
|
|
|
Etiologies of breech presentation at term include
|
hydramnios
multiple fetuses relaxed uterus placental and uterine abnormalities fetal malformations |
|
|
Complications of persistant breech presentation include
|
perinatal M&M from delivery
low birthweight from preterm delivery, growth restriction, or both prolapsed cord placenta previa fetal, neonatal, infant anomalies uterine anomalies/tumors |
|
|
Common complicatoin in breech is
|
placenta previa
|
|
|
Complete breech is
|
one or both knees flexed
|
|
|
Frank breech is
|
hips flexed
knees extended |
|
|
footling breech
|
one or both feet presenting
|
|
|
most problematic breech presentation is
|
footling breech
|
|
|
Breech is dx by
|
abdnominal exam
location of FHT above umbilicus |
|
|
Vaginal exams in dx of breech is
|
confusing esp after long labor
|
|
|
___ used if dx of breech uncertain
|
u/s
|
|
|
Breech presentations place ______ at higher risk compared to cephalic
|
mother and fetus
|
|
|
Maternal M&M in breech related to
|
higher incidence of operative delivery
|
|
|
Maternal risk in breech presentations is even more elevated with ______ compaed to ____
|
emergency c-sec
elective c-sec |
|
|
Deaths of fetus in breech much higher at ____
|
any gestational age
|
|
|
contributors to perinatal loss in breech presentations are
|
preterm delivery
congenital anomalies birth trauma (forceps) |
|
|
Preterm breech fetus is even more susceptible than normal fetus because
|
disparity between body and head even greater
|
|
|
What is done sometimes to aid in head delivery of breech presentation?
|
incisions in cervix to release head
|
|
|
Hyperextension of fetal head with vaginal breech may cause ____ and instead delivery should be ____
|
severe spinal cord damage
c-sec |
|
|
frequency of cord prolapse is increased in small fetus and esp highest with _____
|
footling breech
|
|
|
Possibility of _____ in footling breech is too great and one should ______
|
cord prolapse
deliver via c-sec |
|
|
in a term fetus with breech presentation, _____ will decrease infant M&M
|
elective c-sec
|
|
|
Aftercoming head in a breech preterm can easily _______ by_____
|
become entrapped
incompletely-dilated cervix |
|
|
ACOG recommends _____ for presistant breech presentatoin except ______
|
c-sec
birth imminent |
|
|
Delivery techniques of breech babies includes
|
spontaneous (no traction or help)
partial breech extraction (spontaneous delivery to umbilicus, rest delivered) Total breech extraction (entire body of infant extracted by OB) |
|
|
Complicatoins of breech delivery include
|
anoxia d/t cord compression
birth injury (13x greater) entrapment of head nuchal arms |
|
|
greatest number of breech delivery injuries occurs in
|
total breech extraction delivery
|
|
|
External cephalic version may be attempted at ______ and is done with ________. Success is 60%
|
36 weeks
u/s guidance and tocolytics |
|
|
Abortion is
|
termination of pregnancy (spontaneously or induced) before fetus can survive (before 20 wks or < 500 gm)
|
|
|
spontaneous abortion
|
occurs w/o medical or mechanical means
|
|
|
effective therapies for abortion are
|
none
|
|
|
Pt hx of elective abortions include
|
< 25
white unmarried female 60% done during 1st 8 weeks 88% during 1st 12 weeks |
|
|
indications for therapeutic abortion include
|
persistant heart disease after cardiac decompensation
advanced hypertensive vascular disease invasive carcinoma of the cervix |
|
|
non-medical indications of abortion include
|
cases of rape or incest
prevent birth of fetus with significant anatomical/mental deformity elective |
|
|
counseling consists of offering 3 choices to pregnant women
|
continue pregnancy with its risks and maternal responsiblity
continue pregnancy with its risk and arrange adoption terminate pregnant with its risks |
|
|
Abortion can be
|
medical or surgical
|
|
|
Surgical abortion may remove the pregnancy ...
|
through dilated cervix
transabdominally via hysterotomy or hysterectomy |
|
|
D&C abortion procedure
|
dilation of cervix and scarping/suctioning out
(dilation and curettage) |
|
|
complications of D&C abortion increased after
|
first trimester
|
|
|
D&C abortion MUST be done before
|
14-15 wks
|
|
|
D&E abortion is performed after
|
16 weeks
|
|
|
D&E abortion involves
|
destruction of fetus and suctioning of POC
|
|
|
Pts receiving surgical abortion should receive ...
|
prophylactic antibiotics
Rhogam for Rh(-) pts |
|
|
Laminaria used in abortion
|
draws water out of proteoglycans causing dissociation and softening/dilation of cervix
|
|
|
Steps in D&E
|
Laminaria to ripen/dilate cervix
local anesthetic into cervix an ddilation to allow introduction of suction cannula |
|
|
Most common complication of D&E abortion
|
perforation
most likely to occur with retroverted uterus |
|
|
Pt who wants termination and sterilization may receive
|
hysterotomy or hyesterectomy abortion
hysterectomy in pts with significant uterine dz |
|
|
Medical abortion is an acceptable alternative in women with
|
pregnancy < 49 days
|
|
|
3 drugs and classes used in medical abortion include
|
antiprogestine - mefepristone
antimetabolite - methotrexate prostaglandin - misoprostol |
|
|
Medical abortion drugs cause abortoin by
|
increasing uterine contractility either by reversing progesterone induced inhibition of contractions or direct uterine stimulation
|
|
|
Drug regimens for medical abortion include
|
mifepristone plus misoprostol
methotrexate plus misoprostol |
|
|
Abortion must be completed with methotrexate and misoprostol because
|
they are both teratogens
|
|
|
relative risk of complications of induced abortion doubles for
|
each 2 weeks past 8 weeks gestation
|
|
|
fertility with elective abortoins is usually not
|
diminished
|
|
|
ovulation may resume as quickly as ______ after abortion procedure
|
2 weeks, thus important to start pt on contraceptives
|
