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Emergency: Reproductive
Emergency: Reproductive
93
Anatomy
Graduate
01/09/2012

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Cards

Term
Bleeding after intercourse is __ __ until proven otherwise.
Definition
cervical cancer
Term
Children with vaginal bleeding is either __ __ or __.
Definition
foreign body
abuse
Term
__ consecutive months without a period is menopause. Any bleeding after this is always __ and possibly __.
Definition
- 12
- abnormal
- precancerous
Term
36 year old woman presents to the ER complaining of light spotting for two days. She had a positive pregnancy test 4 days ago. Her LMP is 4 ½ weeks ago.
What tests do you want to order?
Definition
- Urine hcg (quantitative)
- CBC to make sure hemodynamically stable
- Blood type
- Ultrasound
Term
normal hemoglobin and hematocrit levels in women?
Definition
- hemoglobin: 12-16
- hematocrit- 38-46%
Term
When should the gestational sac appear on OB ultrasound?
Definition
4.5 weeks
Term
When should the yolk sac appear on ultrasound?
Definition
5 weeks
Term
When should the fetal pole or embryo appear on OB ultrasound?
Definition
5-6 weeks
Term
When should cardiac activity show up on OB ultrasound?
Definition
- around 6 weeks, definitely by 7 weeks
Term
When is Crown to Rump Length (CRL) assessed?
Definition
7-13 weeks
Term
How is CRL determined?
Definition
via vaginal ultrasound
Term
Which ultrasound is most accurate at determining how far along the pregnancy is?
Definition
the first ultrasound
Term
3 measurements of the pregnancy assessed at the 20 week ultrasound:
Definition
- Biparietal Diameter (BPD)
- Femur Length (FL)
- Abdominal Circumference (AC)
Term
What is the most important measurement used to monitor fetal growth?
Definition
Abdominal circumference
Term
A Biophysical Profile (BPP)combines an __ with a __ __ __ to determine fetal health in the third trimester. This test is performed if there is a question about fetal health and well being resulting from either an examination, maternal/fetal symptoms, or if the pregnancy is considered high risk.
Definition
- ultrasound with a non-stress test
Term
The NST portion of the BPP measures the baby's __ __, ___, and __ __ reactivity to __ for 20-30 minutes. Then an ultrasound is done.
Definition
- heart rate
- movement
- heart rate reactivity to movement
Term
5 fetal attributes scored during a BPP:
Definition
- Breathing (normal: 1 breathing episode in 30 mintues, abnormal: 0 breathing episodes in 30 minutes)
- Movement (normal: 2 or more movements in 30 minutes, abnormal: less than 2 movements in 30 minutes)
- Muscle tone (normal: 1 or more movements of active flexion or extension, abnormal: slow extension/flexion or partially open fetal hand)
- Heart Rate (normal: 2 or more episodes or reactive heart rate acceleration w/in 2o minutes, abnormal: 1 or more episode of unreactive heart rate acceleration)
- Amniotic fluid (normal: 1 or more adequant pockets of amniotic fluid, abnormal: no/inadequate pockets of fluid)
Term
List 5 aspects assessed during BPP:
Definition
- Breathing
- Movement
- Muscle tone
- Heart Rate
- Amniotic fluid
Term
When is a BPP performed?
Definition
usually after 32 weeks gestation
Term
The BPP gives you an __ __ __. If there is excessive amniotic fluid, it is called ___. If there is decreased amniotic fluid, it is called ___.
Definition
- Amniotic Fluid Index
- polyhydramnios
- oligohydramnios
Term
What type of ultrasound is best when pregnancy is still early on?
Definition
trsnsvaginal
Term
how do you assess placental location?
Definition
OB ultrasound
Term
36 year old woman presents to the ER complaining of light spotting for two days. She had a positive pregnancy test 4 days ago. Her LMP is 4 ½ weeks ago.
Most likely dx?
Definition
- threatened abortion
- implantation bleeding
Term
considering previous flashcard, what would be the next test you order?
Definition
Quantitative hcg, repeat in 48 hours
Term
considering previous flashcard, what would be the next test you order?
Definition
Quantitative hcg, repeat in 48 hours
Term
A 23 year old G2P1 woman presents to the ER complaining of some crampy pain and bleeding x 2 days which stopped this morning. Her LMP was 10 weeks ago.
On exam: ~8 week uterus with diffuse mild tenderness of pelvis
SSE: brownish discharge in cervical os, no pooling noted
US: irregularly shaped gestational sac with 8 week fetal pole visualized, no cardiac activity
What is her most likely dx?
Definition
missed abortion
Term
With an abortion, what are the patient's options?
Definition
- wait and see approach
- D&C
Term
Even if mother has abortion, if she is Rh negative, give her ___.
Definition
Rhogam
Term
At what gestational age do you give Rhogam prophylactically?
Definition
28 weeks
Term
Implantation bleeding
Common
Minimal, at time of the first missed period
1-2 days, spotting to menstrual flow
20% to 25% of all pregnant women spot or bleed in the first trimester
Must always consider:
threatened, inevitable, complete, or incomplete abortion
ectopic pregnancy
molar pregnancy
Definition
Term
Threatened abortion SSE:
Definition
- bleeding
- closed cervix
- uterus appropriate size
- +/- uterine tenderness
Term
Incomplete Abortion SSE:
Definition
- some products of conception are expelled while some remain
- cervix usually dilated
- bleeding (may be profuse)
- enlarged uterus
- uterine cramping
- more common at greater than 6 weeks gestation
Term
Complete Abortion SSE:
Definition
- uterus has expelled its contents
- cervical os is closed
- minimal bleeding
- uterus is near normal size
- little/no uterine pain/cramping
Term
Missed abortion findings:
Definition
- pregnancy is lost but products not expelled
- uterus involutes so it is small for dates
- minimal dark red/brown vaginal bleeding
- pregnancy tests may remain positive for some time
Term
Septic abortion findings:
Definition
- infection occurs concurently with abortion
- temperature elevation
- elevated WBC and ESR
Term
If patient is having an abortion and bleeding profusely in the ER what could you give them?
Definition
- Uretotonic agent

also probably need a D&C if bleeding profusely
Term
what are some uretotonic agents?
Definition
- Ergonovine maleate (Ergotrate)
- Methylergonovine maleate (Methergine)
Term
Anyone past __ to __ weeks, should have fetal heart tones done. Normal fetal heart tones are __ to __.
Definition
- 10-12 weeks
- 120-160 bpm
Term
A 27 year old G2P1 with previous C/S, presents to your rural ER at 32 weeks on the way back from Christmas vacation with complaints of vaginal bleeding. She reports that she had a gush of bright red blood at a nearby Dairy Queen prior to her arrival.
BP 120/80, P 92
Fetal status is reassuring with FHT 140’s
No contractions noted
A small amount of bright red blood is noted in the introitus and there is no free bleeding.
Hb 9.2, Hct 27
The next step in her evaluation should be?
Definition
sonogram
Term
with placenta previa, do not do SSE
Definition
Term
Placenta previa
Often bright red blood in vagina usually in 3rd trimester
Instrumentation, digital examination of the cervix, and speculum examination can provoke severe hemorrhage
1/3 of placenta previa cases are <30wks
admission and obstetric consultation are indicated
Definition
Term
With placenta accreta, anchoring placental villi attach to the ___, rather than being contained in the decidual cells. Thus, the placenta is abnormally adherent to the uterus. This can cause life threatening __ __ _ and increases the need for immediate hysterectomy.
Definition
- myometrium
- post-partum hemorrhage
Term
Placenta Increta occurs when the placenta invades __ the __.
Definition
into the myometrium
Term
Placenta percreta occurs when the placenta invades through the __ with possible invasion to surrounding __ like the __.
Definition
- through the serosa
- tissues
- bladder
Term
If pt in 3rd trimester is bleeding, what do you do first?
Definition
ultrasound, do NOT do SSE
Term
UTERINE TENDERNESS IS KEY HERE TO PLACENAL ABRUPTION. This is really easy to miss. Pts may be really sick and vomiting , bleeding a lot, or they may be feeling fine after a car accident. ANY CAR ACCIDENT SUSPECT THIS WITH PREGNANT WOMEN, EVEN IF FEEL FINE, MONITOR THEM, PUT THEM ON FETAL MONITOR, ESPECIALLY IN 2ND AND 3RD TRIMESTER. Shearing force from MVA separates placenta. Sometimes even the u/s won’t show this, so MONITOR.
Definition
Term
Pts with placental abruption will usually have __ __ and may or may not have vaginal bleeding, if they do have bleeding it tends to be __ ___.
Definition
- uterine tenderness
- dark red/brown
Term
MCC of intrapartum fetal death:
Definition
Abruptio Placentae (placental abruption)
Term
With placental abruption there tends to be __ __ in the vaginal vault. The amount of bleeding does NOT correlate with severity. This is distinguished from placenta previa by presene of __ __.
Definition
- dark blood and clots
- abdominal tenderness
Term
Dx studies to be done with placental abruption?
Definition
- US
- fetal monitoring
- fibrin
- platelet count
- PTT to make sure don't slip into DIC
Term
Placental abruption is associated with __.
Definition
DIC
Term
Risk factors for ectopic pregnancy:
Definition
- Non-white race
- Older age
- h/o STD or PID
- Infertility tmt
- IUD
- BTL or tubal repair
- Previous ectopic pregnancy
- DES exposure
Term
If anyone has a hx of ectopic pregnancy, never give them an __.
Definition
IUD
Term
Ectopic pregnancy S/Sx: (?Intraperitoneal hemorrhage, ?Infection)
severe, sharp constant pain at affected side
more diffuse abdominal pain with intraperitoneal hemorrhage
shock may be present (hypovolemia due to hemorrhage)
+/- cervical motion tenderness
+/- vaginal bleeding (Ectopic pregnancies cause vaginal bleeding because of the separation of the decidua from the endometrium as the ectopic pregnancy dies )
Definition
Term
In a normal pregnancy, beta hcg doubles every ___ hours.
Definition
48
Term
Dx for ectopic pregnancy:
Definition
- UPT positive
- US transvaginal
- Culdocentesis- to determine if there is a hemorrhage- put needle in posterior fornyx of vagina and see if there is blood or not
Term
possible locations for ectopic pregnancies to occur:
Definition
- cervical
- interstitial
- tubal (isthmus)
- ovarian
- tubal (ampular)
- infundibular (ostial)
- ovarian
Term
83% of ectopic pregnancies are ___.
Definition
ampular
Term
when does the placenta take over the pregnancy?
Definition
10-12 weeks
Term
with total placenta previa, cannot have intercourse
Definition
Term
Placenta previa presentation:
Definition
bright red bleeding
no abdominal tenderness
Term
Ectopic pregnancies usually cause pain around weeks __ to __. If they are going to rputure its around weeks __ to __. If the ectopic is discovered around weeks 4-6, __ can be used.
Definition
- 4 to 8 weeks
- 8 to 10 weeks
- methotrexate
Term
A 32 year old G4P3 woman presents to the ER with bleeding and clots. She thinks she is miscarrying. Her LMP was 9 weeks ago. She also reports n/v daily x 3 weeks.
Vital signs are stable
Physical exam reveals 10-12 week nontender uterus, and on SSE you note grape like clots oozing out of the cervical os.
UPT positive, CBC WNL, Type AB+
What is ddx? What tests would you order to confirm your suspicion?
Definition
DDx: molar pregnancy or partial mole
Tests: US, quantitative hcg
Term
US of a molar pregnancy aka trophoblastic disease would show:
Definition
snow storm appearance
Term
Most trophoblastic tumors are __ __. This occurs in one of every 1000 gestations in non-oriental women.
Definition
hyatidiform moles
Term
SSx of trophoblastic disease:
Definition
- vaginal bleeding
- enlarged uterus for dates
- passage of grapelike structures
- HTN, edema, and proteinuria can occur
Term
Dx of trophoblastic disease:
Definition
- US: snow storm appearance
- elevated quantitative hcg greater than 100,000 mIU/ml
Term
With trophoblastic disease in ddx, be sure to rule out:
Definition
- normal gestation
- multiple gestation
- uterine enlargement due to other reasons like myoma
- hydramnios
Term
Molar pregnancies are suggested by:
Definition
- vaginal bleeding
- uterus large for dates
- serum hcg levels greater than 100,000 mIU/ml
Term
When measure the fundus, anything within 2 cm +/- is normal.
Definition
Term
33 year old G1P0 woman at 33 weeks EGA presents to your ER c/o contractions Q10 minutes for the past 3 hours. She states she has had ctx every few hours for the past week. Her OB put her on bedrest two days ago but is out of town for the next week.
FHT 150’s and S=D
Toco/NST reveals regular contractions at Q9 minutes.
What is most likely Dx?
Definition
preterm labor
Term
What could be given in the ER to stop contractions?
Definition
Terbutaline or Ritodrine (beta mimetics)
Magnesium sulfate

(both have horrible side effects- respiratory depression, HA, decreased DTRs)
Term
What are two drugs that increase contractions?
Definition
Ptocin
Cervadil
Term
What does HELLP syndrome stand for?
Definition
- Hemolysis
- Elevated Liver Enzymes
- Low Platelets
Term
Premature labor is defined as uterine contractions with __ __ before __ weeks gestation.
Definition
- cervical changes
- before 37 weeks
Term
Leading cause of neonatal mortality :
Definition
premature labor
Term
Risk factors for premature labor:
Definition
- Lower SES
- Extremes of age
- Tobacco, cocaine use
- h/o preterm delivery
- Infections (UTI, genital tract, other)
Term
Premature labor dx:
Definition
fetal monitoring
us
Term
Criteria for delivery with premature labor:
Definition
- Eclampsia: PIH, proteinuria, grand mal seizures
- Fetal demise
- Congenital anomalies
Term
Premature Rupture of Membranes (PROM) is aka ___. This refers to rupture before labor, not to fetal prematurity.
Definition
- amniorrhexis
Term
Dx of PROM
Definition
SSE:
- Nitrazine paper testing- turns blue with ph of 7.1-7.3- amniotic fluid (normal vaginal pH pregnancy is 3.5 to 6.0)
- Ferning- amniotic fliuid turns white and crystalizes on slide when heated and dried
( Vaginal secretions carmelize and turn brown on slide )
Term
with PROM you should avoid:
Definition
direct digital exam of cervix
Term
With PROM, what cultures should be obtained?
Definition
- group B streptococci
- Chlamydia
- gonorrhea
Term
Nitrazine paper- blue- amniotic fliud, yellow= negative, green- not sure b/c blood can cause this.
Definition
Term
Delivery complications: For the passenger (Baby)
Chorioamniotitis
Shoulder dystocia
Breech presentation
Face/brow presentation
Umbilical cord prolapse
Multiple Gestations
Definition
Term
PID outpatient tmt:
Definition
Cephtriaxone 250 mg IM once + Doxycycline 100 mg bid for 14 days po + Metronidazole 500 mg bid for 15 days po
Term
Inpatient PID tmt:
Definition
- Cefoxitin 2 g IV q6h + Docycline 100 mg PO/IV q12h (do this for 24 hours or until patient is stable)
- then ouput docycylcine 100 mg po bid for 14 days.
Term
PID with a tubo-ovarian abscess tmt:
Definition
- Clindamycin + Aminoglycoside

OR

- Clindamycin + Metronidazole/Doxycycline
Term
Gonorrhea tmt:
Definition
250 mg IM Ceftriaxone

if they have an IUD, remove it after starting abx
Term
PID indications for hospitalization:
Definition
TAPHIPUG:
- Tubo-ovarian abscess
- Adolescents
- Pregnancy
- Hx of operative/dx procedures
- Inadequate response to outpatient treatment
- Peritonitis in upper quandrants
- Uncertain dx
- GI symptoms
Term
Sequelae of PID:
Definition
- recurrent acute PID
- ectopic pregnancy
- chronic pelvic pain
Term
Tmt for tubo-ovarian abscess if enterococcus is suspected:
Definition
Clindamycin + Aminoglycoside + Ampicillin (for enterococcus)
Term
For the treatment of tubo-ovarian abscesses, metronidazole is an effective replacement for anaerobic infections, but Metronidazole does NOT cover ___ ___ organisms.
Definition
does NOT cover gram negative organisms
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