Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
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Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
- 1. OB Jeff Rundio D.O. Arrowhead Regional Medical Center 1-8-14 Adapted from Intensive Review for the Emergency Medicine Qualifying Examination
- 2. Physiologic changes in pregnancy Cardiovascular system Increased cardiac output Blood volume increases Resting hear rate increases by 10-15bpm SVR increases Decreased BP in 1st trimester Diastolic falls more than systolic Left lateral decubitus positioning may relieve hypotension Uterus places pressure on the IVC and decreases blood return to the heart
- 3. Physiologic changes in pregnancy Respiratory system Increased tidal volume but decreased FRC because of elevated diaphragm Minute ventilation increases this leads to respiratory alkalosis However, RR remains mostly unchanged
- 4. Physiologic changes in pregnancy Gastrointestinal system Gastric reflux is common secondary to delayed gastric emptying, decreased lower esophageal sphincter tone and decreased intestinal motility Increased risk of gallstones
- 5. Physiologic changes in pregnancy Renal-metabolic system Increased kidney size, renal blood flow and GFR Increased peripheral resistance to insulin Compensatory metabolic acidosis (to counteract the respiratory alkalosis) In addition to relative insulin resistance, pregnant women are more prone to DKA
- 6. Physiologic changes in pregnancy Hematopoietic system Hemoglobin decreases secondary to volume dilution Leukocyte count increases mildly although polymorph leukocyte function is depressed beginning in the 2nd trimester Coagulation factors and ESR increase
- 7. Diagnosis B-hCG Serum levels double about every two days in normal early Pregnancy Failure to double suggests ectopic or nonviable pregnancy Levels peak in 2-3 months and plateaus at 4 months Urine testing is sensitive at 20 mIU/mL and in serum at 10mIU/mL Can have false negative in dilute urine or early in pregnancy
- 8. Diagnosis Ultrasound in ED used to rule in an IUP not rule out an ectopic Transabdominal U/S Gestational sac at 6 wks Yolk sac, fetal pole, fetal heart motion at 8 wks Transvaginal U/S Gestational sac at 5 wks: hCG 1000 Yolk sac 6 wks :hCG 2500 Fetal pole and heartbeat 7 to 8 wks: hCG 5000-17000 Discriminatory zone: B-hCG level above which an IUP can confidently be expected to be apparent on US Transvaginal level is 1500 Transabdominal is 6000 After abortion B-hCG levels may take up to 2 months to return to negative
- 9. Complications of Pregnancy Vaginal bleeding in pregnancy Abortion Loss of pregnancy <20 wks or <500g About 30% of pregnancies abort spontaneously Usually 2/2 chromosomal abnormalities Risk increases with increasing maternal age, toxin exposure, smoking, ETOH, cocaine), multiparous women, endocrine and autoimmune disorders
- 10. Complications in Pregnancy Types of abortions Threatened ab: vaginal bleeding with closed os Inevitable ab: vaginal bleeding with open os Incomplete ab: passage of parts of POC Complete ab: passage of all fetal tissue Missed ab: fetal death <20wks without passage of fetal tissue
- 11. Complications in Pregnancy Management of abortions Threatened ab: DC with close follow up Incomplete ab: Uterine evacuation Complete ab: DC with close follow up Missed ab: D&C if infection or POC > 4wks otherwise, DC with close follow up RhoGAM for all Rh-neg women Must be given within 72hrs of fetal blood exposure Dose 50mcg if <12wks Otherwise 300mcg
- 12. Ectopic Pregnancy Extra uterine implantation of pregnancy Risk factors PID Tubal surgery Prior ectopic IUD In vitro fertilization
- 13. Ectopic Pregnancy Signs and symptoms Classic triad of vaginal bleeding, abdominal pain and pregnant/amenorrhea May have a relative bradycardia 2/2 vagal effects May have no vaginal bleeding May have a normal pelvic exam
- 14. Ectopic Pregnancy Diagnosis hCG Levels will likely decrease or not rise normally US findings suggestive of ectopic Ectoopic fetal heart beat Free fluid and absent IUP Adenxal mass and absent IUP US should be done despite low hCG levels
- 15. Ectopic Pregnancy Management Surgical Medical methotrexate
- 16. Abruptio placentae Separation of the placenta from the uterine wall Signs and symptoms PAINFUL vaginal bleeding But bleeding not always present Uterine tenderness Uterine contractions Rising fundus (indicates active bleeding) Fetal distress
- 17. Abruptio placentae Diagnosis Based on clinical suspicion US not great because blood and placenta look similar 50% will have coagulopathy on labs Management IV fluids FFP as needed Emergent OB consult Emergent delivery if fetus or mother in distress
- 18. Placenta Previa Implantation of placenta over cervical os Signs and symptoms PAINLESS bright red vaginal bleeding Diagnosis Transvaginal US Never perform digital or speculum exam if suspected Management Stabilize mother Fetal monitoring Emergent OB consult
- 19. How was Chuck Norris Born?
- 20. How was Chuck Norris Born?
- 21. Uterine Rupture Becoming more common 2/2 VBAC still less than 1% Sudden pain and termination of contractions, tearing sensation, vaginal bleeding Management, C-section
- 22. Preeclampsia Hypertension (sbp >140) and proteinuria >20 wks gestation +/- pedal edema Headache, visual changes, edema and/or abdominal pain May occur up to 6 weeks partum Becomes eclampsia when seizures occur Management mag sulfate 4 to 6 grams Follow DTRs
- 23. Postpartum Complications Retained POC May cause post partum bleeding If causes infection, leads to pain, fever and discharge Diagnosis Clinical suspicion and diagnosis US Management Supportive Removal of POC by D&C
- 24. Endometritis Inflammation of the uterine endometrium Acute endometritis caused by S. aureus or Strep infections Develop fever, foul smelling discharge, abdominal pain Diagnosis by Clinical suspicion, obtain US to r/o retained POC Management Supportive IV ABX Clindamycin and Aminoglycoside or 2nd or 3rd generation cephalosporin
- 25. Mastitis Inflammation of mammary gland Must distinguish cellulitis from abscess Management Anti-staph PCN (dicloxacillin) Cephlasporin Warm compresses Continue nursing
- 26. Medications in pregnancy Tylenol is safe ABX Sulfonamides: near term, may cause kernicterus Aminoglycocide: ototoxicity and renal tox Tetracyline: maternal- liver disease. Fetus- yellow discoloration of teeth and other congenital defects Quinolones: musculoskeletal dysfunction (tendons) Fluconazole: craniofacial bone abnormalities Antihistamines are safe except for meclizine in 1st trimester Oral hypoglycemics are unsafe, but insulin is safe
- 27. The END