ob-gyn emergenciesacoep.org/files/patel-obgyn-ir-2016.pdf · fetal/maternal death, dic. dx? us...
TRANSCRIPT
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EMERGENCIESOB-GYN
Nilesh Patel, DO, FACOEP, FAAEMPROGRAM DIRECTOR
ST. JOSEPH’S REGIONAL MEDICAL CENTER, PATERSON, NJ INTENSE REVIEW, JANUARY 16, 2016
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DISCLOSURESCSL Behring
Paid speaker/consultantKcentra, 4 factor PCC
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DIAGNOSISSoft ragged edge
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CHANCROIDHaemophilus ducreyi
PainfulSoft ulcerUnilateral inguinal lymph node
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DIAGNOSIS?Cauliflower like papules
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VENEREAL WARTS-HPVCondyloma Acuminatum
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Diagnosis?
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SECONDARY SYPHILIS
Condyloma lataFlat wart like lesions
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DIAGNOSIS?
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UMBILICATED PAPULE
TERMSMOLLUSCUM CONTAGIOSUM
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MOLLUSCUM CONTAGIOSUM
Umbilicated papuleSemisolid white materialAnywhere on skin
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DIAGNOSIS?Erythematous base
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GENITAL HERPESPainfulVesicles + ErythematousBase → Ulcerate
MC-HSV-2
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TERMSMULTINUCLEATE
GIANT CELLS
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TERMSMULTINUCLEATED GIANT CELL HERPES
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES
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DIAGNOSIS?
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
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• LYMPHOGRANULOMA VENEREUMChlamydia trachomatis
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PELVIC INFLAMMATORY DISEASEOne of the following:CMTAdnexal tendernessUterine tenderness
Treat NG/CT
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PELVIC INFLAMMATORY DISEASE Admit
IV ABX
Pregnant TOAPeritonealSeptic
No POUnknown DXIUD
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PIDMild – moderate PID can be treated as an OUTPATIENT due to similar efficacy of IV vs PO antibiotics
Clinical pearl
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ABX
INPATIENTOUTPATIENT
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PIDEctopic pregnancy
Complications
AdhesionsTOAInfertility
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FITZ HUGH CURTISQuick pearls
Shoulder/RUQ pain – Kehr’s signBacterial perihepatitis
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VIOILIN STRING ADHESIONSTERMS
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS
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DIAGNOSIS?Hard raised edge
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SyphilisTreponema pallidum
Painless Indurated UlcerPainless LN
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
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SECONDARY SYPHILIS
CONDYLOMA LATAMACULOPAPULAR RASH
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TERMSTERTIARY SYPHILIS TABES DORSALIS, GUMMA
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SYPHILISTx
PCN G ( 2.4 million units)
Doxycycline
DX SEROLOGY- VDRL/RPR
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DIAGNOSIS?Strawberry cervix
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONAS
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Trichomonas VaginalisStrawberry cervixGray/ yellow frothy discharge
ABX--METRONIDAZOLE
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DIAGNOSIS?Clue cells
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS
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BACTERIAL VAGINOSISGardnerella vaginosis
ABX--METRONIDAZOLE
CLUE CELLSKOH test-”FISHY ODOR”
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DIAGNOSIS?
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CANDIDACottage Cheese D/CKOH test - PSEUDOHYPHAE
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOUSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS
COTTAGE CHEESE D/C CANDIDA VAGINITIS
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OVARIAN CYSTSComplications (HuRT)
HemorrhageRuptureTorsion
DX: US/LAP
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DIAGNOSIS??OVARIAN TORSION
ABSENT DF
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OVARIAN TORSION Risk Factors → Tumors & CystsMC: DERMOIDDX: LAP US
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FAST FACTS OVARIAN CA
2 ND MC GYN CAHIGHEST MORTALITY
AGE > 60DX: US/CT/LAP
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OVARIAN CACLINICAL PEARLNEW ONSET ASCITES IN FEMALEGYNECOLOGIC CA (TILL PROVEN OTHERWISE)
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FAST FACTS Uterine CA
MC type?Most virulent?
Dx : Pap? (20%)
Age 60 -70
EndometrialSarcoma
DX: D&C/BX
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UTERINE CAClinical PearlPost menopausal female withbleeding / abnml uterine enlargementUterine CA (Till proven otherwise)
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FAST FACTS Pregnancy
Position - SymphysisPosition – Umbilicus
Blue, soft cervix
12 Weeks
Chadwick’s sign20 Weeks
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TERMSUMBILICATED PAPULE MOLLUSCUM CONTAGIOUSUM
MULTINUCLEATED GIANT CELL HERPES BUBOES LGV
VIOLIN STRING ADHESIONS FITZ HUGH CURTIS CHANCRE SYPHILIS
STRAWBERRY CERVIX TRICHOMONASCLUE CELLS BACTERIAL VAGINOSIS
COTTAGE CHEESE D/C CANDIDA VAGINITISCHOCOLATE CYST ENDOMETRIOMA
CHADWICK’S SIGN (Early) pregnancy
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FAST FACTS Human Chorionic Gonadotropin
Earliest (+) hCG?Peak?
Doubles q 2-3 days
10-12 weeks8-9 days
1 st 7-8 weeks?
(+) Post delivery / abortion? 2-3 weeks post
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B - hCGClinical PearlDON’T FOLLOW THE ABSOLUTE NUMBER TO DETERMINE VIABILITY, FOLLOW THE US(Especially > 10 WEEKS)
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DSC Zone = HCG 1500Gestational SAC
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Gestational Sac + Yolk Sac
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Double decidual sign
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Yolk sac & fetal pole
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FAST FACTS Physiologic changes in pregnancy
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23 yo G1 LMP 8 weeks ago presents with the following labs:(+) Hypokalemia(+) Ketonuria
IV hydration (D5NS)/ Antiemetics
HYPEREMESIS GRAVIDARUM
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DIAGNOSIS?
SUBCHORIONIC HEMORRHAGE
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FAST FACTS 1 ST TRIMESTER BLEEDING
50/50~20-25% affected 3 DDx ECTOPIC
ECTOPICECTOPICSCHABORTION
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KEY FEATURES TREATMENTOS CLOSED RESTTHREATENED
TISSUE @OS D&CINCOMPLETEOS OPEN/TISSUE AT UTERUS ±D&CINEVITABLE
PASSED TISSUE RESTCOMPLETE
RETAINED POC IV ABX/D&CSEPTICRETAINED POC MISSED ±D&C
FAST FACTS 1 ST TRIMESTER BLEEDING
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FAST FACTS RhoGHAM
Risk of fetal maternal hemorrhageWHO? WHEN?DOSE? 300 mcg 2/3 trimester
50 mcg 1st trimester
Risk of isommunization to <1%
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DIAGNOSIS?
ECTOPIC PREGNANCY
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FAST FACTS ECTOPIC PREGNANCY
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ECTOPIC PREGNANCY & hCGNO SINGLE HCG IN ISOLATIONRULES OUT ECTOPIC
CLINICAL PEARL
IF NO GS WITHIN DISCRIMINATORYZONE = ECTOPIC TILL PROVEN OTHERWISE
1500 TV 6500 TA
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Methotrexate candidates:
FAST FACTS ECTOPIC PREGNANCY
HCG < 5000Hemodynamically stableSize < 3-4 cmWBC > 2k; Platelets > 100k
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“SNOWSTORM”Molar pregnancy
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FAST FACTS MOLAR PREGNANCY
PAINLESS VAGINAL BLEEDINGUTERINE SIZE > GESTATIONAL AGEHIGHER THAN EXPECTED hCGHYPEREMESIS
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VAGINAL BLEEDINGBLOODY SHOWABRUPTIO
MC CX?
(late pregnancy – 4%)
MC LIFE THREATNING CX?
WHAT’S LEFT? PLACENTA PREVIA VASA PREVIA UTERINE RUPTURE
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DIAGNOSIS?PLACENTA PREVIA
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PLACENTA PREVIA
DX: US
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PLACENTA PREVIACLINICAL PEARLHemorrhage often stopsspontaneously and then recurs with labor
TX: SUPPORTIVE(ABCs, T & C, emergent consultation)
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PLACENTA ABRUPTIOPAINFUL DARK/CLOTTED (3RD TRI) VBPAINFUL/FIRM/TENDER UTERUS
DX: CLINICAL, US, FETAL MONITOR
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FAST FACTS PLACENTA ABRUPTIO
Spontaneous RFs? HTN, age, multiparous, stimulants, pre-eclampsia
Spontaneous MC v. Trauma
Complications? Fetal/Maternal Death, DIC
Dx? US (Nonspecific) Tocolytic monitoring
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PLACENTA PREVIACLINICAL PEARLDegree of bleeding DOES NOT correlate with potential severity
TX: SUPPORTIVE ± DELIVERY(ABCS, T & C, Coags, Kleihauer-Betke test, Emergent consultation)
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DIAGNOSIS?PLACENTA ABRUPTIO
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AN 18 YO FEMALE PRESENTS TO YOUR ED WITH CC OF HA AND “DIFFICULTY SEEING”
VITALS 162/94; 104; 24; 99EXAM B/L EXTREMITY & FACIAL EDEMA
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PREECLAMPSIA>20 WEEKS NEW ONSET HTN (140/90)
PROTEINURIA (300MG/24H)
<20 WEEK THINK MOLAR PREGNANCY
RFs PRIMIGRAVADAAge extremesDiabetesMolar pregnancyMultiple gestationRenal, Vascular, CTD
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FAST FACTS PREECLAMPSIA (3-7%)
EXAM? EDEMA (HANDS/FEET/FACE)
VITALS? HYPERTENSIVE
URINE? PROTEINURIA
PROGRESSION TO ECLAMPSIA? 1 IN 200
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FAST FACTS PREECLAMPSIA (3-7%)
ABCs, GLUCOSE, IV, FETAL MONITORING, LEFT LATERAL DECUBITUS
WORKUP? CBC, PLATELET, RENAL/LIVER FUNCTION, COAGS
WORKUP? HOSPITALIZE, ± ANTI-HTN, DELIVERY MAG (PREVENT/STOP SZ)
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FAST FACTS MAGNESIUMDose: 4-6 gm IV over 20 min,2 gm/hrToxicity: Hypotension, Respdepression, AMSCa Gluconate 10%-10 ml over 3 minutes
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FAST FACTS HELLPHemolysis, Elevated Liver enzymes, Low PlateletsPresentation: EpigastricpainTreatment: Same as preeclampsia
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FAST FACTSECLAMPSIA
HYDRALAZINE 5-10 mg IV q20 min maximum 30 mg iv LABETALOL10-20 mg IV
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DIAGNOSIS?
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FAST FACTSTRAUMA IN PREGNANCYMaternal prognosis determines fetal prognosis
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FAST FACTSTRAUMA IN PREGNANCY
Signs of fetal distress (DECELS) >8 Contractions/hour suggest abruption
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KLEIHAUER BETKE
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FAST FACTS TRAUMA – FMH
KEYS UNIVERSALRHOGHAM 300 MCG FOR RH (-) MOMS SUSTAINING BAT
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FAST FACTS TRAUMATIC ARREST
KEYS TO FETAL SURVIVAL Cause of maternal deathGestational age Quality of CPRTIME FROM ARREST TO DELIVERYVertical abdominal and uterlne incision
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Obstetric HemorrhagePreeclampsia/EclampsiaObstetric InfectionPulmonary EmbolismAmniotic Fluid EmbolismCardiomyopathyAnesthetic
33%
20%15%
13%
9%7% 3%
CAUSES OF PERIPARTUM MATERNAL DEATH
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FAST FACTS POST PARTUM HEMORRHAGE
MC CX? UTERINE ATONY
TX UTERINE ATONY? FUNDAL MASSAGE, OXYTOCIN
OTHER CAUSES? UTERINE RUPTURERETAINED PLACENTAUTERINE INVERSIONLACERATIONCOAGULOPATHY
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AN 32 YO FEMALE PRESENTS WITH CC OF “FOUL SMELLING” VAGINAL DISCHARGE AND ABDOMINAL PAIN. PATIENT REPORTS RECENT C/S 5D AGO
Vitals 110/60; 104;24;101.4
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FAST FACTS ENDOMETRITIS
HIGH RATES IN C/S
PRESENTATION?
POLYMICROBIAL
FEVERABDOMINAL PAINFOUL SMELLING D/C Admit Broad spectrum ABX
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DIAGNOSIS?MASTITIS
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FAST FACTS MASTITIS
PRESENTATION? PAINFEVERERYTHEMASWELLING
CX? STAPHYLOCOCCALTX? CEPHALOSPORIN
SAFE TO BREASTFEED