Women's Health (Exam 3) - OBGYN Emergencies, Domestic Violence & Sexual Assault

Half of TSS cases associated with ____________

menstruation

MC pathogen of TSS

s aureus

Release of exotoxins & enterotoxins causes Massive activation of cytokine production in a host with poor antibody response to the toxin(s)

TSS

S/Sx:

•Fever/ chills

•Hypotension

•erythroderma, desquamation

•abdominal pain, vomiting, diarrhea

•weakness, myalgias

•hyperemia, sclera-conjunctival hemorrhages, ulcers, petechiae, vesicles, bullae

•elevated BUN and creatinine, metabolic abnormalities, elevated LFTs

•thrombocytopenia, anemia, prolonged PT and PTT, DIC

•headache, somnolence, confusion, irritability, agitation, hallucinations

•pleural effusion, pulmonary edema

•cardiomyopathy

TSS

begins w diffuse, red, macular rash that looks like a sunburn and involves the palms and soles

TSS

Pruritic maculopapular rash & desquamation 1-3 weeks after onset of illness

TSS

TSS dx

clinical

An otherwise healthy individual with rapid onset of:

•Fever

•Rash

•Hypotension

•Multisystem organ involvement

•Relevant risk factor: recent tampon use, surgery, infection

TSS

TSS management

fluids, pressors, surgical debridement, abx

TSS abx

vanc AND clinda AND zosyn

S/Sx:

•Lower abdominal pain, bilateral, acute

•Irregular uterine bleeding

•Cervical motion, uterine, and/or adnexal tenderness of bimanual exam

•RUQ pain, pleuritic, sometimes referred to R shoulder (Fitz-Hugh Curtis Syndrome)

PID

PID abx

ceftriaxone AND doxy AND metronidazole

PID abx time frame

14d

Potentially life-threatening complication of PID

TOA

collection of pus involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs such as bowel and bladder

TOA

agglutination of pelvic structures

tubo ovarian complex

Risk factors and clinical presentation same as PID but can present subacutely

TOA

Ruptured abscess leaks contents into abdominal cavity; more likely to present with acute abdomen and sepsis (occurs in 15% of cases)

TOA

TOA dx

us

management of TOA:

•____________ for rupture or postmenopausal women (d/t risk of concurrent GYN malignancy)

•Can try __________ alone in pre-menopausal women who are hemodynamically stable without evidence of rupture with abscess <____cm in size

surgical exploration, abx, 7

TOA abx

ceftriaxone AND doxy AND metronidazole

Rotation of the ovary on its ligamentous support causing compromised blood supply (Will cause necrosis and loss of ovarian function)

ovarian torsion

ovarian torsion is more common in the _________ ovary

right

S/Sx:

•Acute onset of moderate-to-severe pelvic pain

•Nausea and vomiting

•Low-grade fever, more common in necrosis

•Typically, in women with h/o ovarian mass

ovarian torsion

ovarian torsion management:

•________________ for pre-menopausal pts with viable, nonmalignant ovary

•________________ for non-viable ovary, malignancy, postmenopausal pts

operative detorsion, salpingo-oopherectomy

to prevent recurrence of ovarian torsion, start pt on __________ to suppress ovarian cysts

COC

Infection of upper urinary tract/kidney, ascends from lower urinary tract

pyelonephritis

MC pathogen of pyelonephritis

e coli

Increased risk of pyelonephritis in pregnancy due to ureter ___________ from growing uterus and ______________ changes

dilation, hormonal

S/Sx:

•Fever/chills

•Flank pain

•Costovertebral angle (CVA) tenderness

•Nausea and vomiting

•May or may not be accompanied by cystitis symptoms (dysuria, hematuria, etc.)

pyelonephritis

pyelonephritis dx

UA and culture

outpatient tx of non-pregnant pyelonephritis

cipro OR levo

outpatient tx of pregnant pyelonephritis

bactrim OR augmentin

inpatient tx for non-pregnant and critical pyelonephritis

imipenem or meropenem AND vanc

inpatient tx for non-pregnant and non-critical pyelonephritis

ceftriaxone OR zosyn

inpatient tx for pregnant and mild to mod pyelonephritis

ceftriaxone

inpatient tx for pregnant and severe pyelonephritis

zosyn

spontaneous abortion is up to _____wks GA

20

•Gestational sac without yolk sac or embryo

•Previously caused blighted ovum

anembryonic pregnancy

first trimester (early) pregnancy loss is up to ______w_______d GA

12, 6

fetal demise is fetus measuring at least ____wks GA without ___________ activity

10, cardiac

2 or more spontaneous losses

recurrent pregnancy loss

2nd trimester pregnancy loss is between ________w and _______w_____d

13, 19,6

stillbirth or fetal death is loss at ______wks or greater GA

20

Bleeding in early pregnancy without clear diagnosis of loss

threatened miscarriage

miscarriage:

•__________: bleeding and cramping/pain

•__________: hemorrhage and/or infection

uncomplicated, complicated

miscarriage Dx:

• __________confirmation for anyone with suscepted miscarriage to evaluate for IUP and viability

•Confirmed if previously confirmed IUP or __________ activity no longer seen

•Labs: type & screen

•Serial beta-quantitative _____________

us, cardiac, hCG

miscarriage management:

•Inquire about ______________ pregnancy loss

•Inquire about present ____________ about the process

•Inquire about patient’s comfort with passing _____________ versus having a provider remove the pregnancy.

•Inquire about patient’s comfort with minor surgeries/procedures and their concerns about ____________ control.

previous, worries, naturally, pain

expectant management of miscarriage can be used:

•<______w GA

•Pt counseled on risk of pain, fluctuations in _________ flow, duration of +/-____ days

13, blood, 14

medication management of miscarriage can be used up to _______w_____d

19, 6

meds for miscarriage

mifepristone, misoprostol

management of miscarriage over 20wks GA

delivery

MC location of ectopic pregnancy

fallopian tubes

1st trimester vaginal bleeding and/or abdominal pain typically 6-8 weeks after LMP

ectopic pregnancy

ectopic pregnancy dx

TVUS, hCG (slow rise)

preferred management of ectopic pregnancy

medical

ectopic pregnancy meds

methotrexate

medication management of ectopic pregnancy:

•_________, stable, no __________ activity, hCG <___________ mIU/mL, can comply with posttreatment follow-up

tubal, cardiac, 5000

management of ectopic pregnancy if:

•Hemodynamically unstable

•Impending or ongoing ruptured ectopic pregnancy

•Need for concurrent surgical procedure (e.g., tubal ligation)

•Contraindication to or failed methotrexate therapy

surgical

New-onset hypertension plus significant end-organ damage dysfunction- most commonly proteinuria- after 20 weeks gestation

preeclampsia

preeclampsia:

SBP over ________mmHg and/or DBP over ______mmHg on 2 occasions 4hrs apart after ______wks gestation PLUS 1 or more of the following:

-proteinuria

-platelets under 100,000

-SCr over 1.1

-LFTs over 2x ULN

-pulm edema

-headache

-visual sx

140, 90, 20

preeclampsia w severe features:

SBP over ________mmHg or DBP over ________mmHg PLUS

-sx of _____________ dysfunction

-____________ abnormality

-thrombocytopenia

-_________ function impairment

-___________ edema

160, 110, CNS, hepatic, kidney, pulm

S/Sx:

•Severe headache that does not respond to analgesics

•Visual abnormalities

•Abdominal pain (upper, retrosternal, epigastric)

•Altered mental status

•New orthopnea or dyspnea

preeclampsia

atypical preeclampsia:

•Onset <20 weeks, rare, associated with _________ pregnancy or ________

•Postpartum-- >____ days but <____ weeks after birth

molar, APS, 2, 6

preeclampsia screening

BP checks

preeclampsia prevention includes _________ 81mg between ________wks GA

aspirin, 12-16

preeclampsia management:

•≥ 37w0d– ____________

•<37w0d- ___________ management with ___________ for severe or complications

delivery, expectant, delivery

New-onset, generalizes, tonic-clonic seizures or coma in a pt with preeclampsia.

eclampsia

Eclampsia Management:

•_________ position with supplemental oxygen

•___________ for severe HTN to preduce risk of stroke

•__________ medications

•____________

lateral, antihypertensives, antiseizure, delivery

Antiseizure meds for eclampsia:

•_____________ after seizure cessation to reduce risk of recurrence

•___________ or _____________ for seizures >5 minutes

Mg, lorazepam, diazepam

HELLP syndrome

hemolysis, elevated liver enzymes, low platelets

S/Sx:

•RUQ pain

•Proteinuria

•Hypertension

•Malaise

•N/V

HELLP syndrome

management of HELLP syndrome

delivery

actual or threatened psychologic, physical, or sexual harm by a current or former partner or spouse

intimate partner violence

Risk factors for DV perpetration:

•Exposure to ___________ violence

•Unresolved ___________especially related to returning veterans

•Recent _______ loss or instability

•___________ use disorder

childhood, PTSD, job, substance

S/Sx:

•Inconsistent explanation of injuries

•Delay in seeking care or missed appointments

•Frequent ED visits

•Late prenatal care

•Inappropriate affect

•Overly attentive partners

•Reluctance to be examined

•Difficulty with daily activities

•Difficulty with ambulation

•Memory loss

•Injuries without good explanation, especially head/neck, trunk, forearms

DV

when to screen for intimate partner violence:

-___________ primary care and obgyn visits

-pts w ______________ (particularly older adults)

-pts seen in __________ and/or upon admission

-_________________ pts

-pts w chronic unexplained _______ pain or headaches

-pts w STDs

-older adults w signs of ___________

initial, injuries, ED, pregnant, abd, neglect

penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim

sexual assault

The ______________ operates a National Sexual Assault Hotline (800-656-HOPE)

•Automatically routes caller to nearest sexual assault service provider

•Free, confidential services

RAINN (Rape, Abuse & Incest National Network)

____________ creates and supports comprehensive, cost-effective responses to sexual assault, intimate partner violence, dating violence, and stalking.

•Allows for sexual assault examination without requiring law enforcement involvement.

VAWA (Violence Against Women Act)

sexual assault STI prophylaxis

ceftriaxone AND doxy AND metronidazole

additional prophylaxis following sexual assault

hep B and HPV vaccine, HIV PrEP

Assessment of safety prior to discharge of SA pts:

•Follow-up within ___________

•Complete any ______________ started

•Repeat syphilis and HIV testing in _____ and _______weeks

2wks, vaccines, 12, 24

Mandatory reporting in NC applies to _________ and ___________ adults

minors, disabled