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Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine
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Jeff Rundio, DO- OB Board Review 2014 - ARMC Emergency Medicine

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  • 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

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