Category: Obstetrics and Gynecology

Breast Complaints

All breast complaints are cancer until proven otherwise!!!

History

  • Increased risk of breast cancer
    • Family history of breast cancer (especially 1st degree)
    • Delayed childbearing (no children until after 30)
    • Age >50
  • Associated with menstrual cycle

Exam

  • Asymmetric appearance of breasts
  • Palpable mass
    • Red Flags
      • Non-mobile
      • Overlying skin changes
      • Lymphadenopathy
      • Located in upper/outer quadrant of breast

Differential Diagnoses

  • Red/inflamed/painful breast
    • Postpartum engorgement
      • Treat with warm compresses, continue breastfeeding/pumping, massage
    • Infection (“Mastitis”)
      • Treat with antibiotics and continue breastfeeding
    • Abscess
      • Treat with needle aspiration
      • Refer to breast surgeon
  • Non-inflamed breast pain
    • Fibrocystic changes
      • Associated with menses
      • Treat with supportive bra
  • Breast mass
    • Fibroadenoma
      • Slippery/mobile
    • Fibrocystic changes
  • Nipple discharge
    • Red flags
      • Unilateral discharge
      • Bloody discharge

Additional Reading

  • Breast Cancer Screening Guidelines (CDC)

Non-Pregnant Vaginal Bleeding

Common Causes

  • Structural
    • Cancer
    • Post-menopausal bleeding is cancer until proven otherwise
    • Fibroids
    • Adenomyosis
    • Polyps
  • Coagulopathy
    • Present in approximately 20% of non-pregnant vaginal bleeding
    • Most common = Von Willebrand Disease
  • Hormonal causes
    • Dysfunctional uterine bleeding

Basic Approach to Non-Pregnant Vaginal Bleeding

  • Step 1: Pelvic exam
    • The utility of this is debated
    • It is best to sound thorough on your clerkship
    • Have a chaperone present and document this (include the chaperones name)
  • Step 2: Obtain Labs
    • CBC
      • Anemia?
      • Thrombocytopenia?
    • Coags
      • aPTT is prolonged in 50% of patients with Von Willebrand Disease!
    • Thyroid (TSH)
      • Can be obtained outpatient
      • Common cause of hormonal related vaginal bleeding
  • Step 3: Pelvic ultrasound
    • Evaluates for ANATOMIC causes of vaginal bleeding
  • Step 4: NSAIDS
    • This treats both abdominal pain/cramping
    • Also improves bleeding
  • Step 5: Oral contraceptive pills
    • Can be started on an outpatient basis
    • Useful in patients with hormonal/dysfunctional uterine bleeding
      • Stabilizes endometrial lining

Additional Reading

1st Trimester Vaginal Bleeding

The pregnancy test is the most important test in females of reproductive age!

Five Important Tests in 1st Trimester Vaginal Bleeding

  • CBC
    • Hemoglobin/Hematocrit
      • Mild anemia in pregnancy is physiologic and normal
    • Thrombocytopenia
  • Type and Screen
    • Required for blood transfusion
    • Determines if patient needs RhoGAM
      • Rho(D) immune globulin
        • Binds fetal Rh antigens from a fetus so that mother doesn’t develop antibodies against future Rh positive children
        • Prevents hemolytic disease of the newborn
        • Give to Rh negative mothers to protect future Rh positive children
  • Quantitative hCG
    • hCG >1500
      • “Cutoff” where definitive pregnancy should be seen on ultrasound
      • If no pregnancy is seen, highly concerning for ectopic pregnancy
    • hCG <1500
      • Ectopic pregnancy still possible
      • Common for healthy early pregnancies to not be visualized below this level
  • Urinalysis (UA)
    • Treat asymptomatic bacteriuria in pregnant patients
      • One of the only times UTI should be treated in asymptomatic patients
      • Theoretical increased risk of miscarriage
  • Pelvic ultrasound
    • Evaluates for ectopic pregnancy
    • Subchorionic hemorrhage
    • Miscarriage

Additional Reading

Preeclampsia

Never ignore a pregnant woman’s blood pressure.

Introduction

  • Pre-Eclampsia
    • Pathophysiology unknown
    • Pregnancy induced multi-organ dysfunction
    • Definition
      • Pregnancy
        • PLUS
      • BP 135/85
        • PLUS
      • Proteinuria
  • Eclampsia
    • Preeclampsia
    • PLUS
    • Seizures
  • HELLP Syndrome
    • Preeclampsia
    • PLUS
    • Hemolysis
    • PLUS
    • Elevated liver enzymes
    • PLUS
    • Low platelets

Step 1: Evaluate For Four Big Symptoms

  • Swelling/edema
  • Headache
  • Visual changes
  • Abdominal pain

Step 2: Testing

  • Urinalysis
    • Proteinuria
  • CBC
    • Hemolysis
    • Thrombocytopenia
  • Electrolytes
  • Liver function tests

Step 3: Start Magnesium

  • Hypomagnesemia = Hyporeflexia

Step 4: Control the Blood Pressure

  • Hydralazine
  • Labetalol

Step 5: Admit

  • OB emergency
  • All patients need fetal monitoring

Additional Reading

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