General obstetrics Flashcards
what is CKC
cold knife conization
what is LEEP
loop electrocautery excision procedure
what is BTL
bilateral tubal ligation
what is TVH
trans vaginal hysterectomy
what is TAH
trans abdo hysterectomy
define ASCUS
atypical squamous cells of undetermined significance
define LGSIL
low grade squamous intra epithelial lesion
define HGSIL
high grade squamous intraepithelial lesion
when is home UPT positive
8-9 days
what should your beta-hCG be at 10 weeks
100 000
what should your beta-hCG be at 5 weeks
1500-2000 (can maybe see gestational sac this early)
what should your beta-hCG be at term
10 000
what is the discriminatory zone
b-hCG is 1200-1500
evidence of a pregnancy should be seen on transvaginal U/S (5 weeks)
when b-hCG is 6000 you can see evidence on a transabdominal U/S
when can you see fetal heart tone on U/S? doppler?
U/S at 6 weeks
doppler at 12 weeks
naegeles rule
LMP-3 months + 7 days + 1 year
when should you feel fetal quickening
16-20 weeks
list the signs and symptoms of pregnancy
- chadwick’s sign–blue hue of cervix
- Goodells sign–softening and cyanosis of cervix at 4 weeks
- Laddin’s sign–> softening of uterus at 6 weeks
- breast swelling and tenderness
- linea nigra
- palmar erythema
- telangiectasias
- nausea
- amenorrhea
- quickening
list 3 drugs that are okay in first trimester
tylenol
benadryl
phenergan
when do you give rhogam
28 weeks
when do you go GBS screen
35-37 weeks
what advice should be given to mothers reaching term
“go to labour and delivery is you have contractions every 5 min, if you feel sudden gush of fluid, if you dont feel the baby move for 12 hours, or if you have bleeding like a period. normal to have pink discharge or mucus in weeks preceeding labour”
list examples of routine problems of pregnancy
back pain
hemorrhoids
pica
edema
GERD
varicose veins
dehydration
frequency
constipation
braxton hicks
round ligament pain
what does increased MSAFP indicate
neural tube defects
omphalocele
gastrochisis
multiple gestation
fetal death
incorrect dates
what does decreased MSAFP indicate
down syndrome
certain trisomies
how do you test for fetal lung maturity
lecithin/sphinomyelin ratio–> over 2.0 indicates fetal lung maturity
FLM–> over 55mg/g is mature, good for use in diabetics
phosphatidyl glycerol–> positive or negative–> hyperglycemia delays lung maturity
what effect does hyperglycemia have on lung maturity
delays it
what lecithin/sphinomyelin ratio indicates lung maturity
over 2.0
where is the most common place for an ectopic pregnancy
ampulla of the fallopian tube
can also be in ovary, abdo wall, cervix, bowel
risk factor for ectopic
infection of tubes
PID
IUD use
previous tubal surgery
assisted reproduction
rate of ectopic
1/100 pregnancies
symptoms of ectopic
episodic lower back pain
abnormal bleeding due to inadequate progesterone support
b-hCG decreased–> normally doubles every day but doesnt in ectopics
unilateral tenderness
may have mass
Cullen’s sign–> periumbilical hernia
U/S finding of complex adnexal mass, can see sac or fetus outside uterus
what is the dosing of methotrexate for ectopics
50 mg/m2
what is the Arias-Stella reaction
associated with ectopic pregnancy
endometrial change that looks like clear cell carcinoma (but is not cancerous)
what are some things that can cause second trimester abortion
infection
maternal anatomical defects
cervical defects
systemic disease
fetotoxic agents
trauma
what is McCune Albright disease
polyostotic fibrous dysplasia –> degeneration of long bones, sexual precocity, cafe au lait spots
treat precocious puberty with medroxyprogesterone acetate
define a “reactive” NST
2 accelerations of 15 beats per minute for 15 seconds in 20 min strip
how do you “grade” a BPP
look at: NST amniotic fluid index fetal breathing movements fetal extremity movements fetal tone
give either 2 points or zero points and then grade it
above 8 is good, less than 4 is bad
define contraction stress test
nipple stimulation or oxytocin–shows 3 uterine contractions in 10 min to be good
what is EDD
40 weeks from LMP
how big is the uterus at 10 weeks
grapefruit
how big is the uterus at 20 weeks
at umbilicus
what are the requirements to use outlet forceps for delivery (these are the same requirements for vacuum delivery)
- visible scalp
- skull on pelvic floor
- occiput anterior or posterior
- fetal head on perineum–can see without separating labia
- adequate anesthesia–bladder drained
- maximum 45 degrees of rotation
requirements for use of low forceps
station 2 but skull not on pelvic floor
requirements for mid forceps
station higher than 2 with engaged head (NOT DONE)
what are the risks of vacuum delivery
cephalohematoma
lacerations
indications for induction
preeclampsia at term
PROM
chorioamnionitis
fetal jeopardy/demise
above 42 weeks GA
IUGR
name 3 types of prostaglandins used in labour induction
prepidil
cervidil
cytotec
what do prostaglandins do in labour
dilate cervix and increase contractions
when are prostaglandins contraindicated in labour induction
prior C/S
nonreassuring fetal monitoring
what is the dosing for oxytocin in labour induction/augmentation
10 U in 1000mL IV piggyback on pump at 2mU/min
if over 40 mU/min are used watch for SIADH
describe the process of delivering a baby vaginally
- crowning
- Ritgen’s maneuver–> hand pressure on perineum to flex head
- head out
- check for nuchal cord
- delivery of anterior shoulder gently by pulling straight down
- deliver posterior shoulder with upward movement
- clamp cord with 2 Kelly’s
- cut cord with scissors
- hand off baby
- get cord blood
describe how to deliver the placenta
- gentle traction on cord with suprapubic pressure to prevent uterine involution
- massage uterus
- retract placenta out and inspect
- inspect mom for tears, visualize complete cervix
what do you use to do episiotomy repairs
2.0 chromic or vicryl locking suture superiorly to repair vaginal mucosa
interrupted chromics to repair deep fascia if needed
simple running to repair mid fascia
sub Q stitch inferiorly and superficially
how is dating done on U/S
biparietal diameter
head circumference
femur length and abdominal circumference
what do we look at on doppler velocimetry
systolic/diastolic ratio in the umbilical cord
what is chorioamnionitis
infection of the amniotic fluid
how should you manage chorioamnionitis
requires DELIVERY
increased risk with increasing length of rupture of membranes
AMPICILLIN and GENTAMYCIN–> add clinda if C/S
signs and symptoms of chorioamnionitis
fever above 38
high white count
tachy
uterus tender
foul discharge
what is the most common cause of neonatal sepsis
chorioamnionitis
risk factors for endometritis
prolonged labour
PROM
more associated with C/S than vaginal delivery
what organisms cause endometritis
anerobes/aerobes, polymicrobial
i.e e coli, GBS, bacteroides
symptoms of endometritis
uterine tenderness
foul lochia
treatment for endometritis
GENTAMYCIN and CLINDAMYCIN (continue until 24-48 hours afebrile)
define post partum hemorrhage
more than 500 mL blood loss following vaginal delivery
more than 1000 mL blood loss following C/S
causes of PPH
uterine atony
forceps
macrosomia
coagulopathy
uterine rupture
uterine inversion
treatment of PPH
- vigorous fundal massage
- oxytocin 20 U in 1000 mL NS
- repair laceration
- methergine 0.2 mg IM (contraindicated in HTN)
- take out placental remnants
- PgF2-alpha (Hemabate)–> contraindicated in asthma
- cytotec 800 mg rectal
- hysterectomy if medical therapy fails
what is the dosing of oxytocin for PPH
20 U in 1000 mL NS
what is the dosing of methergine for the tx of PPH
0.2 mg IM
dosing of PgF2-alpha (hemabate) for PPH
?
dosing of cytotec for PPH
800 mg rectal
why do we care about Rh antibodies
can cross the placenta and cause a hemolysis in the newborn which may cause death
what is rhogam and when is it given
passive immunization to prevent sensitization to Rh antigen in Rh - mom
given at 28 weeks
check baby at delivery
if Rh+–> give rhogam again to mom within 72 hours
what do you do if a woman is a multip who has been sensitized to Rh
check a titre–> if over 1:8, do fetal survey on U/S and amniocentesis at 16-20 weeks to measure the OD 450 with the spectrophotometer
look at LILEY CURVE
if in zone 2 or 3, so intrauterine blood transfusion through umbilical artery of Rh neg blood
what is erythroblastosis fetalis
hemolytic anemia in the fetus caused by transplacental movement of Rh antibodies made by Rh- mom against Rh+ kid
heart failure, diffuse edema, ascites, pericardial effusion, bilirubin breakdown–> jaundice, neurotoxic effects
why do we care about retained POC in the setting of intrauterine fetal demise (IUFD)
retained IUFD over 3-4 weeks leads to hypofibrinogenemia secondary to the release of thromboplastic substance of the decomposing fetus–>
can cause DIC
how do you diagnose IUFD on U/S
no FHT
why do we care about babies being post dates
increased risk of macrosomia, oligohydramnions, meconium aspiration, IUFD
what do you do for a woman who has not yet delivered at 41 weeks
NST–> if nonreassuring, do induction
what do you do for a woman who has not yet delivered at 42 weeks
do BPP and NST twice a week–> if non reassuring, do induction
when do you induce for post dates
MUST induce after 42 weeks even if fetal testing normal
what is the rate of twins and triplets
1/80 twins
1/7000-8000 triplets
what are some complications associated with multiple gestation
PTL
placenta previa
cord prolapse
PPH
what are some fetal complications associated with multiple gestation
preterm
congenital abnormalities
SGA
malpresentation
when do twins usually deliver? triplets?
twins–> 36-37 weeks
triplets–> 33-34 weeks
define “di/di” monozygotic twins–> when does separation occur?
dichorionic diamniotic –> 2 chorions and 2 amnions
separation occurs BEFORE trophoblast on embryonic disk –> splits BEFORE 72 hours
define “mono/di” monozygotic twins–> when does separation occur?
has one placenta but two amnions
separation 5-10 days before amnion forms
define “mono/mono” twins
monochorionic monoamniotic
can be conjoined
one chorion and one amnion
what are dizygotic twins
fraternal
dichorionic and diamniotic
two eggs and two sperm
what are monozygotic twins
one egg one sperm
what is HELLP syndrome
hemolysis, elevated liver enzymes, low platelets
usually in the severe pre-eclampsia classification
how do you treat HELLP
delivery
magnesium sulfate
hydralazine
what is eclampsia
pre-eclampsia plus seizures
can have cerebral herniation, hypoxic encephalopathy, aspiration, thromboembolic events
what type of seizures are associated with eclampsia
tonic clonic
25% pre-labour
50% labour
25% after labour (even 7-10 days)
how do you treat eclampsia seizures
magnesium sulfate for membrane stabilization
lorazepam IV
define asymptomatic bacteriuria and why do we care about it in pregnancy
more than 100 000 colonies
5% of pregnancies
causes increased susceptibility to cystitis and pyelonephritis
15% complicated by bacteremia, sepsis, ARDS
why do we treat asymptomatic bacteriuria in pregnancy
risks of preterm labour associated with pyelonephritis
causes of UTI in pregnancy
staph saprophyticus
chlamydia
e coli
klebsiella
pseudomonas
enterococcus
proteus
coag - staph
GBS
symptoms of UTI
dysuria
frequency
urgency
diagnosis of UTI
UA with positive nitrites, WBC esterase, bacteria
treatment of UTI in pregnancy
nitrofurantoin
signs and symptoms of pyelonephritis
CVA tenderness
fever
dirty UA
*must have 2/3 criteria to diagnose
treatment of pyelonephritis
IV ancef until afebrile for 48 hours then 7-14 days of PO keflex
why is pyelonephritis more likely to occur on the right in pregnancy
because uterus is dextrorotated
why are women predisposed to pyelonephritis in pregnancy
progesterone can cause urinary stasis which can predispose to pyelonephritis
by when does morning sickness usually resolve
16 weeks
define hyperemesis gravidarum
more pernicious vomiting associated with weight loss, electrolyte imbalances, dehydration and, if prolonged, hepatic and renal damage
how do you treat hyperemesis gravidarum
maintain nutrition
NS with 5% dextrose
compazine
phenergan
reglan IV/IM
if needed–> TPN
why should you not give coumadin in pregnancy
skeletal anomalies
nasal hypoplasia
what should you use to treat DVT in pregnancy
heparin or lovenox
no coumadin
symptoms of fetal alcohol syndrome
growth retardation
CNS effects
abnormal facies
cardiac defects
treatment for alcoholism in pregnancy
aggressive counseling
adequate nutrition
what are the risks of tobacco in pregnancy
increased SAB preterm birth abruption decreased birth weight SIDS respiratory disease
what are the risks of cocaine in pregnancy
increased risk of abruption (from vasoconstriction)
IUGR
increased PTL
as a child, kid may have developmental delay
what is the test for vasa previa
APT test–> uses KOH
if colour is pink–fetal
if brown–maternal
what is the risk with heroine/methadone use in pregnancy
not so much use—it is the withdrawal that is the risk
what is the risk of heroine/methadone use
miscarriage
PTL
IUFD
what is the management of heroine/methadone addiction in pregnancy
enroll in methadone program
do not restart methadone if patient has not used for 48 hours
when does milk letdown occur after delivery
24-72 hours
can you continue to breastfeed with mastitis
YES
what do you use to treat mastitis
dicloxacillin
what should be used for birth control after delivery if breastfeeding
depo
micronor
(progesterone)
what should be used for birth control after delivery if not breastfeeding
OCP
norplant
depo
orthoevra
(can have estrogen)
define PPH
blood loss over 500 cc for vaginal delivery
over 1000 cc for C/S
causes of PPH
4 Ts Tone (UTERINE ATONY) Trauma Thrombin Tissue
i.e uterine atony, retained products, placenta accreta, lacerations, uterine rupture, uterine inversion
risk factors for uterine inversion
fundal placenta
atony
accreta
excess cord traction
treatment for uterine inversion
manually revert
NTG
laparotomy
risk factors for uterine atony
multiparity
history of atony
fibroids
treatment for PPH
carbitocin
diagnosis of hyperemesis gravidarum
persistent vomiting
weight loss above 5% pre-pregnancy weight
ketonuria
clinical dx
ddx for hyperemesis gravidarum
multiple gestation
hyaditiform mole (molar pregnancy)
preeclampsie
HELLP
what causes hyperemesis gravidarum
elevated serum progesterone and estrogen–> slowed gastric transit time–> delayed gastric emptying
and/or
elevated b-hCG–> higher levels may be correlated
cause is not definitively known these are only guesses
non pharmacological tx for hyperemesis gravidarum
folic acid and multivitamin before preg
smaller more frequent meals
avoid spicy, fatty, strong odoured foods
more rest, shorter working days
motion sickness bands
ginger, peppermint
pharmacological treatment for hyperemesis gravidarum
stepwise treatment protocol
- pyridoxine (vitamin B6) with doxylamine (antihistamine) –> AKA DICLECTIN
- can add a second antihistamine
- IV fluids and thiamine if dehydrated
- onsansetron if still not well managed
- consider dopamine antagonist (metoclopramide)
- prednisone tapered over two weeks
- consider enternal/TPN if absolutely required
what can happen if hyperemesis gravidarum is left untreated
wernicke’s encephalopathy
malnutrition
rare complications:
mallory weiss tear, esophageal rupture, pneumothoraces, pneumomediastinum, rhabdo, osmotic demyelination syndrome
recurrence risk high
what are post partum blues
changes in mood, appetite, sleep–> will resolve
50% of women experience
what is post partum depression
decreased energy apathy insomnia anorexia sadness
can get better or proceed to post partum psychosis
5% of women experience
treatment for post partum depression
SSRIs
what is endometritis
a polymicrobial infection invading the uterine wall after delivery
signs and symptoms of endometritis
fever
increased WBCs
uterine tenderness at 5-10 days
foul discharge
how do you manage endometritis
look for retained products–> do a D and C
treat with triple antibiotics until afebrile for 48 hours and pain gone –> AMPICILLIN, GENTAMICIN and METRONIDAZOLE
–> doxy should be used if chlamydia is the cause
