Gyne Flashcards
Which leg is more likely to have a DVT in pregnancy?
- Left iliac vein crosses over left iliac artery, leading to relative compression (left leg deep venous thrombosis is three times more likely than right in pregnant patients).
COCP Contraindications
absolute:
- smoker (>15 cig/day) and >35 y old
- HTN (>160/100)
- Hx VTE, CAD, CVA, Afib, endocarditis, pulmonary HTN, migraine with aura, current breast ca, diabetes with micro complications, severe cirrhosis, liver tumor.
- migraine without aura and >35 y, or migraine without aura after starting COCP
relative:
- smoker (35 y old
- symptomatic gallbladder, mild cirrhosis, Hx COCP related cholestasis
- > 35 y with BMI >30
Missed Pill Guidelines
COCP
- >48h and two or more missed pills: take one ASAP, take next at usual time. 7 days backup. Emergency contraception if necessary. *If missed dose is in last week of cycle (days 15-21 of a 28-day pill pack), omit hormone-free interval (discard rest of pack) and start next cycle.
Progestin Only Pill
- >3h past dose time or vx/dx within 3h of dose: take 1 pill ASAP, take next pill at usual time. Backup 2 days. Consider emergency contraception.
Emergency Contraception
- copper IUD: most effective within 120h (~100%), up to 7 days post-coitus. Contraindicated in pregnancy, PID
- ulipristal acetate: most effective, especially 70-120h compared to levonorgestrel. 30 mg tab x 1.
-
Plan B (levonorgestrel): 1.5 mg x 1, 95% effective within 24h
- notes: will not cause abortion, make sure bleeding within 21 days otherwise preg test
- Can resume any contraceptive method after EC. Barrier method for 7 days post (14 days post Ella/ulipristal).
- Take pregnancy test if no withdrawal bleeding within 3 weeks. If vx within 3 hours, repeat dose of EC.
Causes of AUB
-
Structural
- Polyp
- Adenomyosis
- Leiomyoma
- Malignancy/hyperplasia
-
Non-structural
- Coagulopathy
- Ovulatory dysfunction
- Endometrial
- Iatrogenic
- Not yet classified
Causes of PVB/abdo pain after 20 wks preg
No speculum before ultrasound excludes placenta/vasa previa
-
abruptio placentatae
- from trauma or spontaneous
- peaks at 24-28 wks
- US specific but not sensitive
- dx is clinical
- pain +- tenderness +- PVB
- labs, RhoGAM + fetal NST
-
placenta previa & vasa previa
- painless PVB
- RhoGAM
- US, no pelvic
- OB
Pre-Existing Hypertension in Pregnancy
Pre-existing hypertension
- BP > 140/90 starting before pregnancy or
- treat with labetalol, alpha-methyldopa, clonidine, nifedipine if BP >150/100 (140/90 if renal disease)
Gestational Hypertension
Gestational Hypertension
- BP 140/90 starting in pregnancy beyond 20 wks
Mild vs. Severe Preeclampsia
Mild Preeclampsia
- after 20 wks and
- SBP >= 140 or DBP >= 90 and
- proteinuria >0.3 g/24h collection
- no other systemic ssx
Severe Preeclampsia
- SBP >=160 or DBP >= 110 measured on two occasions at least 6h apart at rest and
- visual/mental status disturbance or
- pulmonary edema/cyanosis or
- epigastric/RUQ pain/abnormal LFT’s or
- thrombocytopenia or
- oliguria
- proteinuria >=5 g/24h collection or >= 3+ on two random urine samples at least 4 h apart or
- impaired fetal growth
HELLP Syndrome
Hypertension
Elevated Liver enzymes
Low Platelets
- schistocytes, low plt, LFT’s, abnormal coags, high LDH
- manage like eclampsia
Eclampsia
- eclampsia + seizures (sometimes seizures without HTN)
- tx: MgSO4 4-6 g IV over 20 min then 1-2 g/h, monitor levels Q1-2h if AKI/CKD, otherwise monitor presence of reflexes, u/o 100 mL/h, BP, RR
Treatment of Gestational HTN, preeclampsia
- Labetalol: 100 mg PO BID, increase to 200-400 PO BID (usual)
- Methyldopa: 250 mg PO QID, increase to max 750 mg QID (3 g/day)
- Nifedipine XL (Adalat XL): 30 mg daily increase to 120 mg daily slowly
- Admit severe preeclampsia + HELLP and give MgSO4 as for eclampsia
Vulvovaginal Candidiasis
- White, cottage-cheese d/c, no odour, can cause skin irritation
- Treatment
- Clotrimazole 1% cream QHS x 7d or 2% x 3 d or 100 mg supp QHS x 7d or 200 mg x 2 d or 500 mg x 1 dose
- Fluconazole 150 mg PO x 1
- Pregnant: topical azoles x 7d
- Complicated/recurrent: topical x 7-14d or fluconazole 150 mg day 1 and 3 or day 1, 4, 7
Trichomonas Vaginitis/cervicitis
- 50% asymptomatic. Green/yellow, foul-smelling. Frothy. Stawberry (petechiae) cervix.
- Flagyl 2 g PO x 1 or 500 mg BID x 7d
- Treat partners also
Bacterial Vaginosis
- Homogeneous, thin, grayish-white discharge that smoothly coats the vaginal walls
- Gold standard is Gram’s Stain
- Culture is +ve in most symptomatic women but is also +ve in 50-60% healthy asymptomatic women therefore DO NOT USE.
- Treatment:
- Flagyl 500 mg PO BID X 7d (safe preg)
- or
- Metronidazole gel 0.75% 5 g once daily X 5 days
- or
- Clindamycin 300 mg PO BID x 7d
- Flagyl 500 mg PO BID X 7d (safe preg)
- 30% relapse within 3 months, 50% within 12 months, consider prolonged oral Flagyl (14d)
- Partners: no testing/treatment needed
- Pregnancy: questionable benefit, do not test asymptomatic women; may treat with oral or vag Flagyl if +ve
PID
- Polymicrobial, target GC/CT +- anaerobes (controversial)
- minimum for tx is CMT/adnexal tenderness and low AP
- better if NAAT +ve, discharge, bleeding, ESR/CRP or US thickening of tubes
- US check to TOA
- R/A in 72h for improvement if outpatient
- Ceftriaxone 250 mg IM + Doxy 100 mg BID x 14 d, + Flagyl 500 mg BID x 14d, consult ID/Gyne if anaphylaxis to penicillins
- treat partners without waiting for results
Nausea/Vomiting in Pregnancy
Diclectin:
- 10 mg doxylamine/10 mg pyridoxine
- 1 tab QAM 1 tab QPM 2 tabs QHS
- studies show safety at higher doses (8 tabs/day)
Gravol
Maxeran
Zofran
Dex (risk of cleft lip before 10 weeks)
PPI’s
Hyperemesis Gravidarum:
- 5% pre-pregnancy weight loss, abnormal labs, ketonuria
- US
- beta
- CBC, lytes, TSH, Cr, LFT’s, U/A
Endometriosis
Review Evernote “Dysmenorrhea”
CMV Infection in Pregnancy
- heterophile -ve mono-like syndrome
- common ~1% all pregnancies
- 90% fetuses asymptomatic at birth –>15% of these develop late disabilities
- 10% symptomatic at birth –> severe neurologic complications
- transmission saliva, urine, sexual
- can be reactivation or new infection, often asymptomatic
- does not confer immunity
- 4x rise IgG over 14-21 days (IgM not as helpful)
GTPAL
G: total preg any gestation T: # term (>37 wks) P: # premature (20-36+6 wk) A: # abortions (loss
When is Beta-hCG +ve (urine and blood)?
Serum: 9d post-conception Urine: 28d after 1st day LMP
How fast does Beta-hCG double?
Q 1-2d
When does Beta-hCG peak?
8-10 wks (then plateaus until delivery)
Ddx for low Beta-hCG
Ectopic, abortion, inaccurate dates
Ddx for high Beta-hCG
Multiple gestation, molar pregnancy, trisomy 21, inaccurate dates
Trimesters
T1: 0-12 wks T2: 12-28 wks T3: 28-40 wks Term: 37-42 wks
Normal Cr in pregnancy
35-45 mmol/L
Cholestatic Jaundice of Pregnancy
Cholestatic Jaundice of Pregnancy
- pruritus precedes jaundice by 7-14 days
- usually 17-29 w GA
- ALT
- ursodiol 20-25 mg/kg/d, cholestyramine, prophylactic Vit K before delivery, consider induction
Naegle’s Rule
1st day LMP + 7d - 3 mo
SFH
12 wk: @pubic symphysis 20 wk: @umbilicus 20-36 wk: within 2 cm of GA 37 wk: at sternum
Rhogam (WinRho)
Who should you give it to, how much, and when?
300 mcgs to all Rh -ve and antibody screen -ve women:
at 28 weeks (protects for ~12 weeks)
within 72h of birth of Rh +ve fetus
+ve Kleihauer-Betke test
Any invasive procedure (CVS, amnio)
In ectopic preg
With miscarriage or TA (only 50 mcgs required)
With antepartum hemorrhage
300 mcgs enough for 30 mL fetal blood, give additional 10 mcgs for every 1 mL fetal blood over 30 mL
When is quickening first felt?
18-20 weeks
What to do if feeling decreased fetal movements (after 28 weeks).
Drink juice, eat, change position, move to quiet room.
Choose a time when fetus normally active and count movements for 2 hours. if
NV of Pregnancy
Dose of ginger
Dose of Diclectin
Dose of Gravol
2nd line
Dose of Metoclopramide, Ondansetron
Ginger: max 1000 mg/day
Diclectin (10 mg doxylamine succinate + vitamin B6): 4 tablets PO daily (ii bedtime ii morning, i afternoon) to max of 8
Gravol: 50-100 mg Q4-6h PO
- *Metoclopramide:** 5 to 10 mg every 8 h IM or PO
- *Ondansetron:** 4 to 8 mg every 6 to 8 h PO
UTI in Pregnancy
Drugs and dosages?
1) Amoxicillin: 250-500 mg PO TID X 7d
2) Nitrofurantoin: 100 mg PO BID X 7 d
ROS for Hypertension in Pregnancy
Weight
HA, vision, LOC, reflexes
Bleeding, petechiae
RUQ/EPIG, NV
UO/Colour
Non-dependent edema (hands, face)
FM, NST, US, BPP, Doppler flow
Labs for Gestational HTN
FM, NST, US, BPP, Doppler flow
CBC with film
PTT, INR
ALT, AST, LDH, bili
Udip, Cr, uric acid
24h urine for protein + Cr clearance
Management of HTN in pregnancy (all kinds)
Labetalol 100-300 mg PO BID/TID
Nifedipine 30-50 mg PO daily
alpha-methyldopa 250-500 mg PO TID/QID
Induce at 37 weeks
When is risk for seizures highest in preeclampsia?
1st 24h postpartum
What is HELLP Syndrome?
Hemolysis
Elevated Liver enzymes
Low Platelets
What is the incidence of eclampsia in preeclamptic/severely preeclamptic women?
0.5% of mild
2-3% of severe
What to monitor in NV of pregnancy?
Weight, hydration, urine for ketones
Diclectin (10 mg
Trauma in Pregnancy
Placental Abruption
- most common cause of fetal death after maternal death
- 1-5% minor injuries
- most sensitive finding is uterine irritability
- >3 contractions/h
- US is only 25% sensitive
- all minor trauma (even without obvious adbo injury) > 20 wks needs cardiotochodynamometry for at least 4-6 hours
- pelvic only after US to r/o previa
- RhoGam to all Rh -ve women with abdo trauma
Discriminatory Zone
(For GS)
- 1, 500 TV
- 3, 000 AB
Criteria for IUP
US Criteria for IUP (need all three, otherwise NDIUP)
-
decidual reaction
- echogenic lining
-
gestational sac
- (fluid in endometrium)
-
yolk sac
- ring
- should be visible when gestational sac is 10 mm by TV and 20 mm by AB
- ~ 6 wks GA by AB
-
myometrial mantle (thickness) must be > 5 mm (8 mm to be safe)
- to r/o cornual/interstitial pregnancy
Fetal Cardiac Activity on US
- usually around 7-8 wks AB
- never test by doppler
- OK to use M mode
- should always be present if fetal pole > 5 mm TV or 10 mm AB
Blighted Ovum
- GS > 20 mm with no yolk sac = likely (but can still be pseudogestational sac of ectopic)
- GS > 25 mm with no yolk sac = certain
- as good as IUP to r/o ectopic
Ectopic Algorithm
Evernote Ultrasound –> Ectopic
General Breastfeeding Considerations
* In early period, mothers need to pump Q2-3h
* CT Contrast: continue breastfeeding, totally OK <0.1% absorbed
* Sedation: propofol, ketamine, etomidate all OK, continue breastfeeding
* Analgesia: avoid oxycodone and demerol, otherwise toradol, naproxen, morphine, dilaudid, fentanyl, and morphine are all OK to keep breastfeeding.
* In premature infants, tell mom to dilute breastmilk with stored milk 1:1
* Antihistamines/decongestants: avoid, will dry up breastmilk
* illness: keep breastfeeding (unless HIV, acute Hep C, herpetic lesions, or Ebola)
* V/Q: pump + dump x 24h
* LactMed: good NIH database
