High YIELD ob Flashcards
HTN after 20 wks
Gestational Hypertension
Evidence of Hypertension of pregnancy
HTN before 20 weeks
Chronic Hypertension
HTN after 20 wks and proteinuria (300mg/24h)
end organ dysfunction
Preeclampsia
fetal malposition
0-37 weeka
No intervention
37+ weeks
Fetal Malposition
Extrernal Cephalic Version
37+ weeks
Fetal Malposition
Extrernal Cephalic Version
Fetal Malposition
Active Labor at any time
C-section
37+ weeks with failed ECV, active labor or any contrindication to vaginal delivery
C-section
Contraindications for external Cephalic version
Placenta previa or abruption
Multiple gestation
Ruptured Membranes
Before 37 weeks
Preterm
before the onset of contractions
Premature
<34 wks, mgt?
Corticosteroids
<32 wks , PPROM, mgt?
Magnesium Sulfate (neuroprotective)
> 34 wks, PPROM, mgt?
Delivery
Multiple “grouped” ulcers, eythematous base
Herpes Simplex Virus
Severe painful ulcers with exudate + friable base
Painful inguinal lymphadenopathy with pus leakage
Chancroid (Haemophilus ducreyi)
Single painless chancre
Priary Syphilis (Treponema Pallidum)
Multiple painless ulcers
No lymphadenopathy
Granuloma Inguinale (Kleibsiella Granulomatis)
small, shallow, painless ulcers
Large, painful, inguinal ympahdenpathy
LLymphogranuloma Venereum
First growth spurt for girls
Bud development
(8-13 years)
areolar growth
White thick, cottage cheese appearance
ph : Normal <4.5
Vaginal inflammation
Treatment : Oral Fluconazole (topical Miconazole if pregnant)
Candidiasis
Off-white fishy odor
ph : Normal >4.5
No Vaginal inflammation
Treatment : Metronidazole for patient only (Clindamycin)
Bacterial vaginosis
Greenish, frothy discharge
Red spots on cervic (strawberry cervix)
vaginal inflammation
Metronidazole for patient and partner
Trichomonas vaginalis
What is the normal Ranges for AFI
5-24 cm
deepest pocket 2-8 cm
Amniotic fluid index (AFI) 24 cm or Single deepest pocket 8+ cm
enlarged uterus
inability to swallow (esophageal atresia, eA + TEF, duodenal atresia) diabetes, multiple gestation, anencephaly
Compications: PPROM, umbilical cord prolapse, Fetal Malpositionl
Polyhydramnios
AFI < 5cm or Single deepest pocket < 2 cm
Uterus is less than estiamted dates
Potter’s sequene (Pulmonnary hypoplasia, flattened face, dysmorphic limbs)
Complications: Meconium aspiration, Umbilical cord compression
Oligohydramnios
Unilateral breast erythema
Skin dimpling
warmth
Inflammatory Breast carcinoma
PCOS with post menopausal bleeding for 1 month
Endometrial carcinoma
patient with fever, RUQ pain, rebound and guarding
Appendicitis
beefy protrusion of tissue at the urethral meatus
Urethral Prolapse treat with topical estrogen
Purulent vaginal discharge
Mass at the Vaginal introitus
Vaginal Foreign body
Non-tender abdominal bulge in postpartum patient with no facial defect on palpation
Rectus Abdominis diastasis
Post menopausal bleeding, thickened endometrial stripe
ovarian mass
Granulosa Cell tumor
Amenorrhea and cyclic abdominal pain each month
Imperforate Hyrmen
History of multiple miscarriages, positive VDRL and elevated PTT
Antiphospholipid Antibody Syndrome
Pregnant woman with fever, dysuria, flank pain
Pyelonephritis
Pregnant woman at 0 weeks with uterine size larger than estimate dats
severe nausea and vomiting
BP 155/95
markedly elevated B-hG
Complete Hydatidiform Mole
Pregnant woman with severe nausea, vomiting, orthostatic hypotension, ketones in urine
Hyperemesis gravidarum
Pregnant woman with anemia, thrombocytopenia, LFTS elevated
HELLP Syndrome
Pregnant woman with severe RUQ pain, thrombocytopenia, profound hypoglycemia, elevated LFTS and DIC
Acute Fatty Liver of pregnancy
Erythematous unilateral nipple rash, itchy and refractory to steroids
Paget Disease of the breast
Pregnant patient with fever, uterine tenderness, vaginal discharge, fetal tachycardia
Chorioamnionitis
Amenorrhea, anosmia, cleft palate
Kallmann syndrome
What is the management of Lichen Planus
Reassurance + steroid
What is the management of Vulvovaginitis in Prepubertal Girls
Reassurance , Steroid
A girl deveop labial fusio past h/o of vulvovaginitis which was treated successfully. No voiding difficulties. Most approp advice?
Reassurance
Post menopausal female comes to you with enterococele prolapse and stress incotinence
What is the management
Pessary
A woman taking OCP containing 30mg estrogen now comes to you with hypertension
What is the next step?
POP
Mentally retarted girl complaining of menorrhagia
Best tx?
Mirena
Levonorgestrel-releasing intrauterine system
Young lady came for contraception advice
she feels headache
BP 130/90
What to prescribe?
POP
Girl came for repeat prescription for OCP
Some headache with visual disturbance
Best advice?
OCP is contraindicated
Girl comes with a period pain
Best treatment?
Mefenamic Acid
Newly delivered pregnant woman and is on breastfeeding
Wants to conceive as soon as possible again
What contraception you should give?
Progesterone Pill only
After delivery, breast feeding whicn contraception?
Levonorgestrel
How does the Microgynon works?
In the hypothalamus
A patient comes in asking for OCPS
She also reports that she has been experiencing migraine
What do you do?
Start Progesterone
Female using 30 mg ocp
Presents with continuing painful periods
Want to conceive after 12 to 12 months
What to advice?
use 50mg ocp
Woman with 3 kids, has otosclerosis with hearing aid
Which contraceptive is best for her?
IUCD
Lady with obesity, hirsutism and PCO
asking for contraception
COCP
A lady comes to your practice concern about her OCP compliance ont he 10th day
She missed her pill on the 7th and 8th day
She has unprotected intercourse on the 6th and 7th day
What is your management?
Give emergency contracptionw ith levonogestrel twice dose 12 hrs apart
What is the gold standard for the abnormal uterine bleeding?
Hysteroscopy and D and C
Young girl with h/o Epilepsy well controlled with Phenytoin wants to have an OCP. What will be your advice?
IUCD
Most important contraindication for prescription of OC pill in this patient?
Breast Cancer
A 20 yo woman came to you and ask for contraception advice. Mother and sister has DVT episode.
What is the next best step?
Do thrombophilia screening
A menopausal woman came with complains of hot flushes and vaginal dryness
Vaginal exam shows atopic vagnitis.
She had hysterectomy 10 years ago and she said she also has VT
What is the best treatment?
Low dose transdermal oestrogen
A 10 wk pregnant patient comes to you for her first antenatal visit
You see the strings of the IUCD. What is your next step?
Remove the IUCD now
A woman taking OCP containing 30 mg esterogen now comes to you with hypertension
What is the next step?
POP
Young lady came for contraception advice. She feels headache and her BP is 130/90. What to prescribe?
POP
Ladi with migraine, pins and needle sensation, shes asking for cotnraception. What to give?
POP
Mentally retarded girl complaining of menorrhagia, looking for best contraception.
COCP
45 yo female with menorrhagia and consultation is due in a few weeks, what can you give for the meantime?
NET
Came for contraception, mother and sister has DVT and found out to have factor V defect
What will be approp for her?
Progestogen only
Mirena IUD
Young lady comes to you on the 10th day and she missed her pill on the fay 6 , 7 and day 8 she had intercourse
She took her first pill from the new pack today
What will you advice her?
Emergency Contraception
Which would be the best option for OCP for a smoker female?
Norethisterone
HcG <2000 IU/L
Repeat tVS / HCg in 48-72 hrs
Hcg > 2000 IU/L abd TVS with no IUP
Complex adnexal mass and/or free fluid
High probability of ectopic pregnancy
hcg > 2000 IU/L and TVS with no IUP
and no abnormal findings
Repeat TVS /HCG in 48-72 hrs
Vaginal bleeding prior to 20 weeks gestation
Threatened Abortion
Passage of POC of a non-viable IUP or expected to occur imminently
Inevitable
Retention of POC od a non-viable IUP
Incomplete
Ultrasound scans diagnosis of a non-viable IUP in the absence of vaginal bleeding
Missed
Misscarriage complicated by infection
Septic
Three or more consecutive miscarriages
Recurrent
Full epulsion of POC of an IUP
Complete
HSIL
Refer for Colposcopy
Negative cytology
Repeat HPV test in 12 months
Possible lwo grade intraepithelial lesion and definite LSIL
Repeat HPV test in 12 months
Unsatisfactory cytology result
Repeat test in 6-12 weeks
Pap test
negative smear - no Endocervical cells
Repeat in 2 years
Pap Test
negative Smear - inflammatory Cells
Repeat test in 2 years
Unsatisfactory smear
Repeat smear in 6-12 wks
LSIL and definitive LSIL
Repeat Pap test at 12 months
If the woman is 30+ years and has no negative cytology in previous 2-3 years, refer to Colposcopy
or Repeat the test in 6 months
Possible HSIL and definite HSIL
Refer for Colposcopy
Glandular abnormalities
Refer to gynecologist
Invasive Squamous cell carcinoma or Adenocarcinoma
Refer to a gynecologist
Inconclusive - raising possibility of high grade disease
Refer for colposcopy and possible biopsy
Post coital bleed
Atrophic vaginal
Postmenstrual Bleeding
Endocervical Ca until proven otherwise
Post menstrual bleeding
bleeding within 1 year
Graaffian Follicles
53 yo bleeding
Postmentrual symp
Atrophic Vaginitis
postmenstrual bleeding + growth
Cervical Cancer
Intermenstrual bleeding
multiple sexual partners
no vaccine
Carvical Ca
Dysmenorrhea
1st line treatment?
Mefenamic Acid
Heavy Menstrual bleeding
1st line?
Mefenamic
acute flood - Tranexamic Acid
Young girl + OCP user + bleeding
Cervical Ectropion
Postcoital bleeding
55 years
Cervical CA or Atrophic Vagintis
Postcoital bleeding 25 years
Polyp or cervical ca or Ectopian
Abnormal uterine bleeding
Fibroids
50 years recently menopause 8 months
new onset of bleeding
Anovulatory cycle (Graddian follicle)
60 years old female with post menopausal bleeding
Endometrial CA
53 years postcoital bleeding
[ain during coitus
Atrophic Vaginitis (lack of estrogen)
58 years post coital bleeding
Cervical cancer
Mass seen in the vagina
Cervical cancer
Menopause within a year
Graaffian F
Any age group universal cancer
Ca of the cervix
clear mass
cancer mostly
bleed on touch
Ca polyp
What are teh premenstrual treatment
Hormone therapy
Vaginal Estrogen
Antidepressants
Gabapentin
T score of -2.5 or lower indicates that you have
Osteoporosis
T scoring of -1.5 to -2.5
Osteopenia
tx: Calcium and Vitamin D
T scoring of >2.6
Osteoporosis
tx: Alendronate / Zollindronic Acid
IV more preferable
Osteoporosis is known + low trauma fracture
DEXA first
T score of -2.5, Osteoporosis
tx?
Alendronate
Osteoporosis + fracture
DEXA
Osteoporosis + PUD
Zolindronic Acid
Osteoporosis + Breast Ca
Tamoxifen / Raloxifen
Severe osteoporosis + HRT for 6 years
what to give?
Alendronate
Drug of Choice for hypertension with pregnancy
Methyldopa
What must be avoided in pregnancy
ACEI
What are the other antibiotics that should be avoided in pregnancy?
SAFE
Sulfonamides
Aminoglycosides
Fluoroquinolones
Erythromycin
Ribavirin
Grieofulvin
Chloramphenicol
new onset of grand mal seizures in women with preeclampsia
Eclampsia
What are the signs of preeclampsoa
Persistent headache
visual disturbances
epigastric pain or RUQ pain
Vaginal bleeding due to Hypertension
hyperreflexia
The only cure for preeclampsia is
Delivery of the fetus
If the patient is close to term
in peeclampsia
What to do?
Induce Delivery
If the patient is far from termin preeclampsia
what to do?
Expectant Management
What is the first step to control BP in the severe preeclampsia
Labetalol and or hydralazine
the goal is <160/110 with DBP of 90-100 to maintain the fetal blood flow
What is the second step of management in severe preeclampsia
Prevent seizures with continuous magnesium sulfate
continue sezure prophylaxis for 24 hours postpartum
What is the third step in severe pre-eclampsia
Deliver by induction or C section
used to accelerate the fetal lung maturity
Dexamethasone given at 24th to 34th week
If there is seizure for the first time what is the next step?
Glucose Electrolytes
If there is seizure for 4 years and recurrent what is the next step?
Glucose
What is the first step in Eclampsia?
ABCs with supplemental O2
What is the second step of management in Eclampsia
Seizure control / prophylaxis with magnesium
if seizures recur then give IV diazepam
What is the third step of management in Eclampsia?
Delivery
What is the first sign of toxicity of magnesium sulfate
loss of deep tendon reflexes
What is the serious sign of magnesium sulfate toxicity?
Repiratory Depression
Comma
What is the treatment for the toxicity of magnesium sulfate
IV calcium gluconate
Pain + amenorrhea + vaginal bleeding
Ectopic Pregnancy
What is the most common site of ectopic pregnancy
Ampulla of the fallopian tube
What is the recurrence rate for Ectopic pregnancy?
10-15%
What are the predisposing factors for the Ectopic Pregnancy?
Scarring to the Fallopian tubes
What is the most common cause of Ectopic Pregnancy?
History of PID
Woman of reproductive age presenting with abdominal pain and vaginal bleeding
dx?
Ruptured Ectopic Pregnancy
What are the steps of management for Ruptured Ectopic Pregnancy?
First step: Pregnancy Test
if (-) : NO PREGNANCY
if (+) : transvaginal Ultrasound
If you find a sac in the uterus: Normal Pregnancy
Empty uterus: do Serial HcG
Doubling : Normal Pregnancy
No doubling: Ectopic
What is the medical treatment for ectopic pregnancy?
Methotrexate
What is the endoscopic management for the unruptured ectopic pregnancy and stable patient?
laparoscopy
How to diagnose unruptured Ectopic pregnancy?
B Hcg titer <1,500 mIU
No intrauterone pregnancy is seen in vaginal sonogram
Ectopic pregnancy is always seen in 1st trimester
true
Defined as any bleeding that occurs after 20 weeks
Antepartum hemorrhage
The most common caused of Antepartum Hemorrhage are
Placental abruption and placenta previa
Separation of the placenta from the inner wall of the uterus before the baby is delivered
Abruptio Placenta
Placenta is implanted in the lower part of the uterus obstructing vaginal birth
Placenta Previa
placenta covers the cervical os
Total
placenta extends to the margin of the os
Marginal
placenta is in close proximity to the os
Low-lying
What is the most common risk factors for placenta previa
Prior C section
others are:
Grand multiparity
Multiple Gestation
prior placenta previa
What to give if the mother is Rh D negative?
Anti-D prophylaxis
What is the most common cause of Placenta Abruption ?
Hypertension
What is the very impt cause of Placental abruption?
Cocaine
painful dark vaginal
abdominal painn + uterine contraction
on exam : Uterine tenderness
Uterine hypertonicity
fetal Distress
Placental Abruption
How to manage patient with Placental abruptio?
Stabilize patients
hospitalize
start IV and fetal monitoring
fetal vessels crossing the internal Os
vasa previa
What is the main management of Vasa previa
CS
What is the most common risk factor for placental abruption
Hypertension
What is the most common risk factor for placenta previa
Previous CS
Bleeding with placental abruption
Painful
bleeding with placenta previa
painless
Most impt sign with the placental abruption
Uterine tenderness
Main route of delivery with both of them
Vaginal
Mgt if there if fetal distressed?
CS
Main inv with placenta previa
US
Main inv with placental separation
US
The drug that causes placental infarction
Cocaine
What is the main complication with placental separation
DIC
Main risk factor for stroke
Hypertension
Main risk factor for MI
Hyperlipidemia
Main risk factor for placental separation
Hypertension
Main factor causing damage of kidney in diabetic patients
Hypertension
What is the most common cause of abdominal pain with pregnancy
in 2nd trimester
usually site is the Right side
jabbing sensation or sharp stabbing pain felt when a pregnant woman suddenly changes position
Round Ligament Pain
What is the differential diagnosis of Round ligament pain
Appendicitis
What is the tx for the round ligament pain?
Analgesic and Rest
What is the most common cause of uterine prolapse
Premature ruprute of the membranes
What are the steps of management in the Round ligament pain
1st step: Assess the pulsation of the umbilical cord to see if the fetus is still alive or not
2nd steo: Put patient in the knee - chest position (trendelenburg)
3rd step; Push the presenting part back ward to decrease the pressure
4th step: CS
jaundice and itching at the third trimester
bilirubin and ALT elevated
Cholestasis of Pregnancy
What are the risk for cholestasis of pregnancy
fetal distress and mortality
What is the inv for Cholestasis of pregnancy
CTG
What is the treatment for the Cholestasis of pregnancy?
Ursodeoxycholic acid
What is the complication of Pyenephritis with pregancy
Preterm delivery
What is the tx for the Pyelonephritis in pregnancy
Hospitalization
IV Ceftriaxone and Gentamycin
10 wks gestation with uterine bleeding, pelvic pressure and multiple episodes of non-bloody and non-bilious emesis
bleeding is like a prune juice
uterus is larger than gestational age
Gestattional Trophoblastic Disease
Snow storm
cluster of grapes
honey comb
Gestational trophoblastic
inv: B-hcg
chest xray if patient presents with pulmonary symptoms
69 XXX or XXY
missed abortion
Partial Mole
46 XX or XY
molar gestation
Complete mole
defined as a birth weight > 90 th percentile
fetal macrosomia
Most common cause of fetal macrosomia
DM
Defined as the AFI > 20 on ultrasound
Polyhydramnios
Duodenal atresia
tracheoesophageal distula
Potter Syndrome
Polyhydramnios
AFI < 5 cm on ultrasound
Oligohydramnios
what is the most common cause of polyhydramnios
Renal Agenesis
What is the risk factor for Shoulder dystocia
Obesity and Diabetes
Prolonged second stage of labor
Recoil of the perineum or turtle sign
Shoulder Dystocia
What are the treatment for Shoulder Dystocia
Help reposition
Episiotomy
Leg elevated (first step ( McRobert’s MAneuver)
Pressure suprapubic - s econd most important
Reach for the fetal arm
What are the complications of shoulder dystocia
Clavicle Fracture
Brachial plexus Injury
Most important risk factor for the shoulder dystocia
Diabetes Mellitus
What is the first step mgt in Shoulder dystocia
Elevation of the patient’s legs
second step: suprapubic pressure
What is the most common nerve injury with the shoulder dystocia
Brachial Plexus
What are the signs of clavicle fracture
fullness, crepitus or deformity
What are the roots that are affected in the Erb’s palsy?
C5 and C6
internally rotated arm, adduction (waiter tip) hand
it is associated with the diaphragmatic paralysis
resolve in 3 months
Erbs palsy
What are the roots affected in Klumps palsy
Associated with the horner Syndrome
C7, C8 and T1
rupture of membranes occuring at <37 wks gestation
PPROM
Defined as rupture > 18 hours prior to the delivery
Prolonged ROM
sudden gush of clear or blood tinged amniotic fluid
Rupture of membrane
What are the steps in diagnosing the Rupture of membranes
First step: Sterile Speculum ecam - pooling of amniotic fluid in the vagina
Nitrazine paper test is - when the paper turns blue - indicated that the paper is alkaline of ph amniotic fluid
Second step: ultrasound
What is the treatment for the Rupture of membranes?
Induce Labor
Rupture of membranes mgt if it is >34-36 wks
Labor induction
Rupture of membranes mgt if <25-32 wks gestation
Expectant management with bed rest
try to delay as long as possible so that the baby become more mature
a high vaginal swab is advisable
defined as onset of labor between 20 and 37 weeks
Preterm labor
What is the inv to confirm the preterm labor
Fetal fibronectin
1st tri pregnant woman
cervical screening test + for HPV 16 and 18
HSCIL
Colposcopy oc cervix ith biopsy
Most common symptom of endometriosis
Dysmenorrhea
If ovarian cyst is less than 5 cm in size
Repear Ultrasound in 4 months
lower abdominal pain, significant vaginal bleeding and amenorrhea
Ectopic pregnancy
Has intrauterine gestational sac (altho empty) abd b fkuid in the Pouch of Douglas
no tenderness and cervical os is closed
Missed abortion
If intrauterine pregnancy tissue is completely expelled
Complete miscarriage
Intrauterine pregnancy tissue is partially expelled
Incomplete miscarriage
three or more consecutive miscarriages
Recurrent Miscarriage
miscarriages complicated by infection
Septoc
ultrasound scans diagnosis of a non-viable IUP in the absence of vaginal bleeding
Missed
Some retention of POC (products of conception, IVP , intrauterine pregnancy) of a nonviable IUP
Incomplete
Passage of POC of a nonviable IUP occuring or expected to occur imminetly
Inevitablee
Vaginal bleeding prior to 20 wks gestation
Threatened
headache that occurs one day before the onset of menses
pain starts in the occipital area and spreads towards the left frontal region
aggravated by walking
irritable and sensitive to light
Menstrual headache
What is the most comon presentation of the ovarin cancer?
Abdominal mass and ascites
What is the screening marker for the ovarian cancer
CA 125
and transvaginal ultrasound
What is the average age group diagnosed with ovarian cancer
50-64
Carries the lowest risk in developing the ovarian cancer
Oral contraceptive pill
HPV can call all these subtypes of cancers except:
Cancer of cervic
cancer of oropharyngeal cavity
Squamous cell carcinima of anus, penis and agina
Cancer of the uterus
except: ESOPHAGEAL cancer
post menopausal woman presented with mild vaginal bleeding for the last 12 hrs after the sexual acitivity
Atrophic Vagintis
What are the risk factors for urinary incontinence
Obesity
Prenatal urinary incontinence
Constipation
Instrumental delivery
Third and fourth degree tears
Baby with a right birth weight of more than 4.0 kg
40 yo with hx of postcoital bleeding
periods were normal and regular for the last 12 months
now she is complaining of intermenstrual bleeding for a year
she has multiple sexual partners
What to do next?
Cervical Screening test as well as liquid base cytology
Asking for contraception advice
she has a family history of DVT and thrombophilia
Most appropriate contraception?
Levonorgestrel intrauterine device
A petient had undergone total abdominal hysterectomy
complaint of clear fluid discharge from the vagina
Discharge is continuous in nature but without any odor or itching.
What is the most likely cause of her symptoms?
Reactionary fluid from vaginal wall
A middle age woman presented with peristsent lower back pai and sensation of heaviness in the vagina
A bulge protruding out of the vagina is noted on the examination
What is the responsible for this?
Uterosacral ligament
- patient developed uterine prolapse - weakening of the uterosacral ligament
1st line contraceptive choice for women with epilepsy using enzyme inducing antiepileptic drug
Levonorgestrel-releasing intrauterine contraceptive device
OCPS increase the incidence of
Cervical Cancer
What is the investigation of choice for the earlier diagnosis of endometriosis
Diagnostic laparoscopy with histopathology
Breast tender, swollen and painful
not sexuallya ctive and not planning to have any relationship in the future
mgt?
Primrose oil
- mastalgia
premenstrual women
simple ovarian cyst <5cm
Do not require follow up
Reassurance no further action required
premenstrual women
simple ovarian cyst 5-7cm
Repeat Ultrasound
premenstrual women
simple ovarian cyst >7cm
Refer to gynecologist
Postmenopausal women
simple ovarian cyst <5cm and low risk of malignancy
Manafe conservatively
it will resolve in 3 months
Postmenopausal women
simple ovarian cyst 2-5 cm
should be rescanned 3-4 months
This contraception is contraindicated in pregnancy, breast cancer and undiagnosed vaginal bleeding
Progestgen only
contraceptive use with a past medical history in hypertension
Progestogen only pills
Which outcome has the most sutiable outcome to the treatment of infertility?
Stein-Leventhal Syndrome or PCOS
Postmenopausal woman with frequent hot flushes had a hx of oestrogen dependent breast cancer ten years ago
What is the mgt?
Paroxetine
mestrual irregularities and hirsutism
PCOS
Woman inability to conceive last 12 months
Pelvic USG shows 3-4 follicles in both ovaries. Blood test low estrogen and elevated FSH and LC
Keen to get pregnant
Mgt?
In vitro fertilization
Danazol for endometrisos treatment
Side effects?
Lighter or absent menstruation, since danazol causes endometrial atrophy
Best emergency contraception
Copper intrauterine contraceptive device
next is Ulipristal Acetate and Levonorgestrel
Invasive squalous cell carcinoma was diagnosed
What is the nest step?
refer to a gynecologist at tertiart hospital
Nulliparous woman presents onset of painful menstrual irregular bleeding
bleeding isheavy and erratic with 25-37 day cycle. She is sexually active and no history of hyspareunia or postcoital bleeding.
The couple doesnt want to have children in the future
Mgt?
Endometrial Ablation
Risk factor for the development of ovarian cancer
Increased body mass index
Which of the ff is the advantage of using progestogen implant over the contraceptive options?
It provides contraception for three years and is easily reversible
HPV non 16 and 18 and Low grade Intraepithelial lesion o reflex liquid basec cytology
Repeast Cervical screening test in 12 months
Gray vachinal discharge with burning and itching
Gardenerella vaginali
History of vaginal bleeding after sexial interourse
She has a mucupurlent cervical discharge
What to do
Vaginal swab for chlamydia and gonorrhea
64 yo woman with painless vaginal bleeding lasted for 2 months
TV shows endometrial thickness of 6mm
Associated with increased risk of endometrial cancer?
PCOS associated with Chronic Anovulation
Not correct regarding the peri-menopause stage
Decrease in FSH
She never had a sexual activity with a male
She is a lesbian and has a gf
she prefers a lesbian friendly health care provider
What is the approp advice?
Refer to a lesbian friendly clinic in the area
diffuse pelvic pain and vaginal bleeding
painw ith defecation, dyspareunia and dysmenorrhea
dx?
Endometriosis
c/o urinary incontinence
Suggestive of urge incontinence
urinarylysis is negative
mgt?
Instruct her to eliminate excess water and caffeine from her daily fluid intake
Gradual onset of bilateral pain associated with fever, vaginal discharge and mild dysuria
Adnexal and cervical motion tenderness
Cause of the pain?
PID
free fluid within the abdominal cavity
abdominal pain and vaginal bleeding
Ruptured Ectopic pregnancy
amenorrhea came to hospital with massive per vaginal bleeding
Urine Pregnancy test
PMS symptoms - depression and emotional symptoms
Tx?
Fluoxetine
Treatment for hirsutism and facial acne
OCPS
Pap smaer: test result: HGSIL
Coposcopy confirms the presence of a cervical lesion consistent with cervical dysplasia (CIN III)
Which of the ff type of HPV confirms this type of lesion
HPV 16
1 hr acute onset of progressively worsening pain in her RLQ
Immediate laparoscopic surgery
Increasing hair growth in her face, chest and abdomen
coarse, dark hair on her face and abdomen
enlarged clitoris
7cm left adnexal mass
What type of ovarian tumor?
Sertoli Leydig Cell
Occasional abdominal cramping associated with bleeding without passage of fetal products
closed cervical os
dx?
Threatened abortion
9 cm right ovarian mass
Shows the evidence of glial tissue and immature cerebellar and cortical tissue
dx?
Immature teratoma
KOH prep - fishy odor
tx?
Metronidazole
Small amount of urine when sneezing
Stress incontinence
She has cyclic pain during premenstrual period and during her menses
inv?
MRI
Biopsies show chronic cervicitis but no evidence of dysplasia
mgt?
Conization of the cervix
Post op total vaginal hysterectomy 2 wks ago
also had the Burch procedure for uterine prolapse and stres urinary incontinence
she complains a constant loss of urine throughout a day
denies any urgency or dysuria
dx?
Vesicovaginal Fistula
Postmenopausal had cancer 5 years ago
complains of mood swings, disturbed sleep and hot flushes
mgt?
Paroxetine
highly suggestive of pCOS
Elevared LH
Least likely site for Endometriosis
Cervix
Planning to conceive. Labtest results are LH low, FSH low, TSH Low and Prolactin is high
mgt?
Bromocriptine
Pre-menstrual period has bloating, headached, reduced libido and reduced concentration and anger management
symptoms get worse 1 week before the menses
Mgt
Sertraline
50yo with history of hysterectomy and DVT
with hot flushes
mgt?
Osterogen Dermal Patch
history of smoking and asking for contraception
Progesterone only pills
Best option for the treatment of endometriosis
Danazol
Ovulatory dysfunctional uterine bleeding
Mgt?
Tranexamic Acid
INCORRECT regarding menopause
Decresed FSH level
Fishy, offensive gray vaginal discharge
Clue cells are present
mgt?
Clindamycin
- Bacterial Vaginosis
Asking for contraceptive advice
She had hx of DVT and currently on treatment with anti-coagulants
She is on combined oral Contraceptive Pill
Mgt?
Progesterone only pill
purulent lochial dischage
Endometriosis
Best invt to establish ectopic pregnancy
Transvaginal Ultrasound
1st line of inv for Ectopic Pregnancy
B-Hcg
NOT A risk factor for cervical cancer
Alcohol
Absolutw contraindication to use the progestogen only pills
Rifampicin
Which is correct regarding continuous used of combined hormone replacement therapy
It increases the risk of breast cancer
Next choice of investigation to predict ovualtion
Serum progresterone
She has high grade abnormality on cervical screening test
She has colposcopy and has higher abnormal cells in the cervical canal
mgt?
Cone Biopsy
Gold standarc choice of investigation for the diagnosis of abnormal uterine bleeding
Hysteroscopy along with Dilatation and curettage
Vaginal itching and discharge
Red vulva and whitish discharge
tx?
Clotrimazole
Risk factpr for endometrial hyperplasia
Early menarche
Correct description of hysterosalpingogram
Unilateral hydrosalpinx with a normal uterine cavity
Most common type of cervical cancer in Australia
Squamous cell carcinoma
irregular bleeding for the past 5 months
period were reguklar
pap smear norma
Anovulatory cycles
episodes of painless vaginal bleeding
What is the cause of teh postcoital bleeding
Cervical ectropion
- Chlamydia cervicitis a cervical polyp or cervical carcinoma
Tx for severe mastalgia
Danazol
test to evaluate amenorrhea
LH and FSH levels
Troublesome urinary leakage
What is the first step of evaluation?
urinarlysis and culture
FSH and LH high
not started her period, no brest budding, no pubic hair
has cervix and uterus
What is the cause of her delayed puberty and sexual infantilism ?
Gonadal Dysgenesis
Signet cells
Krukenberg tumor
Normal breast and pubic hair development
Uterus and Vagina are absent
dx?
Mullerian Agenesis
One sided pain that is diffuse and dull, occasionally sharp
menses are normal
Smooth mobile andexal mass on the Right side
What is the cause of the pain?
Ovarian Cyst
23F presented amenorrhea for 6 wks
Which of the ff will make you decide to proceed for emergency intervention?
Shoulter tip pain
complainet of amenorrhea for one year duration
what may be the cause of the amenorrhea?
Hormonal dysfunction
CIN2
mgt?
Colposcopy
Absoulute contraindication of COCPs
her premenstrual headaches
multiple fibroids, pakpabkle up to the umbilicus
GnRH analogues for 3 months followed by myomectomy
Treatment for the urge incontinence
bladder training
Vaginal discharge and gush of clear fluid
rupture of membranes and cervix is closed
most approp treatment?
Systemic Steroids
salpped cheek
Parvovirus B19
most frequently responsible for septic shock in Obstettric and gynecology
Escherichia coli
Whixh of the followig is correct regarding cesarian section delivery
Increased rick of adhesions
Uterine bleeding in the presence of closed cervix
Trhreatened abortion
Indicaated for the treatment of Chlamydia; urtehritis in pregnancy
Azithromycin 1 g single dose
DOC for the treatment of bacterial vaginosis in pregnant woman
Clindamycin
12wks gestation
persistent nause and vomiting
mgt
Pyridoxine - treatment for hyperemesis gravidarum
Recommended suppllement for pregnancy
Folic Acid 5mg daily 12 wks befoe conception
150 mg micrograms of Iodine
Planning to conceive in the next 3 months
DM well controlled
current HBA1c is 6%
Supplement needed?
Folic Acid
Not a complication of obesity in pregnancy
ncreased risk of postpartum psychosis
NOT associated with Oligohydramnios
Gestational Diabetes
Not a contraindication to Tocolysis
Materanal Hypothyroidism
Not a risk factor for isolated spontaneous abortion
Retroverted Uterus
32 wks gestation
Diagnosed with breech postion
Not in labour and is still breech position in the pelvic examination
appro step?
Pelvic ultrasoud
38 wks gestation with labor pains since 8 hrs ago
Vaginal examinatio shows 7cm dilated and fully effaced
On Amniotomy - greenish vaginal fluid
140 bpm with accelarations and variable deceleration
beat to beat variability with good contractions
Next step?
Fetal Scalp blood sampling
20 wks pregnant and have found to have thyrotoxicosis and mild enlargement of the thyroid gland
inv?
Ultrasound thyroid gland
Which of the ff can reduce the risk of [pre-eclampsia during the pregnancy
Calcium 1000 mg daily
Most common feature of pre-eclampsia
Proteinuria
DOES NOT increase the risk of postnatal depression
Elective cesarian section
Most likely the cause of oligohydramnios in the second trimester of pregnancy
Renal Agenesis
best negative predictor of imminent birth within the next 7 days
she is at 34wks of gestation
The absence of fetal fibronectin in cervical secretions
Woman who developed epilepsy and has been stable on Lamotrigine
Planning to conceive and is concerned about the medications that can harm her baby
Which of the ff measure would reduce the incidence of neural tube defects?
High dose of folic acid for one month befoe conception and during the first trimester
Which of the ff is correct regarding the shoulder dystocia
Erb is common fetal injury
32 female diagnosed with DVT of calf beins at the 20th week of pregnancy
best mgt?
Therapeutic dose of low molecular weight heparin for 3 months
Which of the dd if present can lead to death during the pregnancy
Mitral Stenosis
Folic acid 0.4 mg is usually recommended one month before conception til 12 wks of gestation. A higher dose of folic acid 5mg daily is recommended in all of the ff situations except
Body mass index of 24
20f Asian with hx of Pulmonary hypertension. What would you advice?
Pregnancy is contraindicated in her condition
Most common method of termination of pregnancy before 20 wks in Australia
suction and curettage
30yo woman decides to conceive and is stable on lithium fir the severe relpasing bipolar disorder
Lithim is continued after discussion witht he aptient
Which one of the ff will be essential during pregnancy
High Resolution of ultrasound 18-20 wks of pregnancy
Hemolysis , relevated liver enzymes, and low platelet levels
HELLP Syndrome
Stool microscopy showed human roundworm infestation
First line option for treatment
Pyrantel
Not elevated in the rhid trimester pf pregnancy
Serum free T4
Which od the ff vaccine is recommened to use during pregnancy
Influenza vaccine
Not a complication related to smoking during pregnancy
less likely to die of sudden infant death syndrome
Which of the ff condition would require intrapartum antibitic prophylaxis
A previous infatn with Grp B strep disease regardless of present culture
Which of the ff is a contraindication to pregnancy
BMI 40
Absence of retinopaty
Age of 38
Absence of nephropathy
history of type 2 DM with HBA1c above 10
history of type 2 DM with HBA1c above 10
Indication to perform cervical cerclage at 14 wks of gestation
2 or more consecutive prior second trimester pregnancy losses
Aboriginal woman have a rubella IgM and IgG positive during routine antenatal screening
What is the approp mgt?
Repeat Rubella serology
24f delivered a baby at 35wks has a
Diagnosed with gestattional hypertension at 22 wks
BP 170/100
Motivated to bresfeed her baby
medication to treat her bp which s safe to both mother and the baby
Metoprolol
24 Aboriginal lady presents at antenatal clinic at 19 wks of gestation
Best time for which of theff
Ultrasound
Ultrasound for identification of phyical abnormalities including neural tube defects is best performed at what age of gestation
18-20 wks of gestation
Maternal Serum screening for Down Syndrome is best performed at what age of gestation
15-17 wks of gestation
Amniocentesis is best perfomed during
between 16-18 wks of gestation
Chronic villus sampling is best perfoemd between
this is accurate for diagnosis of chromosomal anomalies
10-12 wks of gestation
Rubella screen is best perfoem
before conception and not during pregnancy
Sudden onset of severe abdominal pain, vaginal bleeding and cesation of contractions after 28 hrs of active ushing at home
Abdomen is distended
Fetal heart sounds not audible
Uterine rupture
Vaginal bleeding at 16 wks of gestation
RH negative and her baby is Rh positive
Cervix is dilated and product of condeption are visible
Pelvic usg - spontaneous abortion
What will you do regarding anti-D administration?
Give anti-D now
At which weeks of gestation should the gestational diabetes status be checked
28 wks
20 wks pregnant woman has developed palpitatins, sweating of palms and increased nervousness
What other investigations should be done with TSH
Free T4
Purulent lochia discharge noticed on vaginal examination 3 days after cesarean section
Gentamicin and clindamycin - postpartum endometritis
Nausea and vomiting during pregnancy and headache
Past medical history of migraine
Most approp management to prescribe for 1 wk
Codein and promethiazine - dx severe migraine
36 wks of pregnancy presents with BP 40/95, proteinuria, headache and mild upper abdominal pain
Most approp management?
Immediate vaginal delivery - severe preeclampsia management
Right iliac fossa pain esp when she tried to stand up or cough
had a history of appendectomy 12 yrs ago
Mild tenderness in the Right iliac fossa no rebound tenderness and there is no guarding
Diagnosis?
Round ligament pain
Young mothers have a higher risk of several pregnancy complications including which of the ff
Low birthweight infants
Complications of Warfarin use
Warfarin is contraindicated in the
First trimester - it will cause fetal chondrodysplasia punctata
if used in second or third trimester - fetal optic atrophy and mental retardation
involves the vaginal mucosa or perineal ski byt not the underlyig tissue
what type of vaginal delivery tear?
First degree
it involves the underlying subcutaneous tissue byt not the rectal sphincter or the rectal mucosa
Second degree
The rectal sphincter is affected
third degree
extends up to the rectal mucosa
fourth degree
Biophysical profile revealed severe oligohydramnios
Evaluation of the infant for the ff should be included
Renal Agenesis
It promotes lung maturity and decreases the risk of resp syndrome
Bethamethasone
Contraindication for tocolysis
Suspected placental abruption
Best management for Staph saprophyticus
Augmentin
Explusion of all fetal and placental tissue from the uterine cavity at 10 wks gestation
Complete abortion
Major predisposing factors in the developmentEctopic pregnancy
PID
Any opetarive procedure on the fallopian tube may increase the risk
- Tubal sterilization with laparoscopic fulguration
Used in prevention of recurrent eclamptic seizure
Magnesium Sulfate
Pregnant patient at 29 wks developed flu like symptoms - runny nose, mild headache and feels achy.
She is at higher risk of giving birth to a newborn with ?
Wide Pulse Pressure (PDA due to Rubella)
11 wks gestation, uterus is palpable between the symphysis pubis and the umbilicus
No fetal heart tones are audible
mgt?
Shceule an ultrasounf as soon as possible to determine the gestational age and viability of the fetus
Prenatal CMV infections may produce which retinal disturbance
Chorioretinitis
Which of the ff is a reactivation and therefore not a risk to the fetus
Shingles
3 recurrent miscarriages during the first trimester in the last 12 months
inv?
Antiphospholipid antibodies
After delivery, a woman develops lower abdominal pain and uterine tenderness. Large gram negative rods suggestive of clostridia are seen in the smear of the cervix.
Which of the ff is most likely to proceed with hysterectomy
Gas gangre
Which of the ff explanation for the patient’s decreased fundal height
Fetal growth retsriction
What are the tests included in the first trimester
Hepatitis B, HIV and Scrren
the 1 hr glucose tolerance test should be perfomed between 24-28 wks of gestation.
Most appropriare intial management of Hypertension
Methyldopa
Grp B strep infxn in pregnant woman
What is the treatment
Amoxicillin for 3 days
Which of the ff malpositons would require a cesarean section n the absence of fetomaternal distress and cephalopelvic disproportion?
Face presentation
Diagnose with primary genital herpetic lesions at multiple sites iin the genital area
What is the most approp management?
Suppressive antiviral until delvery
Pregnant lady presented with exposure to rubella
never been vaccinated against rubella
What will you do next?
Check serum IgM and IgG for rubella
Most single warning sign of diminishing blood volume withinn the first 4 hours post partum?
Tachycardia
Not a complication of gestational trophoblastic disease
Infertility
Gestational trophoblastic disease can cause complications including
Uterine infection
haemorrhagic shock
Sepsis
Pre-eclampsia
Metastasis to the lungs
True statement regarding the mgt of DVT in pregnancy
Warafarin therapy is CONTRAINDICATED throughout pregnancy but safe during breast feeding
Complication of severe pre-eclampsia that overlaps with acute fatty liver in pregnancy
HELLP syndrome
Abdominal pain and genital bleeding, pregnant woman at 40wks gestation loss 400ml of blood
Vital signs normal and as tender abdomen, no fetal heart sounds
Nesxt step?
Amniotomy
Most approp stepfor the estimation of the fetal gestational age?
Transvaginal ultrasound at 8 wks
28wks pregnant with sudden gush of clear fluid
Premature rupture of membranes with closed cervic
mgt while transferring the patient to the tertiary care?
Bethamethasone
What is contraindicated regarding the Hepatitis C transmission
Fetal scalp blood sampling
Breastfeeding is not contraindicated in Hepatitis C.
Breech presentation at 32 wks, had gestational diabetes and macrosomia, breech presentation for her baby
Most appop advice?
Elective cesarean section
16 wks gestation with a history of lower vaginal pressure, vaginal spotting and lower back pain.
TVS shows cervical shortening of 2 cm, cervical dilation and protrusion of fetal membranes into the cervical canal.
Developed symptoms of cervical insufficiency that may lead to premature delivery.
Most approp treatment?
Reinforcement of the cervicak ring with nonabsorbable suture material
Symptomatic and asymptomatic urinary tract infection in pregnancy
tx?
oral amoxicillin with clavulanate or oral cephalexin for 7 days
Diagnosed with DVT at 18th wks of pregnancy
Best mgt?
Therapeutic dose of LMW heparin for 6 months
Most common cause of cesarean section delivery in Australia
Previous cesearn section
Reason for the Rh sensitizatiom of the patient
Blood transfusion
UNLIKELY Predisposing factors for postpartum Hemorrhage
Oligohydramnios
Risk factor for recurrent pregnancy loss
Antiphospholipid syndrome
Best management for DVT in pregnant patients
LMW heparin
Not a contraindication for tocolysis
Asthma
Can be used in the screening test in both first and second trimester of pregnancy to detect Down Sydnrome
Free beta Hcg level
37wks gestation, sudden gush of clear fluid
apart from giving antibiotics
What’s next?
Induce labor now
Contraindication to the vagiinal delivery for breech presentation?
Clinically inadequate pelvis
Gestational diabetes taking Metformin but was ceased after the birth of the baby four weeks ago
What will you do?
Oral glucose tolerance test at 6-12 wks postpartum
Antenatal Advice
Aside from folic acid, what else should be given to the pregnant lady
Iodine
Weight loss
Moderate to severe dehydration
ketosis
Electrolyte abnormalities
Hyperemesis Gravidarum
Most common cause of post-partum hemorrhage
Uterine Atony
Most common cause of post-partum hemorrhage
Uterine Atony
Risk Factors for uterine atony:
Multiple pregnancy
Polyhydramnios
Macrosomia
Prolonged labour
Multiparity
Other causes of post-partum hemorrhage
Laceration of genital tract
Uterine rupture
Uterine inversin
Coagulopathy
Most common cause of postpartum hemorrhage requiring hysterectomy
Placenta accreta
DOES Not increase the risk for dveeloping postpartum endometriosis
Advanced maternal age
A 34 yo woman who has been using oral contraceptive pills for the last 3 years. She is planning to conceive this year. Drinks regular alcohol.
What is the most approp advice?
Stop Alcohol now
Which one of the ff would not increase the risk for cord prolapse during delivery?
Anemia
Not associated with maternal Vitamin D deficiency in pregnancy
Large for gestational Age
Maternal Vitamin D deficiency is associated with
Hypocalcemia in newborn
Rickets
Defective tooth enamel
Small for gestational duet to effect in skeletal growth
Fetal convulsions or seizures due to hypocalcemia
Rheumatoid arthritis pregnancy
STOP METHOTREXATE and continue SULFASALAZINE
Klympls palsy
C7, C8 and T1
hand and wrist paralysis
Associated with Horner Syndrome
KLUMPLS PALSY
Rupture of membranes occurring < 37 wks gestation
PPROM
Defined as a rupture >18 hrss prior to delivery
Prolonged ROM
How to diagnose Rupture of membranes
A sterile speculum exam
Nitrazine paper test - paper turns blue, indicating alkaline ph of amniotic fluid
Second step: Ultrasound
Never perform digital Vaginal exam
What is the treatment for premature rupture of membrane?
Depends on GA and fetal lung maturity
If it is term: Induce labor
>34-36 wks gestation: Labor induction may be considered
<25-32 wks - Expectant management with bed rest
Try to delay as long as possible so that he baby become more mature. A high vaginal swab is advisabe.
Lung maturity -> mother -> steroid
AntibioticsL Given to prevent infection
Antenatal corticosteroids: BETHAMETHASONE or DEXAMETHASONE 48 hrs - promote lung maturity
If there are signs of infection or fetal distress develop - Antibiotics and induce labor
Onset of labor between 20 and 37 wks gestation
Preterm Labor
Menstrual like cramps
Low back pain, pelvic pressure
Or new vaginal discharge or bleeding
Preterm Labor
How to diagnose preterm labor
Regular uterine contractions
Concurrent cervical change
Fetal fibronectin to confirm
Sterile speculum exam to rule out PROM
Ultrasound
What is the treatment for Preterm Labor
Hydration and bed rest
1st step - Unless contraindicated begin tocolytic therapy - B-Agonist, MgSO4, CCBs, PGIs
Steroids - to accelerate fetal lung maturity
What are the contraindications to tocolysis
Infection - nonreassuring fetal testing, placental abruption, no contractions
Fetus is older than 34 wks gestation
Fetus weighs less than 2500 grams or has inrauterine growth restriction (IUGR) or placental insufficiency
Lethal congenital or chromosomal abnormalities
Cervical dilation is greater than 4 cm
Chorioamnionitis or intrauterine infection is present
Other cause of fetal distress or fetal death
What is the prophylaxis for GBS
Penicillin or Ampicillin
Sudden gush of fluid
PRO
Uterine contraction and dilatation of cervix
PRETERM LABOR
Most impt drug to the PROM
Dexamethasone
Important drug to preterm labor
Tocolytics
Most absolute contraindication to tocolytics
Chorioamnionitis
Key word of Chorioamnionitis
Maternal fever
Once chorioamnionitis occured
Sampling and antibiotics
Tocolytic drugs that are used in the clinical practice
Calcium antagonist - Nifedipine
Oxytocin -receptor antagonists - Atosiban
Inhibitors od prostaglandin synthesis - Indomethacin
NO donors - Nitroglycerin
Betamimetics - Fenoterol, Terbutaline, Ritrodrine
Magnesium
Most common fetal malpresentation
Prematurity
Most common malpresentation
Occipito Posterior
The thighs are flexed, and the knees are extended
Frank Breech (50-75%)
One or both legs are extended below the buttocks
Footling breech (20%)
The thighs are flexed and the knees are extended
Frank Breech
One or both legs are extended below the buttocks
Footling breech
The thighs and knees aee flexed
Complete breech (5-10%)
Attempt only if delivery is imminent
Trial of breech vaginal delivery
Most common indication for CS
Previous CS
Most common cause of Priary C-section
Cephalopelvic disproportion
Prior classical C-section
Never to try vaginal delivery - UTERINE RUPTURE
What type of Episiotomy is the easy one
Midline
Which type of episiotomy is the hardest one
Mediolateral
Uterine shifts from midline
Fetal body part more prominent
Less bleeding more shock.
Uterine Rupture
Loss of > 500 ml blood for vaginal delivery or >1000 ml for C-section
Postpartum hemorrhage
Most common cause of Postpartum Hemorrhage
Uterine Atony
What are the other causes of Postpartum Hemorrhage
Genital Tract Trauma
Retained Placental Tissue
Most common cause of postpartum hemorrhage
Uterine Atony
Palpation of a soft, enlarged, “Boggy” uterus
Postpartum Hemorrhage
What is the first step of treatment in Uterine Atony
Bimanual uterine Massage
What is the second step in Uterine Atony
Oxytocin Infusion
Puerperal fever is defined as raised temperature of >38 C from day 1 to day 10. If fever think of the 3cs - birth cana;, breast, bladder.
Postpartum infections
Characterized by:
Temperature > 38 Deg C
Uterine tenderness
Offensive Lochia
Timing : usually 2nd day or 3rd day
Postpartum Infections
What is the most common risk factor for Postpartum infections
C-section
Postpartum with amenorrhea can’t breast-fed her baby.
What is the diagnosis?
Pituitary Necrosis or Sheehan’s Syndrome (Postpartum Pituitary Necrosis)
Anterior pituitary insufficiency secondary to
Massive obstetric Hemorrhage and Shock - Sheehan’s Syndrome (Postpartum Pituitary Necrosis)
What is the most common presenting syndrome
Failure to lactate due to decrease prolactin levels
Weakness, lethargy, cold insensitivity
Decreased TSH
Genital Atrophy and Menstrual Disorders
Decreased FSH and LH
What are the treatment options for pituitary tumours?
Usually surgery in most cases except for Prolactinoma
Early breast milk
Very rich in protein, fat,secretory IA and minerals
Colostrum
The 6Ws of postpartum fever
Wind (atelectasis) - first day
Water (UTI) - 2nd -3rd day
Womb (endomyometritis) - 2nd or 3rd
Walk (DVT, Pulmonary Embolism) - after 5 days
Wound ( incision, episiotomy) - After one week
Weaning (breast engorgement, absecess, mastitis) - usually more than 10 days
A female postpartum presents with blood pressure 80/50 and pulse 120 with 400 ml blood loss. on examination there was deviated uterus. What is the cause?
Broad Ligament Hematoma
- patient after labor with hypotension + contracted uterus + deviated uterus
The time of the onset of true labor until the ervix is completely dilated to 10cm
First Stage
The period after the cervic is dilated to 10 cm until the baby is delivered.
Second Stage
Delivery of the placenta
Third Stage
It is the longest and involves two phases
First Stage
The time of the onset of labor until the cervix is dilated to 4cm
Latent Phase
Continues from 4 cm until the cervix is dilated to 10 cm
Active Labor Phase
Early labor will last approx 8-12 hrs
Cervix will efface and dilate to 4c,
Contractions will last about 30-45 seconds, giving you 5-30 minutes of rest between contractions
Early Labor Phase
Active Labor will last about 3-5 hrs
Cervix will dilate from 4 cm to 10 cm
Contractions during this phase will las about 45-60 seconds with 3 -5 minutes rest in between
Active Labor Phase
Second stage of labor starts with ___ and ends with _____ with a total duration of ______
Starts with COMPLETE CERVICAL DILATATON and ends with the BABY DELIVERY and with the duration of 1 -3 hours.
The Third stage of labor starts with ____ and ends with _____ and the duration of _____.
Starts with the delivery fof the baby and ends with the delivery of the placenta and duration of Half an hour.
What is the treatment of prolonged Latent Phase
Sedation and rest
Cervix dilatation is around 2 cm with regular contraction
Prolonged Latent Phase
Cervix is dilated around 7cm and 2 cm change in 4 hrs
Regular contractions
Prolonged Active Phase
Dilated around 7 cm with regular contractions
Arrested Active Phase
What is the treatment if HYPOTONIC
Oxytocin
What is the treatment if it is Hypertonic
SEDATION
What if it is Adequate
CS
Regular contraction
Fully dilated cervix
No descent in 3 hrs
Second Stage of Arrest
If the contraction is weak what is the management
Oxytocin
If the head is not engaged in Arrest of labor, what is the management?
CS
If teh head is engaged in Arrest of Labor, what is the management?
FORCEPS (nonrotating)
Increase FHR above the base line
Less than 2 minutes
Not related to contraction
Always reassure
ACCELERATION
Fluctuation in the FHR
Normally occurs (6-25 mins)
If absent —- Abnormal
if marked reliability —– Fetal distress
Variability
Normal range of Fetal Heart Rate
110 - 160
If less than 110
Bradycardia
If more than 160
Tachycardia
Most common cause of fetal Bradycardia
Sleeping baby
Most common cause of Fetal Tachycardia
Maternal Fever
Normal Fetal Ph
7.25-7.35
Gradual Drop in the FHR
Gradual increase in the FHR
Mirror image of the contraction
Cause : fetal Head Compression
Early Deceleration
Gradual drop in FHR
Gradual increase in the FHR
Delay in relation to contraction
Cause is : fetal hypoxia or Fetal Acidosis
First Step is FETAL SCALP PH
Late Deceleration
Sudden drop in the FHR
Sudden increase in FHR
Severe if FHR is less than 60 —-CS
Cause —- CORD COMPRESSION
Variable Deceleration
When to say it is Normal Labor
Baseline 110-160
Acceleration and Variability is present
Deceleration is absent
Less than 110 or more than 160
Absent acceleration
Variability Absent
Late or Variable devceleration is present
ABNORMAL LABOR
Lowest point after onset of an early or late deceleration
and variable
NADIR
VEAL CHOP
Variable
Early
Acceleration
Late
Cord Compression
Head Compression
Okay or Mild Hypoxia
Placenta Insufficiency
The degree of acidemia can be detected through
Sampling the fetalscalp blood to measure either scalp ph or scalp lactate
What is the Fetal Movement assessment
32-34 wks
Normally 10 or more fetal movements in 2 hours
What is the first step in the abnormal fetal movements
History and Examination
First inv for the Abnormal Fetal movements
Fetal Heart doppler
Mgt if fetal heart rate is detected in Abnormal Fetal movements
CTG
If CTG is not available in the abormal Fetal movements
Refer to the hospital
If recurrent abnormal Fetal Heart movements, Near Term
Induction of labor
If recurrent abnormal FHM, away from term
Continuous CTG
Performed with the mother resting in the Lateral Tilt position
FHR is monitored externally by Doppler
Nonstress Test (NST)
two accelerations of > 15 bpm above baseline lasting for at least 15 secons over a 20 minute
REACTIVE (normal response)
Fewer than two accelerations over a 20-minute period
NONREACTIVE
Uses a real time ultrasound to assign a score of
2 (normal) or O (abnormal) to five parameters
fetal tone
Breathing
Movement
Amniotic fluid volume
NST
Biophysical profile (BPP)
Scoring is as follows for BPP
8-10 ?
Reassuring for fetal well-being
Scoring for BPP
6?
Considered equivocal. Term pregnancies are usually delivered
Scoring for BPP
0-4
Strong consideration should be given to immediate delivery
Fetal hips are flexed and the knees extended (pike position)
Frank breech
The fetus seems to be sitting with hips amd knees flexed
Complete breech
One or both legs are completely extended and present before the buttocks.
Footling Breech
One or both legs are completely extended and present before the buttocks.
Footling Breech
The baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees.
Kneeling Position
Is a transverse lie if the fetal long axis is oblique or perpendicular rather than parallel to the maternal long axis
Fetal Position
Oligohydramnios first diagnosed in the third trimester is often associated with
PPROM or with Uteroplacentak Insufficiency due to conditions such as Preeclampsia or other maternal Vascular diseases.
5
Management of gestational Diabetes
75g oRal Glucose tolerance test performed 6-8 wks after delivery
Right iliac fossa pain on getting up the chair and has been coughing and sneezing
No Mass palpable and no rebound tenderness
What is the cause?
Round Ligament Strain
Tx for UTI in pregnancy
Cephalexin
(Co-Amoxiclav and Nitrofurantoin can be used safely in pregnancy)
Safest treament for Acute Migraine causing headache and vomiting
Paracetamol and metoclopramide
TVS shows cervical shortening to 2 cm, cervical dilation, and protrusion of fetal membranes into the cervical canal.
What is the most likely diagnosis?
Cervical Insufficiency
Contraindication to Vagina delivery in breech presentation at term
Anemia
Cervical os is closed
Endometrial thickness of 2mm and an empty uterus
Adnexa are clear and there is no fluid in the pouch of Douglas
Complete Abortion
Most serious diagnosis of hyperemesis gravidarum
Hypokalemia
Which of the ff complications develop if Warfarin is used in second trimester of pregnancy?
Fetal Optic Atrophy
What food should be avoided during pregnany
Soft cheese
Abnormalities not seen in a pregnant woman with hyperemesis gravidarum
Hypothyroidism
Dilated cervic as well a progressive uterine bleeding and painful uterine bleeding contractions
The gestational tissue often can be felt or seen through the cervical os and passage of this tissue typically ocurs within a short time.
Inevitable abortion
Membranes may have ruptured and the conception products may have pastly passed, but significant amounts of placental tissue is still left in the uterus.
Cervical os is open, uterine is not well contraccted.
Gestational tissue is observed int he cervix.
Uterine size is ssmall than expected
Incomplete abortion
Refers to o utero death of the embryo or fetus prior to 20 wks gestation
Women feel that they dont feel pregnant anymore
Vaginal bleeding may occur and the cerix usually remains closed.
Missed abortion
Miscarriage occurs before the 12 wks and the entire contents of the uterus is expelled.
Uterus is small on PE and well contracted with an open or closed cervix.
Scant vahinal bleeding and only mild cramping
Ultrasound will reveal an empty uterus and no extra-uterine pregnancy
Complete Abortion
Screening markers used for both first and second trimester for screening for Down Syndrome
Free Beta HcG level
Increased in size but not blood supply
Total T3 and T4 increased
Free T3 nd T4 is normal
Sheehan Syndrome
Loss of products of conception before 20th week of pregnancy
Abortion
What is the most common cause of Abortion?
Chromosomal Abnormalities
Inhertied thrombophilies associated with abortion
Factor V leiden
No POC is expelled
Uterine bleeding +/- Abdominal pain
Closed os +
Intact membranes + fetal cardiac motion on ultrasound
Threatened Abortion
What is the treatment of Threatened Abortion?
Pelvic rest for 24-48 hrs
No sexual relationships
Progesterone
Completely expelled
No pain
No bleeding
Closed os
Emty uterus on ultrasound
Complete Abortion
Expelled some POC
There is bleeding and pain
Open os
Ultrasound shows retained Fetal tissue
Manual uterine Aspiration or D and C
Incomplete
No POC is expelled
Uterine Bleeding
There is Pain
Open OS.
Ultrasound shows retained fetal tissue.
Manual uterine Aspiration or D and C
Incomplete
No POC is expelled
No fetal cardicac motion
No uterine bleeding
No pain
Closed os
No detal cardiac activity
retained fetal tissue on ultrasound
Missed Abortion
Endometritis leading to septicemia
Septic Abortion
Main Treatment of septic arthritis
Antibiotics then curettage
What is the main risk with curettage of Septic Abortion
Perforation of Uterus
Main treatment of Threatened abortion
Rest
Most common cause of Abortion
Chromosomal
What is the timing of abortion with chromosomal disorders
First Trimester
What is the TTT of abortion in first trimester
Dilataion and Curettage
What is the TTT of abortion in second trimester
Dilatation and Evacuation
What is the best way to assess the gestational age in the first trimester
US
Nonviable pregnancy without vaginal bleeding, uterine cramping or cervical dilation
Missed abortion
Mgt: Scheduled suction D & C
Conservative management or induce cotnrations with Misoprostol
Viable pregnancy with vaginal bleeding but no cervical dilation
Threatened Abortion
Mgt: PFten the cause is Implantation bleeding
Vaginal bleeding and uterine cramping leading to Cervical dilation but not POC has yet been passed.
Inevitable Abortion
Mgt: Emergency Suction
D&C if bleeding is heavy to prevent further blood loss and anemia
Misoprostol
Vaginal bleeding and uterine cramping leading to cervical dilation with some but not all, POC having been passed.
Incomplete Abortion
Mgt: Emergency Suction D & C
Cytotec or Misoprostol - inuce contractions
all POC being passed
Conpleted Abortion
Confirmed by USG
B-HCG should be obtained weekly
Most common cause of fetal demise
Idiopathic
What is the risk of Fetal Demise
DIC
Condition of intrauterine fetal growth slowing
Caused bu infant nutrition and general life support
Intrinsic factors in the fetus itself
Intrauterine Growth Retardation (IUGR)
It is caused by Placental Insufficiency
Asymmetric IUGR
recurrent abortion and IUGR
Second trimester
Antibodies: Antiphospholipic, Anticardiolipin
Most commen congenital abnormaltyL Heart Block
SLE with pregnancy
What is the treatment needed for SLE with prenancy
Low dose Aspirin
Low Dose Heparin (LMWH)
Painless dilation of the cervix
Delivery of Normal baby who quickly dies (premature delivery)
Timing: Second trimester
Painless leakage of amniotic fluid in second trimester often diagnosed with USG
Incompetent Cervix
What are the causes of Incompetent Cervix
History of conization
LEEP
Diethystilbestrol Exposure
What is the ultrasound findings for the incompetent cervix?
Shortening of cervix
Herniation of Fetal Membranes
What is the TTT of Incompetent Cervix
Cerclage
Large ketonuria
Weight Loss
Electrolyte disturbances
Ptyalism (excess salivation)
Hyperemesis Gravidarum
What are the risk factors for Hyperemesis Gravidarum
Molar Pregnancies
Multiple Gestations
UTI
