Lectures 1 Flashcards
Parameters for normal menstrual cycle
(a) duration
(b) time btwn cycles
(c) blood loss
Normal menstrual cycles
(a) 2-7 days, average 5 days duration
(b) 21-35 days from day 1 to day 1
(c) average 30 cc blood loss, normal is under 80 cc
- not clotted w/ endometrial debris
Discharge instructions for postparum mothers to prevent postpartum depression
Good sleep and nutrition
- close monitoring/awareness and screening for symptoms (ex: symptom tracking)
- ensure good support
Differentiate timing of delivery btwn types of twins
Didi
Dimono
Mono-mono
Timing of delivery- earlier and earlier the more the twins are separated
Didi twins- 38 wks
Di-mono- 34-38 wks
Mono-mono: 32-34 wks and C-sxn 2/2 risk of cord entanglement
Ddx for postpartum fever
- endometritis
- UTI (cystitis or pyelo)
- wound infection
- mastitis (clogged ducts)
- HCAP PNA
- C. dif, pelvic thrombophlebitis
Steps to decrease risk for preterm PROM in a pt w/ h/o PROM
Can give progesterone for PROM ppx
Important reminder when transfusing blood products
Need to use 1:1:1 ratio of FFP to pRBC to plts after 2uRBC to prevent dilution
Meig’s syndrome: triad of benign ovarian fibroma
Recall that most ovarian masses present w/ GI symptoms
Meig’s syndrome = triad of benign ovarian fibroma + ascites + right pleural effusion
-typically pleural effusion on the right b/c the transdiaphragmatic lymphatic channels are larger in diameter on the right
What counts as a LARC?
LARC = long acting reversible contraception
- IUD
- Nexplanon
Most common etiology of postpartum hemorrhage
Uterine atony
-uterus feels boggy/soft
2 ways we can try to prevent uterine atony
- fundal massage
- IV/IM oxytocin
= active management of the 3rd stage of labor (delivery of the placenta)
-give 20 of ptosin (oxytcin) + cord traction via suprapubic pressure
Describe some surgical techniques to manage uterine atony
Ligate the uterine artery
UAE = embolize uterine artery (via IR)k
B. Lynch sutures
Last resort = hysterectomy
Workup for adnexal/mass
(a) First line, second line
(b) How different if post-menopausal
Workup for adnexal/mass
(a) First line: Pelvic ultrasound
(b) and if post-menopausal test CA-125 (not if premenopausal b/c can be falsely elevated by endometriosis, fibroids, PID)
Second line (and definitive tx) = surgical exploration
Primary source of amniotic fluid
Amniotic fluid produced mostly by fetal urine output
Risk factors for postpartum hemorrhage
C-section
prolonged labor, prolonged induction
-large baby (anything that over-distends the uterus- b/c then it needs to get much smaller much faster)
-polyhydramnios
-infection
-use of Mg during pregnancy (used to pervent seizures in preeclampsia
Differentiate Braxton-Hicks from true labor contractions
Braxton-Hicks: irregular, inconsistent
- usually in the third trimester
- often can be ‘broken’: stopped when change what you’re doing or are distracted
True labor contractions: regular and consistent
Describe when estrogen peaks in the menstrual cycle
Estrogen produced by ovary and follicle (thing before ovulation causes corpus luteum), peaks at ovulation
-then LH peak comes shortly after
Define post-partum hemorrhage
Over 500 ccs after vaginal delivery
Over 1,000 cc after C-section
Serious consequence of persistent oligohydramnios
Pulmonary hypoplasia
-not enough pressure around the fetal lungs to allow for maturity
When do you deliver if pt has preeclampsia w/ severe features
34 wks
Define antepartum care
Care of pregnant mother before labor/delivery
Tox labs for preeclamspia
- CBC for plts
- BMP for Cr
- LFTs
- Uric acid (b/c builds up if kidneys can’t excrete), LDH
- urine protein and creatinine for ratio (bad is over 3)
Name 3 meds that are well-established teratogens
- coumadin (warfarin)
- isotretin (acutane)
- ACEi
Most common cause of coagulopathy in pregnancy
Placental abruption
Tx for uterine atony: 3 steps
- uterotonic meds
- methergine (contraindicated in HTN)
- hemabate (contraindicated in asthma)
- oxytocin (pit)
- mesoprostol - bakri baloon
- apply pressure to induce uterine tamponade to compress the spiral ateries - surgical management
Describe medical management of uterine atony
Give methergine (unless HTN, then use hemabate first), then give mesoprostol (takes 20 mins to work)- then add more pit (oxytocin)
Describe a possible physiologic mechanism of preeclampsia
Abnormal migration or structure of cytotrophoblasts lining the spiral arteries => there is not appropriate decrease in resistance of the vessels
Also a component of vasoconstriction
3 most common causes of neonatal death in preterm births
- Respiratory distress
- Infection
- Interventricular hemorrhage
Describe diabetes screening during pregnancy
1-hr GCT (glucose control challenge) at 24-28 weeks
Tx for endometritis
IV gentamycin + clindamycin
-or can use single agent unasyn (piperacillin/tazobactam)
When can you detect fetal heart rate on transvaginal US
6 weeks
Contraception recommended for the immediate post-partum period
Progesterone-only options b/c already have so much estrogen (pregnancy is already a hypercoagulable state), dont want to add more
Mirena IUD, Minipel, Nexplanon (lowest failure risk), Depo provera injection
Describe the mechanism for anovulatory bleeding
Unopposed estrogens => no progesterone withdrawal (no corpus luteum to produce progesterone) => disordered growth of endometrium => abnormal shedding
When is the EDD?
Estimated delivery date = 40 weeks after LMP
Mneumonic for AUB
AUB mneumonic: PALM COIEN
PALM = structural/anatomic sources: more common post-menopause
P- polyps
A- adenomyosis
L- Leiomyoma (benign fibroids)
M- malignancy (endometrial or cervical cancer)
C- coagulopathy (VW disease- note echymoses petechiae) Ovarian dysfunction (ex: PCOS) Iatrogenic- on heparin Endometrial process Not yet classified
ex: AUB-L for bleeding 2/2 fibroids
Contraindication for sex during pregnancy
Placenta previa: placenta blocking opening of the cervix, ‘low lying’ placenta
Premature rupture of membranes
Routine labs at first prenatal visit
UA, UCx, CBC, vaccination status, HIV/syphilis, blood type
-TSH
Benefits of breast feeding
(a) for mother
(b) for baby
Benefits of breast feeding: suggest 6+ mo
(a) for mother: wt loss, decreased risk of breast cancer, newborn bonding, cost effective
(b) for baby: passive immunity
PROM vs. PPROM
PROM = ROM before labor (so w/o cervical dilation or contractions)
PPROM = PROM before 32 weeks
What abnormality on pap smear does not require colposcopy
All but ASC-US while HPV negative
Differentiate primary and secondary postpartum hemorrhage
Primary- w/in 24 hrs
Secondary- over 24 hrs until 6-12 weeks post-partum
Physical exam description of atropic vagin
Loss of rugae
Recommendation for cervical cancer screening
Starting at age 21 (regardless of sexual activity) pap smears q3 yrs ages 21-30
-then pap smear + HPV co-testing q5yrs
(if doing just cytology w/o co-testing do pap smear q3y)
What kind of twins have the highest risk of cord entanglement?
Mono-mono
33 yo G1 s/p induction of labor for post-term baby
- lengthy first and second stage
- postpartum: brisk vaginal bleeding not responsive to uterine massage
Dx
Postpartum hemorrhage
-probably 2/2 uterine atony
What kind of twins are most likely to require C-section
Mono mono b/c of the risk of cord entanglement causing fetal death
How to date pregnancy
LMP, then get US to see if dates agree- if inconsistent use US dating over LMP
-consistent if w/in 1 week in the 1st T, 2 weeks in the 2nd, 3 weeks in the 3rd
Maternal management of hep C in pregnancy
- prevention of vertical transmission
- breastfeeding?
Don't treat- ribavirin is teratogenic... hep A and B vaccination -vertical transmission associated w/ maternal viral load -C-section doesn't protect -avoid scalp electrodes -encourage breastfeeding
When does menses return after pregnancy?
4-5 weeks, longer (can be months) if breastfeeding, especially if exclusively breast feedling
When is C-sxn indicated for macrosomic fetuses?
Primary C-sxn if over 4500 w/ diabetes, over 5000 w/o diabetes
Most common presenting feature of ovarian cancer
GI symptoms not gynecologic!
-bloating, abdominal pain
Ddx for postpartum fever refractory to 48 hrs of IV abx
pelvic abscess
thrombophlebitis (inflammation of pelvic vasculature)
Chorioamniontis vs. endometritis
Just depends on if pt has delivered yet
Fever before delivery (like in labor) = chorioamnionitis
After delivery = endometritis
Timing and fxn of anatomy scan
Anatomy scan at 18-20 weeks
- determine sex of the baby
- assess growth of fetus
What kind of twins are at risk of twin-twin transfusion syndrome
Diamniotic monochorionic
-due to collateral flow/vascular anastomosis
3 steps when preterm delivery is imminent
- Steroids
- Tocolytics for 48 hrs
- nifedipine, terbutaline, indomethacin - MgSO4
-use indomethacin over nifedipine if possible when using Mg 2/2 risk of respiratory depression
Differentiate purpose of umbilical artery vs. MCA doppler
Umbilical artery doppler used to assess systolic/diastolic ratio- indicative of uteroplacental insufficiency
MCA doppler to assess for anemia
-b/c there will be increased blood flow/velocity to the brain if fetus is anemic
Treating pain in pregnancy
Use tylenol
-avoid NSAIDs
Name the 3 stages of labor
- Dilation of cervix
- Fully dilated to end of delivery (delivery of fetus)
- Delivery of placenta
You pee on a stick…what comes up as + pregnancy test?
b-hCG over 25 = positive test
5 steps once PROM has been confirmed
- Admit the patient: get them on EFM (external fetal monitor) and toco
- Latency abx (ampicillin, erythromycin) to increase latency period by 5-7 days
- Betamethasone- ensure fetal lung maturity in case delivery is imminent
- If contracting: tocolytics for 48 hrs
- MgSO2 for CP ppx (if before 34 wks) if you think delivery is imminent
- want it on board for at least 4 hrs to be effective for CP ppx
Most common type of malignant ovarian neoplasm
90% of malignant ovarian neoplasms are epithelial
-includes mucinous, serous, clear cell, endometrioid
Pt comes in not in preterm labor, what two things can you do to assess her risk of going into preterm labor
Negative fetal fibronectin (FFN) + cervical length of over 2.5 indicates pt is at very low risk for preterm labor
What is lochia?
Vaginal discharge after birth (puerperium) containing blood, mucus, uterine tissue
-typically continues for 4-6 weeks after childbirth (known as the postpartum period)
lochia rubra (red) –> serosa (brown/pink) –> alba (yellow/white)
2 phases on the menstrual phase based on
(a) Gonadotropins
(b) Endometrial lining
Menstrual cycle phases
(a) follicular and luteal based on LH
(b) Proliferative and secretory based on endometrium
Tx for chorioamnionitis
Ampicillin + gentamicin
-need amp not for the mother but to protect the fetus from GBS
Factor to determine pregnancy wt gain
Ideal wt gain in pregnancy depends on pre-pregnancy weight
-less wt gain if obese, vs. want more wt gain if underweight before pregnancy
Differentiate the cause of symmetric vs. asymmetric IUGR
IUGR = fetus less than 10th percentile
Symmetric IUGR = early onset 2/2 TORCH infection
Asymmetric IUGR = later onset, 2/2 UPI (uteroplacental insufficiency)
-more likely to be reversible
24 yo G1P1 3 days post-op from C-section (2/2 fetal tachycardia to 170 bpm) p/w fever of 102.2 and increased abdominal pain
Dx
Since she’s postpartum = endometritis
-increased risk b/c chorioamnionitis (as evidenced by fetal tachycardia)
Tests for fetal well being in the third trimester
GBS and HIV test
NST = fetal non-stress test: reactive NST is 2 accelerations in 30 mins
