Nagy's favorites Flashcards
Definition of preeclampsia/eclampsia
After the 20th gestational week
- Preeclampsia: BP > 140/90 mmHg
- Proteinuria > 300mg/24 hours
Eclampsia: Tonic-clonic seizures
Gestational diabetes
Part of screening program = check all pregnant at 24-28 gw
Fasting glucose < 5.6mmol/l => Healthy
Fasting glucose 5.6-7.0mmol/l => Do OGTT
Fasting glucose > 7.0mmol/l on two separate measurements => DM
OGTT «5,6,7,8»:
Normal at 0 min: under 5,6 mmol/l
At 120 mins:
- If < 7.8mmol/l => Impaired Fasting Glucose (IFG)
- If 7.8-11 mmol/l => Impaired Glucose Tolerance (IGT)
- If > 11 mmol/l => DM
Indications for C-section
6 groups:
1. Vital maternal
(HF, pulm.edema, severe hemorrhage, DIC)
2. Vital fetal
(asphyxia, cord prolapse, neglected transverse lie, ascending infection, fetal pneumonia)
3. Vital maternofetal
(ecclampsia, uterine rupture, placenta previa/abruption)
- Prophylactic maternal
(maternal illness, previous operation uterus, decr.pelvic capacity, late primiparity (over 30 yrs)) - Prophylactic fetal
(threatened asphyxia, placental dysfunction, or hypoxia, fetal illness, pregnancy after infertility treatment) - Prophylactic maternofetal
(damning gestational history, dystocia, prolonged labor, FDP, malpresentation/position, twins)
__________________________________________________
M/F:
- Cephalopelvic disproportion
- Failed induction of labor
Maternal: Eclampsia
- Cervical cancer
- Fibroids, tumor
- Herpes
Fetal:
- Non-reassuring fetal HR (bradycardia)
- Cord prolapse
- Malpresentation
- Multiple gestations
- Fetal abnormalities => Hydrocephalus
Placental:
- Previa
- Abruptio
US in pregnancy
0 (6-7w) = transvaginal diagnostics
- Confirm (gestational sac, HR)
- Location: Intra-/extrauterine
- Twins
I (11-13+6w) = gestational age & pathology
- Nuchal translucency (Down’s)
- Neural tube defects
- Biometrics: ductus venosus flow
II (18w) = genetic screening
- Congenital malformations
- Chromosomal abberations
III (28-32w) = fetal size screening
- IUGR
- Late congenital malformations
IV (38w) = information for delivery
- Fetal presentation
- Fetal weight
- High-risk?
- gw are from Nagy in lecture
Placenta abruptio / placenta previa
Hello, CTG, use hands to palpate the uterus
Abruptio: Painful, hard uterus => C-section
Previa: Painless, CTG normal
Post-partum haemorrhage
- Tissue: Retained placenta
- Trauma: Vaginal lacerations
- Thrombin: Coagulopathy (DIC)
- Tone: Uterine atony (exclude other causes)
Stages of birth
- Onset of labor: Longest stage
a. Latent (3cm) - nulli: 8-20 hrs, multi: 5-12 hrs
b. Active (3-10cm) - nulli: 5-7 hrs, multi: 2-4 hrs - Birth: 30-90mins (nulli: ~2hrs, multi ~1hr)
a. Propulsive phase (full dilation, descend to pelvic floor)
b. Expulsion phase (delivery) - Placenta: 5-30mins
a. Separation
b. Expulsion - Postplacental stage: 2 hours
a. Incr. risk of bleeding
b. Repair lacerations
c. D-Ig
_____________________________________________________
Dr. Nagy times:
1: Cervix (nulli: 9-11 hrs, multi: half)
2: Fetus (nulli: 50-60 hrs, multi: half) - Placenta (nulli: 5-15 (max 30 min)
- Observation: 2 hrs
Techniques of C-section
Abdominal wall:
- Transverse (Pfannenstiel)
- Vertical (Midline)
Uterus:
- Lower segment incision (Transverse)
- Classical (Vertical)
- (Low vertical)
Pearl index
No. of pregnancies in 100 females/year with chosen contraceptive.
- OCP: 0.1-2.5
- Sterilization: 0.3-6
- Post-coital pill: 0.5-2.5
- IUD: 0.5-5
- Condom: 3-28
Routine exams
- Colposcopy
- Cytology
- Bimanual exam
- Breast exam
Long-term OCP use
Good: All decreased
- Ovarian/endometrial cancer
- Bone loss
- Dysmenorrhea
- Acne
- Risk of trisomies in high maternal age
- Regulates cycle
Bad: all increased
- DVT/stroke
- BP
- Weight
- Depression
Endometriosis (+ Dx, Tx)
Endometrial-like tissue outside the uterine cavity.
Dx: Gold standard => Laparoscopic visualization
Tx:
- Surgery
- Drugs (Pseudopregnancy, Pseudomenopause => GnRH analogue)
Urinary incontinence
1) Irritative: Urinalysis => Cystitis/tumor/foreign body
2) Stress: Loss of bladder support => Cough
3) Urge: Hypertonic => overactive detrusor (Tx: Anticholinergics)
4) Overflow/neurogenic: Hypotonic w/ dribbles (Tx: Cholinergics)
5) Bypass/Fistula
Main vaginal infections
- Bacterial vaginosis
- Trichomonas
- Mycosis (Candida)
Mycosis has normal pH, the others have increased
Tx: metronidazole if pH increased, antifungal if not
Spontaneous abortion (Hx, Dx)
Hx: Pain + bleeding
Dx: Cervix, US, hCG
Contraindications to tocolysis
Obstetric:
- Severe abruption
- Ruptured membranes
- Chorioamnionitis
Fetal:
- Lethal anomaly
- Fetus is already dead
- Fetal jeopardy
Maternal:
- Eclampsia
- Advanced dilation
Leopold maneuvers
- Fundal grip = fundal height, which pole in fundus (head, butt)
- Umbilical grip = One hand on each side of belly (lie, position)
- Pelvic grip (1st pelvic grip) = Grasp lower portion of abdomen just above the pubic symphysis with thumb and fingers of the right hand (presenting part and its relation to pelvic inlet (engagement))
- Pawlick grip (2nd pelvic grip) = Face woman’s feet, attempt to locate fetus’ brow. Fingers of both hands moved gently down the sides of the uterus => Pubis. The side where there is resistance to the descent of the fingers is greatest where the brow is located (presenting part, descent, engagement)
- Zangemeister maneuver = cephalopelvic disproportion
Stopping uterine bleeding
Young: Progesterone => Preserve fertility
Old: D&C
Mayer-Rokitansky-Küster-Hauser Syndrome
Müllerian agenesis.
- Congenital malformation
- Failure of Müllerian duct to develop
o Missing uterus, cervix, vagina
o Variable degree of upper vaginal hypoplasia (shortened)
- Causes 15% of primary amenorrhea
- Ovaries intact, ovulation usually occurs
- Enter puberty with secondary sexual characteristics
Papanicolau classification
P0: Improper sample P1: Negative result P2: No dysplasia, some benign aberration P3: Pathologic cells, but impossible to tell due to inflammation or dysplasia P4: Atypical cells => Suspect malignancy P5: True malignancy
Bethesda
Reporting cervical or vaginal cytological Pap smear results.
Important steps:
- Quality of the slide
- Whether the result is positive or negative
- Details of the slide (LSIL/HSIL)
- Physician recommendation of how to proceed
Puerperium
Period beginning immediately after the birth of a child extending for ~ 6w
When prenatal care starts
Before conception
Mortality rates
Neonatal Mortality Rate: No. of neonatal deaths during the 1st month/1,000 live births.
- Early NMR: 1st week
- Late NMR: 2nd-4th weeks
Perinatal Mortality Rate: No. of perinatal deaths (stillbirths + neonatal deaths, from 22nd gestational week to 7th week postpartum)/1,000 total births.
To exclude ectopic pregnancy
Measure b-hCG:
- 1,000 U/L => Gestational sac
- 7,000 U/L => Yolk sac
- 10,000 U/L => Embryo
Brown spotting and abdominal pain indicates ectopic pregnancy => Check fallopian tubes.
b-hCG doubles every 2nd day. If high but not double => Ectopic pregnancy.
Vitamin supplements
Preconception: Folic acid up to 6 weeks before (400 microgr/day)
2nd trimester: Low dose Iron and Iodine (250 microgr/day)
History taking
- Previous operations
- Allergy to medications
- Obstetric anamnesis
- Illness, drugs
- First day of last menstrual period
o Naegele’s rule: Can only be applied if menses are regular and cycle is 28 days.
Signs of pregnancy
Presumptive: in man and woman
- Nausea, vomit
Probable: in women
- Physical changes
- Positive pregancy test
Definite sign (only in pregnant)
- Fetal HB
- Detecting fetus (US)
Physical signs of pregnancy
Chadwick sign: bluish discoloration over cervix and vagina (ca. 6th gw)
Piskacek sign: Soft prominence over the site of implantation
Goodell’s sign: Softening of the cervix (4-6 gw)
Hegar’s sign: Softening of the cervical isthmus (6-8 gw)
Chloasma
Linea nigra
Location of Bartholin’s Cyst
Lower 1/3 of labia major
Marsupialization of Bartholin’s Cyst
Cyst opened at the edges + sutured, forming an open pocket
Asherman’s syndrome
Adhesions/fibrosis of the uterine cavity, usually from D&C. Reversible infertility.
Types of anaesthetics used
- Vaginal delivery: Epidural
- C-section: Spinal
- Emergency C-section: Intratracheal narcosis
Endometrial cancer staging
0: CIS (Carcinoma in situ) I: Limited to the uterus - Ia: < 50% myometrial invasion - Ib: > 50% myometrial invasion II: Cervical involvement III: Local spread - IIIa: Uterine serosa / adnexa (fallopian tubes, ovarian, ligaments) - IIIb: Vagina/parametrium - IIIc1: Pelvic nodes - IIIc2: Paraaortic nodes IV: Metastasis - IVa: Bladder/rectal mucosa - IVb: Distant metastasis, ascites, peritoneum
Vulvar cancer
0: VIN I: Limited to vulva/perineum < 2cm - Ia: < 1mm stromal invasion - Ib: > 1mm stromal invasion II: Extension to adjacent perineum III: Any size + extension to perineal structures with positive inguinofemoral LN - IIIa1: 1 LN > 5mm - IIIa2: 1-2 LN < 5mm - IIIb1: > 2 LN > 5mm - IIIb2: > 3 LN < 5mm IV: Metastasis - IVa: Bladder, urethra, rectum, bone - IVb: Distant metastasis (Pelvic LN)
Vaginal cancer
0: VAIN
I: Limited to vagina
II: Paravaginal invasion w/ no extension beyond
pelvic side walls
III: Invasion of pelvic side wall
IV: Metastasis beyond pelvis
- IVa: Bladder, rectum
- IVb: Distant metastasisCervical cancer (must know)
0: CIN
I: Limited to cervix
Ia: Invasion dx by microscopy
- Ia1: Stromal invasion < 3mm depth, < 7mm extension (microinvasive)
- Ia2: Stromal invasion 3-5mm depth, > 7mm extension
Ib: Clinically visible lesion
- Ib1: < 4cm
- Ib2: > 4cm
II: Beyond cervix, no pelvic side walls, no lower 1/3 of vagina
IIa: Involved upper 2/3 of vagina, no parametrial involvement
- IIa1: < 4cm
- IIa2: > 4cm
IIb: Parametrial invasion
III:
- IIIa: Lower 1/3 of vagina, no pelvic wall extension
- IIIb: Pelvic side wall extension, obstructive uropathy
IV: Metastasis
- IVa: Bladder, rectum
- IVb: Distant organs
Breast cancer (TNM)
Tis: DCIS (Ductal Carcinoma in situ), LCIS (Lobular Carcinoma in situ)
T1: less than 2cm (a-d) T2: 2-5cm T3: > 5cm T4: Tumor extends to skin or chest wall - T4a: Chest wall - T4b: Skin - T4c: Chest wall + Skin - T4d: Inflammatory cc
N: Lymph nodes (Nx: cannot be assessed)
- N0: no Cancer cells
- N1: (Ipsilateral) movable axillary LN
- N2: (Ipsilateral) fixed axillary LN or internal mammary LN (w/o axillary)
- N3: (Ipsilateral) infra-/supraclavicular LN or internal mammary LNs (w/axillary)
M: Metastasis
- M0: No metastasis
- M1: Metastasis
Ovarian cancer
I: Ovary/fallopian tube
- Ia: 1 ovary (capsule intact, no tumor on surface, negative washings)
- Ib: Both ovaries (same as above)
- Ic: a/b +
- Ic1: Surgical spill
- Ic2: Capsule rupture before surgery, tumor on ovary/fallopian tube surface
- Ic3: Malignant cells in ascites/peritoneal washings
II: Pelvic extension/primary peritoneal cancer
- IIa: Uterus/fallopian tubes
- IIb: Other pelvic intraperitoneal tissues
III: Cytologically/histologically confirmed spread to peritoneum and retroperitoneal LN
- IIIa: Retroperitoneal LN, microscopic metastasis beyond pelvis
- IIIa1(i): Retroperitoneal LN < 10mm
- IIIa1(ii): Retroperitoneal LN > 10mm
- IIIa2: Microscopic extrapelvic peritoneal metastasis
- IIIb: Macroscopic peritoneal metastasis < 2cm
- IIIc: Macroscopic peritoneal metastasis > 2cm
IV: Metastasis
- IVa: Pleural effusion with positive cytology
- IVb: Distant metastasis
LSIL/HSIL
LSIL
- Condyloma
- CIN I
HSIL
- CIN II
- CIN III => In situ => invasive cc
