Ob/Gyn

Question 1

Oral contraceptive pill contraindications

Answer 1

smoking history (>15 cigarettes / day) if >35 years old

history of current or past venous thromboembolism (VTE), known thrombophilia

<6 weeks postpartum if breastfeeding

current breast cancer

uncontrolled hypertension (diastolic >100 or systolic >160)

ischemic heart disease, complicated valvular heart disease

history of cerebral vascular accident (CVA) aka stroke

migraine headache with focal neurological symptoms

over age of 35 and migraine without aura

diabetes with end organ involvement

severe cirrhosis, liver tumor, or active viral hepatitis

systemic lupus erythematous (SLE) with positive anti-phospholipid antibody (APLA)

depression, because OCP may cause mood changes

Question 2

What are routine investigations for an asymptomatic patient at high risk for an STI and how do you complete those investigations

Answer 2

chlamydia and gonorrhoea testing can be by urine or swab

trichomoniasis testing by vaginal swab

Question 3

What are the mechanisms through which OCP prevents pregnancy

Answer 3

By progesterone:

1) inhibiting ovulation (main mechanism)
2) change cervical mucus which blocks sperm
3) cause pseudo decidualization of endometrium to inhibit implantation
4) inhibit tubal peristalsis to inhibit fertilization

Question 4

What does estrogen do in OCP

Answer 4

No role in contraception

Prevents breakthrough bleeding

Question 5

Rare but serious OCP adverse effects

Answer 5

VTE

myocardial infarction (MI)

stroke

increased risk of cervical cancer

Question 6

Progestin only pill MOA

Answer 6

progestin only pill only have 1 mechanism of action because it is at a very low dose - thickening of cervical mucus to block sperm

Question 7

Injectable progestin MOA

Answer 7

High dose so 3 mechanisms of action:
inhibit ovulation
thickening of cervical mucus to block sperm
pseudo-decidualization (atophy) of endometrium that inhibit implantation

Question 8

How often should progestin injectable be given

Answer 8

q3 months (with forgiveness window up to 14 weeks)

Question 9

Breakthrough bleeding with progestin injectable in the first 3-6 months is normal. How do you manage this?

Answer 9

need to reassure patients

exclude genital tract pathology

treat with estrogen and NSAIDs

can ameliorate by shorter interval of injection

Question 10

Does IUD increase risk of infection?

Answer 10

Not in the long term

Relative risk of 4 in first 3 weeks after insertion then return to normal baseline

Question 11

Contraindications for IUD

Answer 11

known or suspected pregnancy

puerperal sepsis (infection and fever post childbirth or miscarriage)

immediate post septic abortion

current pelvic inflammatory disease, purulent cervicitis, chlamydia, gonorrhea (can put in IUD then test and treat STI)

cervical or endometrial cancer

current breast cancer

unexplained vaginal bleeding

distorted uterine cavity anatomy

malignant trophoblastic disease

Question 12

Abortion timeline

Answer 12

most are done before 12 weeks gestation a women

cannot have an elective abortion past 24 weeks gestation

in general, no doctors and no facilities will perform abortion past 20 weeks gestation, which may be offered in US

Question 13

Medication abortion options

Answer 13

methotrexate intramuscular injection

misoprostol oral or vaginal delivery

Question 14

Medication abortion options

Answer 14

up to 7 weeks

Question 15

Requirements for medication abortion

Answer 15

must have surgical abortion back up option available

Question 16

folic acid requirements in pregnancy

Answer 16

if average risk patient:
eat food rich in folate
folic acid supplement 0.4-0.8mg (1mg maximum) for at least 1 month before conception and at least 3 months after conception (ideally throughout pregnancy and postpartum)

if high risk patients
(epilepsy or insulin dependent diabetes or obesity BMI>35 or family history of neural tube defect or high risk ethnicity (Sikh)):
increase dietary intake of folate rich foods
folic acid 4mg (5mg maximum) for at least 3 months before conception until 1st trimester, then 1mg maximum throughout pregnancy and in postpartum period

Question 17

Which vaccines are contraindicated in pregnancy

Answer 17

live vaccines (MMR, rotavirus, chicken pox vaccines)

Question 18

Durations of trimesters

Answer 18

1st trimester is week 0-12

2nd trimester is week 12-28

3rd trimester is week 28-40/delivery

Question 19

Prenatal visit schedule

Answer 19

1) 1st prenatal visit in week 6-10
2) visit every 4 weeks from week 0-28
3) visit every 2 weeks from week 28-36
4) visit every 1 week from week 36 to delivery

Question 20

Uterine location throughout pregnancy

Answer 20

uterus should be palpable above pubic symphysis at 12 weeks; at umbilicus at 20 weeks and then increase 1cm / week until delivery

Question 21

What does 1st trimester screening include

Answer 21

Integrated Prenatal Screen (IPS) testing

ultrasound

laboratory investigation:

CBC including hemoglobin and MCV for anemia and hemoglobinopathies

blood type: ABO group, Rh, Rh antibody screen can identify women in need of Rhogam treatment

hemoglobin electrophoresis if diagnosed with hemoglobinopathies (e.g. sickle cell, thalassemia), then need special monitoring and management

infection: rubella immunity, HBsAg, VDRL (for syphilis), HIV, urine culture & sensitivity, gonorrhoea, chlamydia
if not immune to rubella, must avoid sick contact during pregnancy and immunize postpartum
if gonorrhoea, chlamydia, bacterial vaginosis or trichomonis, then treat
urine culture & sensitivity can pick up group B streptococcus, which warrant prophylactic antibiotics at delivery

Question 22

When do you start monitoring fetal heart rate and fundal height?

Answer 22

FHR - 12 weeks

Fundal height - 20 weeks

Question 23

What does 2nd trimester screening include

Answer 23

morphology ultrasound at 18-20 weeks - anatomical scan to assess fetal anatomy, placental location, detect multiple gestation and date if needed

blood: hemoglobin, ABO, Rh and Rh antibody at 24-28 weeks
hemoglobin for anemia
Rh and Rh antibody screen for need of giving Rhogam

gestational diabetes screening with non-fasting 50g glucose load at 24-28 weeks screen for gestational diabetes mellitus
if positive screening (impaired glucose , need to follow up with further screening (HbA1C)

Question 24

What does 3rd trimester screening include

Answer 24

group B streptococcus (GBS) vaginal and rectal swab at 35-37 weeks

GBS part of normal vaginal flora in 20% of women

1-2% of babies vaginally delivered by GBS colonized mother can develop infection, resulting in bacteremia, meningitis or pneurmonia

if positive, then intra-partum (i.e. just before delivery) antibiotics to eradicate colonized GBS

Question 25

What are the possible ultrasounds that can be performed in pregnancy, their purpose and the timeline for each

Answer 25

5-12 weeks: Ultrasound in Early Pregnancy
can measure crown rump length, which is the most accurate estimation of gestational age in 1st trimester after 6 weeks
indication for early ultrasound:
in bleeding and cramping, ultrasound can rule out ectopic pregnancy
in unclear gestational age where menstrual cycle is irregular, last menstrual period is unknown or uterine size do not match, ultrasound can confirm gestational age
prior miscarriage, ultrasound can confirm viability and reassure mother

11-14 weeks: Ultrasound for nuchal translucency
part of Integrated Prenatal Screening (IPS) high nuchal translucency increase risk of neural tube defect and Down’s syndrome as well as congenital heart defect, Turner syndrome and cystic fibrosis (?)

18-20 weeks: morphology ultrasound
only mandatory ultrasound screening
detailed anatomy scan
anatomical scan to assess fetal anatomy, placental location, detect multiple gestation and date
if needed nuchal fold can also be measured, where high nuchal fold carry same risk of defect as high nuchal translucency
can also determine sex of baby

3rd trimester: Biophysical Profile biophysical profile
usually done in high-risk pregnancies in 3rd trimester
biophysical profile is ultrasound evaluation of fetal well-being using Manning’s score system
5 components: 4 from ultrasound (fetal movement, tone, breathing movement, amniotic fluid volume) and 1 from nonstress test (fetal heart rate)

Question 26

What types of screens are available to screen for birth defects

Answer 26

non-invasive screen include integrated prenatal screen and maternal serum screen

invasive screen include chorionic villous sampling and amniocentesis

Question 27

What does the integrated prenatal screen include

Answer 27

IPS is the integrated results from 2 series of tests to screen for Down syndrome, Edward’s syndrome and neural tube defect

1) nuchal translucency on ultrasound and PAPP-A at 11-14 weeks
both nuchal translucency and PAPP-A evaluate for Down Syndrome

2) maternal serum screening (free beta-hCG, AFP, uE3) at 15-21 weeks, ideally at 15+3 weeks
free beta-hCG in Down syndrome
AFP (alpha fetoprotein) in neural tube defects
uE3 (unconjugated estriol) low in Down syndrome and Edward’s syndrome

Question 28

What are the indications for invasive prenatal screening and what types of invasive prenatal screening are offered

Answer 28

invasive screening can test for other genetic and birth defects outside the Down syndrome, Edward’s syndrome and neural tube defect

indication for invasive screening:

positive prior screening test (IPS or maternal serum screening)

family history of genetic disease

maternal age >40

specific ultrasound finding that need to be followed up

invasive screening include chorionic villous sampling at 11-13 weeks or amniocentesis at 15-22 weeks

Question 29

How many feeds and wet diapers should newborn have per day

Answer 29

8-12 feeds per day

6-8 wet diapers per day