OB Gyn Case Files Flashcards
What’s menometrorrhagia?
Heavy and irregular menses
What’s some risk factors for endometrial cancer?
Hypertension, diabetes, anovulation, early age of menarche, late age of menopause, obesity, infertility, nulliparity
What’s menorrhagia?
Heavy menses
What kind of heart murmurs are common in pregnancy?
Systolic flow murmurs due to increased cardiac output
What does the grey turner sign indicate?
Dis colorization of the flank may indicate intra abdominal or retro peritoneal hemorrhage
What could ulcers in the external genitalia indicate?
HSV , vulvar carcinoma or syphilis
Where would a bartholin glad cyst or abscess be located?
Vulvar mass at the 5 or 7 o’clock position
What’s the concern with pigmented vulvar lesions?
Malignant melanoma - must biopsy
What could modularity and tenderness in the uterosacral lig on rectal exam be a sign of?
Endometriosis
What part of the gyn exam assesses the anterior vs posterior pelvis?
Vaginal exam - anterior pelvis
Rectal exam - posterior pelvis
What are some prenatal labs and purpose? (9)
- CBC - anemia and thrombocytopenia
- Blood type, Rh and Ab screen
- hep B surface antigen (HBsAg) - if + give newborn hep B Ig (HBIG) and hep B vaccine
- Rubella titer - if not immune, vaccine postpartum bc live-attenuated vaccine
- syphilis nontreponemal test (RPR or VDRL)
- HIV
- Urine culture or urinalysis - assess for asymptomatic bacteriuria
- Pap smear - assess for cervical dysplasia or cancer
- Assays for chlamydia or gonorrhea
How do you test for syphilis?
A nontreponemal serology RPR (rapid plasma reagin) or VDRL (venereal disease research lab)
If positive do confirmatory treponemal test like MHATP (microhemagglutination assay for Abs to treponema palladium) or FTA-ABS (fluorescent treponema Ab Absorbed)
Pt might not have developed Ab yet so may have neg serology,
How do you treat syphilis? What if someone pregnant?
IM Penicillin
Treat if pregnant to prevent congenital syphilis
If allergic to penicillin need to desensitize to receive it
How do you test for HIV?
Screening test: ELISA
Confirmatory test: western blot
When and how do u screen for gestational diabetes?
26-28 weeks
50- g oral glucose, assess after 1 he fasting
When do u culture a preg woman for GBS?
35-37 weeks gestation
What lab tests might you order for a threatened abortion? And why?
Quantitative hCG and/or progesterone to establish viability and risk of ectopic preg
What labs might be ordered for pt with menorrhagia due to uterine fibroids?
CBC, endometrial biopsy (assess for endometrial ca), Pap smear (assess for cervical dysplasia or cancer)
What labs might be ordered for a 55 yo or older lady with adnexal mass?
CA-125 and CEA tumor markers for epithelial ovarian tumors
In postmenopausal women what would a thickened endometrial stripe indicate?
Malignancy
What’s the purpose of a sonohysterogram?
Inject small amount Of saline into uterus to better see things like endometrial polyps or submucous myomata
What’s a intravenous pyelogram (IVP) and what’s it’s use?
IV dye used to assess concentrating ability of the kidneys, patency of the ureters and integrity of the bladder. Can also detect hydronephrosis, uretheral stone or obstruction
What’s a hysterosalpingogram (HSG)
Radiopaque dye thru transcervical canal and X-rays taken
Can detect intrauterine abdnormalities like submucosal fibroids or intrauterine adhesions and the patency of the Fallopian tubes (tubal obstruction or hydrosalpinx)
What 3 things is BV associated with?
Preterm delivery, endometritis and vaginal cuff cellulitis (following hysterectomy)
What’s the definition of postpartum hemorrhage? (PPH)
> 500 mL blood loss with vaginal delivery
>1000 mL blood loss with c-section
What’s the MC cause of postpartum hemorrhage? How do to check?
Uterine atony
Check to see if uterus is boggy
What would be like cause of postpartum hemorrhage with a pt with a firm uterus?
Genital tract laceration usu involving the cervix (no atony if firm well-contracted)
What’s the liking diagnosis for a pt with lower abd tenderness, Cervical motion tenderness, vaginal discharge, dyspareunia, and adnexal tenderness?
PID
What are some symptoms of severe PID?
High fever, evidence of sepsis, peritoneal signs, tubo-ovarian abscess seen on US
Treatment for PID?
IM ceftriaxone and oral doxycycline
What’s the gold standard for diagnosing acute salpingitis?
Laparoscopy to visualize the tubes for purulent drainage
What’s the concern with a preg pt. Who develops dyspnea 2 days post pyelonephritis tx? What’s the MOA?
Acute respiratory distress syndrome post Abx due to endotoxins from GN bacteria causing pulmonary injury and capillary leakage of fluid into pulm interstitial space
What’s the classical presentation for pyelonephritis? What causes it?
Fever, flank tenderness and pyuria
Usu GN bacteria like E. Coli
What’s long term consequences of PID?
Ectopic preg or infertility from tubal damage
What’s the end stage of a tubal infection?
Tubo-ovarian abscess with life threatening complication of rupture seen as shock, hypotension. Tx with immediate surgery
What’s the most likely cause of tubal factor infertility?
Chlamydia trachomatis cervicitis which ascended to the tubes causing damage
What are the 3 ways to surgically assess the abd cavity?
- Laparotomy: Incision of the abdomen
- Laparoscopy: small incisions using scope
- Robotic
What’s a hysteroscopy
Insert a media into intrauterine cavity to visualize the endometrial cavity
What does at term mean?
Btwn 37-42 weeks from LMP
What’s the cervix like in active labor?
> 4 cm dilated
For nulliparous, what’s the rate of cervical dilation?
1.2 cm/hr during active labor
What dictates normalcy in labor?
Change in cervix per time (not uterine contraction pattern)
How’s the clinical pelvimetry done?
Digital Palpation of the pelvic bones
Define labor
Cervical changes accompanied by regular uterine contractions
Define the latent phase of labor
Inital part where the cervix mainly effaces (thins) rather than dilates (< 4 cm)
Define the active phase of labor
Dilation occurs more rapidly usually when cervix > 4 cm dilated
What’s protraction of active phase
Cervical dilation in the active phase that’s less than expected (norm nulliparous >= 1.2 cm/hr, multiparous >= 1.5 cm/hr)
What’s arrest of active phase of labor
No progress in active stage for 2 hours
What’s the 3 stages of labor?
First stage: onset of labor to complete dilation of the cervix
Second stage: complete cervical dilation to infant delivery
Third stage: delivery of infant to delivery of the placenta
What’s the baseline fetal heart rate?
110-160 bpm
What are fetal decelerations
Fetal HR episodic changes below baseline
What are the 3 types of fetal decelerations?
Early: mirror image of uterine contraction
Variable: abrupt jagged dips below the baseline
Late: offset following the uterine contractions
What’s fetal acceleration?
Episodes of fetal hear rate that increases above baseline for at least 15 bmp for at least 15 sec (15x15)
What are the 3 things that need to be considered if diagnosed with labor abnormality?
Power
Passenger
Pelvis
If power is believed to be the cause of labor abnormality what should be done?
Give IV oxytocin to augment contraction strength and or frequency
Whats cephalopelvic disproportion?
Pelvis thought to be too small for fetus bc abnorm pelvis or large baby
What’s adequate uterine contractions?
Contractions every 2-3 min, firm on Palpation, last for at least 40-60 sec
What’s Montevideo units used for?
Unit of mm hg rise in assessment tool uses to assess contractions over 10 mins. Add each unit if >200 Montevideo = adequate uterine contraction pattern
What’s the most common fetal deceleration and what could cause it?
Variable
Caused by cord compression
What causes early fetal deceleration
Fetal head compression - benign
What does late deceleration indicate?
Fetal hypoxia (uteroplacental insufficiency) If recurrent (>50%) can mean fetal acidosis
When is fetal acidosis strongly suspected?
When late decelerations occur with decreased variability
What’s fetal HR pattern category I?
Norm baseline and variability
No late or variable decelerations
What’s fetal HR pattern category II?
Bears watching
May have some aspect that’s concerning but not ominous (ex: feral tachycardia without decelerations)
What’s fetal HR pattern category III?
Ominous with high likelihood of severe fetal hypoxia or acidosis
Ex: absent baseline variability with recurrent late or variable decelerations or bradycardia
ex: sinusoidal HR pattern (prompt delivery of no improvement!)
What’s the lower limits of normal for latent period timeframe?
Nullipara: <= 14 hr
What’s the lower limits or normal for second stage of labor timeframe?
Multipara: <=2 hr (3 if had epidural)
What’s the lower limits or normal for third stage of labor timeframe?
<= 30 mins
What’s an anthropoid pelvis and what does it predispose you to?
Anteroposterior diameter greater than the transverse diameter with prominent ischial spines and a narrow anterior segment
Predisposes to persistent fetal occipital posterior position
What does 0 station mean?
The presenting part (usu the bony part of the fetal head) is at the plane of the ischial spine and not at the pelvic inlet
What does station mean?
The relationship of the presenting bony part of the fetal head in relation to the ischial spines (and not the pelvic inlet)
What’s engagement mean?
The relationship of the widest diameter of the presenting part and it’s location with reference to the pelvic inlet
What’s blood show?
Loss of cervical mucus plug - sticky mucus admixed with blood
A sign impending labor
How can you differentiate bloody show from antepartum bleeding?
Bloody show has sticky mucus admixed with blood
Delivery at less than what # of weeks is associated with an increased risk of neonatal complications?
<39 weeks
C section for labor abnormalities in the absence of clear cephalopelvic disproportion is generally reserved for what?
Arrest of active phase with adequate uterine contractions
What’s the MC cause of anemia? How would you treat it?
Iron deficiency - microcytic anemia
Give iron and recheck Hg in 3 weeks
What would a hemoglobin electrophoresis show for B-thalassemia trait? (Heterozygous for B-thal)
Elevated A2 hemoglobin
What’s the levels for anemia in pregnancy?
Hbg < 10.5
Mild: 8-10
Severe: < 7
What would you do with a patient with continued anemia after 3-4 weeks of iron supplement?
Eval for iron stores - ferritin (low in iron deficiency) and hemoglobin electrophoresis
What’s thalassemia
What can it result in?
Decreased production of one or more globin peptide chains (alpha or beta)
Can result in ineffective erythropoiesis, hemolysis and anemia
What’s hemolytic anemia
Abnormally low Hbg due to RBC destruction
What’s G6PD deficiency
X linked condition where RBC may have a decreased capacity for anaerobic glucose metabolism
Certain oxidizing agents like nitrofurantoin- used for UTIs, sulfonamides, and antimalarials can lead to hemolysis
Have dark urine due to bilirubenia, jaundice and fatigue
What’s B-thalassemia minor?
How would you treat a preg pt with this?
Decreased production of the B-globin chain
Prophylactic folic acid and genetic counseling
How would a neonate with B-thalassemia major present?
May appear healthy at birth but as HgF decreases and no B-chains to replace gamma-chains, the infant becomes severely anemic, failure to thrive if not transfused
What’s sickle cell anemia
Recessive disorder caused by a point mutation in the B-globin chain in which AA gluts mic acid is replaced with valine causing improper Hgb folding
What happens to pts with sickle cell during preg?
Increased anemia, sickle cell crisis and more freq infections and pulm complications
Also have higher incidence of fetal growth retardation and perinatal mortality so do serial US
What are the causes of macrocytic anemia?
Vit B 12 deficiency and folate deficiency (more common bc B11 storages last for years)
What causes physiologic anemia of prgnancy?
Hemodilution due to the disproportionate increase in plasma volume over the increased RBC volume
What’s a Hgb electrophoresis look like for a-thalassemia
Elevated Hbg F
What’s the MC cause of uterine inversion?
Undue traction of the cord before placental separation
What are the 4 signs of placental separation?
- Gush of blood
- Lengthening of the cord
- Globular and firm uterus
- Uterus rises up to the anterior abdominal wall
What does the endometrial surface of the uterus look lik
Red shaggy appearance
What’s abnormally retained placenta
Third stage of labor that’s exceeded 30 mins
What’s uterine inversion?
A turning inside out of the uterus where the fungus of the uterus moves through the cervix thru the vagina
What’s the best method for avoiding uterine inversion?
Await spontaneous placenta separation before placing traction on the umbilical cord
Who’s most at risk for uterine inversion?
Grand-multiparous pt with placenta implantation in the fundus (top of uterus) or placenta accreta
How do you treat uterine inversion?
Uterine relaxant like halothane, terbutaline or Mg sulfate and cupping fingers to replacement then give uterotonic agent like oxytocin to prevent reinversion
What’s the MC finding in uterine rupture?
Fetal HR abnormality like fetal bradycardia, deep variable decelerations or late decelerations
How do you treat uterine rupture
Immediate c-section
What can be used to ripen the cervix?
Vaginal misoprostol (prostaglandin )
What are associated complications of misoprostol cervical ripening?
Prolonged decelerations, fetal bradycardia, uterine hyperstimulstion
What’s uterine hyperstimulation?
What can cause it?
> 5 uterine contractions in 10 mins
Causes: prostaglandin cervical ripening agents (misoprostol), oxytocin
What’s the first step in assessing fetal bradycardia? How can you do it?
Differentiate fetal & maternal HR via fetal scalp electrode or ultrasound
What’s a fetal scalp pH assess? what does it require?
Assesses if the fetus is receiving sufficient oxygen during labor
Requires 4cm dilation to get blood sample from fetal scalp
Why does epidural-induced hypotension occur and how do you treat it?
Sympathetic blockade leads to vasodilation -> hypotension and fetal late decelerations
Tx: IV fluids, if still persists vasopressors like ephedrine
What increases the risk for cord prolapse?
Footling breech or transverse lie
Whats the best therapy for umbilical cord prolapse?
Manual elevation of presenting part and emergency c section
Name 7 steps to take with fetal bradycardia
- Confirm fetal HR vs maternal
- Vaginal exam to assess for cord prolapse
- Positional changes - left lateral decubitus
- O2 with mask
- IV fluids
6 pressors if hypotension persists (like ephedrine)
7 discontinue oxytocin
What’s engagement
Largest transverse (biparietal) diameter of the fetal head has negotiated the bony pelvic inlet
What’s fetal bradycardia
Baseline fetal HR <110 bpm for greater than 10 mins
What’s umbilical cord prolapse
Cord enters they cervical is presenting in front of the presenting part
What’s artificial rupture of membranes
Maneuver used to cause perforation in the fetal chorioamniotic membranes
Don’t do it unless fetal head is engaged
What are risk factors for shoulder dystocia
Fetal macrosomia, maternal obesity, multiparous, post term delivery, prolonged second stage of labor, gestational diabetes - elevated insulin assoc with increased central shoulder and abd weight of fetus
What’s the MC injury in shoulder dystocia
Brachial plexus injury like Erb palsy (C5-6 injury- weak forearm flexors, infraspinatous and deltoid muscles with arm at side and internally rotated)
What are the first actions for shoulder dystocia?
McRoberts maneuver or supra public pressure
What are the 5 possible maneuvers for treating shoulder dystocia?
- McRoberts maneuver -hyperflex maternal hips to straight sacrum and anteriorly move symphysis pubis
- Suprapubic pressure- push fetal shoulder Into oblique position
- Delivery posterior arm
- Woods corkscrew maneuver - rotate posterior shoulder 180 degrees
- zavanelli maneuver - cephalic replacement with immediate c-section
What’s a fetal sign of shoulder dystocia
Turtle sign - fetal heads retracted back toward maternal introitus
What’s uterine atony ?
Lack myometrial contraction to cut off uterine spiral arteries that supply the placental bed
What can increase the risk of uterine atony?
overdistended uterus (polyhydroamniosis, multi fetal preg, macrosomia), rapid or prolonged labor and/or delivery, oxytocin use during labor, magnesium sulfate, intraamniotic infection (chorioamnionitis), high parity
What’s methylergonovine maleate (IM Methergine)? What can it tx? Contraindications?
An ergot alkaloid agent that induces myometrial contractions.
Tx: Uterine atony
Contraindications: HTN (increased risk of stroke)
What does IM prostalandin F2-a do? Contraindications?
causes SM contraction
Contraindiciation: asthmatics (potential for bronchospasms)
What’s the difference btwn early and late PPH?
early < 24 hr after delivery; late >24 hr
Initial tx for PPH?
uterine massage (bimaunal compression) w/ IV dilute oxytocin
What’s the second line tx options for PPH?
Uterotonic agents: ergot akyloids (IM methergine), IM prostaglandin F2-a, rectal misoprostol
2 large-bore IVs, foley cathetic, blood, monitor vitals, move to OR
What are options for PPH if in OR?
laparotomy for compression stitches (B-lynch stitch), ligation of blood supplies (ascending branch of uterine artery or internal iliac artery hypogastric artery), hysterectomy, intrauterine balloon, embolizatoin
Causes of early PPH?
uterine atony (MC), coagulopathies, genital tract lacerations, uterine inversion, placenta accreta or retained placenta
causes of late PPH?
subinvolution of the placental site - occurs 10-14 days post delivery
retained products of conception (POC) - uterine cramping, bleeding, fever, foul-smelling lochia
How do you tx subinvolution of the placental site late PPH bleeding?
oral ergot alkaloid and careful f/u; other options IV dilute oxytocin or IM prostaglandin F2a
(bleeding 2 weeks post partum)
How do you treat POC (products of conception)?
uterine curettage and broad-spectrum abx
What are ways to reduce the incidence of PPH?
oxytocin (Pitocin) after infant delivery, early cord clamping, gentle cord traction w/ uterine counter traction w/ a well-contracted uterus
