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Toronto Notes/ Readings > OB/Gyne > Flashcards

OB/Gyne Flashcards

1
Q

Ligaments supporting uterus?

A

Round ligaments (contain Sampson’s artery)
Broad ligament
Utero-sacral ligament
Cardinal ligament

Ovary has suspensory ligament and ligament of the ovary

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2
Q

Ovarian arteries from?

A

Aorta (abdominal)

And venous return is through the left renal vein (left ovarian vein) and the inferior vena cava (right ovarian vein)

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3
Q

Where can the ureter be located?

A

Pelvic brim, as it passes under the uterine artery - water under the bridge

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4
Q

Dermoid Cyst?

A

Almost always benign, also known as a teratoma, consists of mature tissues commonly fat, hair, etc. Occasionally can develop SCC, but very rare, if large enough can lead to ovarian torsion.

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5
Q

Cervical Cyst - most common?

A

Nabothian Cysts - common and benign

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6
Q

Questions to ask at maternal triage?

A

ID: age, GTPAL, Rh, GBS, serology
HPI: Contractions, bleeding, fluid/ROM, fetal movement
Hx of pregnancy: Complications (HTN/ GDM/ infections), prenatal screenings, last U/S, growth concerns, last vaginal exam. Hx of all previous pregnancies and deliveries.
PMHx, FHx, Meds, Allergies, SHx

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7
Q

Exam for maternal triage?

A

Symphysis fundal height, Leopold, +/- pelvic exam

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8
Q

How to screen for GDM?

A

Usually around 24-28 wk GA, can do a 1h or 2h OGTT, modified diet, increase physical activity, start on insulin if needed. Post-partum stop insulin and diabetic diet and then redo 2h OGTT

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9
Q

Hypertensive in pregnancy?

A

Pre-eclampsia - 140/90 with proteinuria after 20 wks GA without end organ dysfunction

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10
Q

Risk factors for pre-eclampsia?

A

Nuliparity, hx of pre-eclampsia, new paternity, age greater than 40 or less than 18, obesity, hx of DM, chronic diseases, fetal concerns

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11
Q

Evaluation of pre-eclampsia?

A

CBC, INR, aPTT, LFTs, creatinine, uric acid, urine dip and 24 hour collection or spot urine creatinine ratio

Check fetal factors

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12
Q

Eclampsia is?

A

1 or more generalized convulsions/ coma in the setting of pre-eclampsia or no other neurological conditions. MUST DELIVER.

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13
Q

Management of Eclampsia/ HELLP

A

Stabilize and deliver. Increase maternal monitoring - urine dip/ maternal vitals and fetal vitals, give IV Mg, and antihypertensives (labetalol, nifedipine, hydralazine)

Monitor post partum so continue Mg

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14
Q

HELLP?

A

Liver disorder thought to be related to pre-eclampsia - Life threatening!

Hemolysis
Elevated Liver enzymes
Low Platelet count

Work up: CBC, Coags, smear AST/ALT, LDH, BUN/Cr, Bili/Hapto, fibrinogen, D-dimer

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15
Q

Presentation of placenta abrupta?

A

Painful bleeding, after 20 week GA

Maternal stabilization, have blood products ready usually have to deliver.

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16
Q

Placenta Previa

A

Abnormal formation of placenta over the internal cervical os

Do U/S and follow - many resolve. Avoid vaginal exams. Will need a c-section if not covered.

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17
Q

Suspect ectopic pregnancy?

A

If vital signs stable - do U/S and BHCG, if small and unruptured - methotrexate
If not stable or large or ruptured - surgical management

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18
Q

Braxton-Hicks?

A

Varying intensity, improve with rest, not associated with change of cervix

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19
Q

Timeline of delivery for nuliparous

A

First stage (6-18 hours) after full dilation in the second stage - 30mins -3 hours, 30 mins for placental expulsion, and monitor the 4th stage (1 hour postpartum)

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20
Q

Time line for multiparous?

A

First stage 2-10 hours, second stage 5-30mins and then 30min from the delivery of baby placenta out, and monitor the fourth stage post partum 1 hour

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21
Q

Management for Pre-term labour?

A

Admit, avoid repeated pelvic exams,

Can initiate: suppression of labour - tocolysis (nifedipine, indomethacin), cervical cerclage (before 24 wks), steroids for fetal lung maturity,

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22
Q

Postpartum hemorrhage think about?

A

Tone - uterine atony - massage, oxytocin
Tissue - inspect the placenta - manually explore uterus, curettage
Trauma - suture laceration, drain hematoma, fix uterine inversion
Thrombin - check coagulation factors - transfusion

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23
Q

Treatment for post partum hemorrhage?

A

Treat cause, uterine packing, ballon tamponade, compression sutures, hysterectomy.

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24
Q

Physiologic skin changes during pregnancy

A

Increased pigmentation of perineum, areola, chloasma, linea nigra, spider angiomas, palmar erythema due to increased estrogen
Striae gravidarum due to connective tissue changes

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25
Q

Physiologic CVS changes during pregnancy

A
  • Hyperdynamic circulation
  • increased CO, HR and blood volume (40-45%)
  • decreased BP, PVR (uterus = shunt) and venous return from uterus compressing IVC and pelvic veins
  • increased venous pressure leads to risk of varicose veins, hemorrhoids and leg edema
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26
Q

Physiologic hematologic changes during pregnancy

A
  • Hemodilution causes physiologic anemia and apparent decrease in hgb and hematocrit
  • Increased leukocyte count but impaired function leads to improvement in autoimmune diseases
  • Gestational thrombocytopenia: mild and asymptomatic, normalizes within 2-12 wk post delivery
  • Hypercoagulable state: increased risk of DVT and PE but also decreased bleeding at delivery
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27
Q

Physiologic respiratory changes during pregnancy

A
  • more likely to have nasal congestion –> dilation of canals
  • Increased O2 consumption (meet metabolic requirements)
  • Elevated diaphragm
  • Increased min ventilation –> decreased CO2 –> mild respiratory alkalosis (helps CO2 diffuse across the placenta from fetal to maternal circulation)
  • Decreased TLC, FRC, and RV
  • No change in VC and FEV1
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28
Q

Physiologic GI changes during pregnancy

A
  • GERD due to increased intra-abdominal pressure AND progesterone (causing decreased sphincter tone and delayed gastric emptying)
  • Increased gallstones due to progesterone causing increased gallbladder stasis
  • Constipation and hemorrhoids due to progesterone causing decreased GI motility
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29
Q

Physiologic GU/renal changes during pregnancy

A
  • Increased urinary f due to increased total urinary output
  • Incr incidence UTI & pyelonephritis from urinary stasis (progesterone)
  • Ureters and renal pelvis dilation (R>L) (progesterone-induced smooth muscle relaxation and uterine enlargement
  • Increased CO –> increased GFR –> decreased creatinine (normal in pregnancy 35-44 mmol/L), uric acid, and BUN
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30
Q

Physiologic endocrine changes during pregnancy

A
  • Thyroid: moderate enlargement and increased basal metabolic rate
  • Increased total thyroxine and TBG
  • Free thyroxine & TSH levels normal

-Adrenal: maternal cortisol rises throughout pregnancy (total and free)

  • Calcium: decreased total maternal Ca2+ due to decreased albumin
  • Free ionized Ca2+ proportion remains the same because PTH results in increased bone resorption and gut absorption, increased bone turnover (no loss of density due to estrogen inhibition)
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31
Q

Folic acid supplementation amounts

A

8-12 wk preconception until end of T1 to prevent NTDs

0.4-1 mg daily in all women

5 mg if:

  • previous NTD
  • antiepileptic medications
  • DM
  • BMI >35
32
Q

Hyperemesis gravidarum

A

Intractable n/v

Etiology: multifactorial - hormonal, immunological and psychological (rapidly rising b-hcg and estrogen levels)

Must r/o other causes (GI, pyelo, thyrotoxicosis, twins, HELLP) and check CBC, lytes, BUN, Cr, LFTs, urinalysis and U/S

Tx: thiamine supplementation, diclectin (10mg doxylamine succinate with vit B6)

Complications: maternal dehydration, acid/base changes, Mallory-Weiss tears, increased risk of IUGR

33
Q

Unstable hyperemesis gravidarum

A
  • Dimenhydrinate can be safely used as an adjunct to Diclectin (1 suppository bid or 25 mg PO qid)
  • other adjuncts: hydroxyzine, pyridoxine, phenothiazine, metoclopramide, also consider: ondansetron or methylprednisolone
  • if severe: admit to hospital, NPO initially then small frequent meals, correct hypovolemia, electrolyte disturbance, and ketosis, TPN (if very severe) to reverse catabolic state
34
Q

Timing of prenatal visits

A

Uncomplicated pregnancies: q4-6 wk until 30wk, q2-3 wk from 30wk, and q1-2 wk from 36wk until delivery

35
Q

SFH < dates

A
  • Date miscalculation
  • IUGR
  • Fetal demise
  • Oligohydramnios
  • Early engagement
36
Q

SFH > dates

A
  • Date miscalculation
  • Multiple gestation
  • Polyhydramnios
  • LGA (familial, DM)
  • Fibroids
37
Q

Assess at Every Prenatal Visit

A
  • estimated GA
  • history: fetal movements, uterine bleeding, leaking, cramping, questions, concerns
  • physical exam: BP, weight gain, SFH, Leopold’s maneuvers (T3) for lie, position, and presentation

-investigations:
urinalysis for glucosuria, proteinuria;
fetal heart rate starting at 10-12wk using Doppler

38
Q

Thalassemia high risk populations

A

Mediterranean, South East Asian, Western Pacific

CBC (MCV and MCH), Hb electrophoresis, or HPLC

39
Q

Sickle cell high risk populations

A

African, Caribbean

CBC (MCV and MCH), Hb electrophoresis, or HPLC

40
Q

Cystic fibrosis high risk populations

A

Family history of CF in patient or partner or medical condition linked to CF like male infertility

CFTR gene DNA analysis

41
Q

Tay Sachs disease high risk populations

A

Ashkenazi Jewish, French Canadians, Cajun

Enzyme assay HEXA, or DNA analysis HEXA gene

42
Q

Fragile X syndrome high risk populations

A

Family history – confirmed or suspected

DNA analysis: FMR-1 gene

43
Q

> 10 weeks Screening Investigations

A

NIPT - Measures cell free fetal DNA in maternal circulation

44
Q

10-12 weeks Screening Investigations

A

CVS

45
Q

11-14 weeks Screening Investigations

A

FTS
IPS part 1

Measures

  1. Nuchal translucency on U/S
  2. β-hCG
  3. PAPP-A
46
Q

15-16 weeks to term Screening Investigations

A

Amniocentesis

47
Q

15-20 weeks Screening Investigations

A

IPS Part 2 (or MSAFP only for patients who did FTS earlier)

Measures

  1. MSAFP
  2. β-hCG
  3. Unconjugated estrogen (estriol or μE3)
  4. Inhibin A
48
Q

18-20 weeks Screening Investigations

A

U/S for dates, fetal growth, and anatomy assessment

  • Number of fetuses
  • GA (if no prior U/S)
  • Location of placenta
  • Fetal anomalies
49
Q

24-28 weeks Screening Investigations

A

Gestational Diabetes Screen 50 g OGCT

50
Q

28 weeks Screening Investigations

A

Repeat CBC

RhIG for all Rh negative women

51
Q

35-37 weeks Screening Investigations

A

GBS screen

52
Q

6 weeks postpartum Screening Investigations

A

Discuss contraception, menses, breastfeeding, depression, mental health, support
Physical exam: breast exam, pelvic exam including Pap smear (only if due as per provincial screening)

53
Q

Summary of U/S screening for pregnancy

A

8-12wk: Dating U/S (most accurate dating)

  • measurement of crown-rump length (± 5 d)
  • change EDD to U/S date if >5 d discrepancy from EDD based on LMP

11-14wk: NT U/S

  • measures the amount of fluid behind the neck of the fetus
  • early screen for Trisomy 21 (and cardiac/other aneuploidies (Turner’s syndrome))
  • NT measurement is necessary for the FTS and IPS Part 1

18-20wk: Growth and Anatomy U/S (±10d)

54
Q

Indications for diagnostic tests

A

age > 35 yr (increased risk of chromosomal anomalies)

Risk factors in current pregnancy: abnormal U/S, abnormal prenatal screen (IPS, FTS, or MSS)

Past history/family history of:

  • chromosomal anomaly or genetic disease
  • either parent a known carrier of a genetic disorder or balanced translocation
  • consanguinity
  • > 3 spontaneous abortions
55
Q

Isoimmunization happens how?

A

Antibodies produced against a specific RBC antigen as a result of antigenic stimulation with RBC of another individual

56
Q

Isoimmunization and relevance to pregnancy

A

Antibodies produced against a specific RBC antigen as a result of antigenic stimulation with RBC of another individual

Maternal-fetal circulation normally separated by placental barrier, but sensitization can occur and can affect the current pregnancy, or more commonly, future pregnancies

57
Q

Isoimmunization - etiology

A
  • Anti-Rh Ab produced by a sensitized Rh-negative mother can lead to fetal hemolytic anemia
  • Risk = 16 % in Rh-negative mother with Rh-positive ABO-compatible babe

Sensitization routes:

  • incompatible blood transfusions
  • previous fetal-maternal transplacental hemorrhage (e.g.ectopic pregnancy, abruption)
  • invasive procedures in pregnancy (prenatal diagnosis, cerclage, D&C)
  • any type of abortion
  • labour and delivery
58
Q

Isoimmunization - investigations

A
  • Screening with indirect Coombs test at first visit for blood group, Rh status, and antibodies
  • Kleihauer-Betke test used to determine extent of fetomaternal hemorrhage by estimating volume of fetal blood volume that entered maternal circulation
  • Detailed U/S for hydrops fetalis
  • MCA dopplers are done to assess degree of fetal anemia or if not available bilirubin is measured by serial amniocentesis to assess the severity of hemolysis
  • cordocentesis for fetal Hb should be used cautiously
59
Q

Isoimmunization - prophylaxis

A

Rhogam binds to Rh antigens of fetal cells and prevents them from contacting maternal immune system

  • Rhogam (300μg) given to all Rh negative and antibody screen negative women in the following scenarios (or else it wouldnt work if mom already had antibodies)
  • routinely at 28 wk GA (provides protection for ~12 wk)
  • within 72 h of the birth of an Rh positive fetus
  • with any invasive procedure in pregnancy (CVS, amniocentesis)
  • in ectopic pregnancy
  • with miscarriage or therapeutic abortion
  • with an antepartum hemorrhage
  • Betke-Kleihauer test or Flow cytometry can be used to determine whether more than 300μg of RhIg is required (>30 ml fetal blood)
  • additional 10 μg Rhogam for every mL of fetal blood over 30 mL

-If Rh negative and Ab screen positive, follow mother with serial monthly Ab titres throughout pregnancy + ultrasounds ± serial amniocentesis as needed (Rhogam = no benefit)

60
Q

Isoimmunization - treatment

A

Falling bili = no intervention

-intrauterine transfusion of O-negative pRBCs may be required for severely affected fetus or early delivery of the fetus for exchange transfusion

61
Q

Isoimmunization - complications

A

anti-Rh IgG can cross placenta –> fetal RBC hemolysis –> fetal anemia, CHF, edema, ascites

-Severe cases can lead to:
fetal hydrops (edema in at least two fetal compartments due to fetal heart failure secondary to anemia)

or

erythroblastosis fetalis (moderate to severe immune-mediated hemolytic anemia)

62
Q

Iron supplementation in Pregnancy

A

0.8 mg/d in T1
4-5 mg/d in T2
>6 mg/d in T3

  • supports maternal increase in blood cell mass
  • supports fetal and placental tissue

-iron = only nutrient that cannot be met by diet
alone (in pregnancy)

63
Q

Supplementation in pregnancy

A

Folate: 0.4 mg/d for first 12 wk (5 high risk)
-supports increase in blood volume, growth of maternal and fetal tissue, decreases incidence of NTD
-spinach, lentils, chick peas, asparagus, broccoli, peas, brussels
sprouts, corn, and oranges

Calcium: 1200-1500mg/d
-maintains integrity of maternal bones, skeletal development of fetus, breast milk production

Vitamin D: 1,000 IU
-promotes calcium absorption

Essential fatty acids – supports fetal neural and visual development
-vegetable oils, margarines, peanuts, fatty fish

64
Q

Lifestyle in pregnancy

A
  • continue exercise - “talk test” = should be able to speak while exercising and avoid supine position after 20 weeks
  • weight gain: depends on pre-pregnancy BMI (6.8-18.2 kg)
  • air travel is acceptable in T2
  • intercourse: may continue, except in patients at risk for: abortion, preterm labour, or placenta previa
  • try to stop smoking!! Increased risk of decreased birth weight, placenta previa/abruption, spontaneous abortion, preterm labour, stillbirth
  • no alcohol
  • cocaine: microcephaly, growth restriction, prematurity, placental abruption
65
Q

Medications in pregnancy

A

Most meds cross placenta, few are teratogenic but even fewer have been proven safe in pregnancy

-tylenol is preferred over ASA or advil

Contraindications:

  • ACEI = Fetal renal defects, IUGR, oligohydramnios
  • Tetracycline = stains infants teeth, may affect long bone development
  • Retinoids = CNS, craniofacial, cardiac and thymic anomalies
  • Misoprostol = mobius syndrome (congenital facial paralysis with or without limb defects, spontaneous abortion, preterm labour)

Others with documented adverse effects, consider changing:

  • Phenytoin = IUGR, mental retardation, facial dysmorphogenesis, congenital anomalies
  • Valproate = oNTD in 1%
  • Carbamazepine = oNTD in 1-2%
  • Lithium = cardiac anomaly, goitre, hyponatremia
  • Warfarin = spontaneous abortion, stillbirth, prematurity, IUGR, fetal warfarin syndrome
  • Erythromycin = maternal liver damage
  • Sulpha drugs = Anti-folate properties, therefore theoretical risk in T1; risk of kernicterus in T3
  • Chloramphenicol = grey baby syndrome
66
Q

Immunizations in pregnancy

A

Intrapartum:

  • Tdap, influenza, hepatitis B, covid-19
  • avoid live vaccines (polio, MMR, varicella)

Postpartum:
-rubella for all non-immune mothers
hep B to infant within 12 hours if moms status unknown or positive (f/u at 1 and 6 mo)
-any other required

67
Q

Tx for leiomyomas

A

GNRH agonists are first line, OCP/IUD are only for symptomatic control.

68
Q

Tx for chlamydia when pregnant?

A

Can still give usual dose of azithromycin but second line is amoxicillin

69
Q

Developed breasts but no secondary hair growth, and no vagina or uterus

A

Androgen insensitivity syndrome - child is XY but insensitivity to testosterone has lead to breast development

70
Q

How long after ROM to induce labour

A

12 hours so long as the patient is past 34 weeks GA

71
Q

Can you use erogots in pregnancy?

A

NO

72
Q

Most important risk factor for endometritis?

A

C-section - post op day 2

73
Q

Day of ovulation by temps?

A

Day before the switch to high temp - progesterone causes the rise right after ovulation

74
Q

Benign appearing ovarian cyst in post menopausal woman

A

Get a CA 125 then just monitor

75
Q

Tx for endometritis

A

Broad spectrum - Gentamycin, clindamycin if breastfeeding, Ctx or Levo and metronidazole if not.

76
Q

Lactation is suppressed by

A

Estrogen

77
Q

Combination OCP can worsen what common condition

A

HTN

Toronto Notes/ Readings (16 decks)

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