OB/Gyne Flashcards
Ligaments supporting uterus?
Round ligaments (contain Sampson’s artery)
Broad ligament
Utero-sacral ligament
Cardinal ligament
Ovary has suspensory ligament and ligament of the ovary
Ovarian arteries from?
Aorta (abdominal)
And venous return is through the left renal vein (left ovarian vein) and the inferior vena cava (right ovarian vein)
Where can the ureter be located?
Pelvic brim, as it passes under the uterine artery - water under the bridge
Dermoid Cyst?
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.
Cervical Cyst - most common?
Nabothian Cysts - common and benign
Questions to ask at maternal triage?
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
Exam for maternal triage?
Symphysis fundal height, Leopold, +/- pelvic exam
How to screen for GDM?
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
Hypertensive in pregnancy?
Pre-eclampsia - 140/90 with proteinuria after 20 wks GA without end organ dysfunction
Risk factors for pre-eclampsia?
Nuliparity, hx of pre-eclampsia, new paternity, age greater than 40 or less than 18, obesity, hx of DM, chronic diseases, fetal concerns
Evaluation of pre-eclampsia?
CBC, INR, aPTT, LFTs, creatinine, uric acid, urine dip and 24 hour collection or spot urine creatinine ratio
Check fetal factors
Eclampsia is?
1 or more generalized convulsions/ coma in the setting of pre-eclampsia or no other neurological conditions. MUST DELIVER.
Management of Eclampsia/ HELLP
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
HELLP?
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
Presentation of placenta abrupta?
Painful bleeding, after 20 week GA
Maternal stabilization, have blood products ready usually have to deliver.
Placenta Previa
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.
Suspect ectopic pregnancy?
If vital signs stable - do U/S and BHCG, if small and unruptured - methotrexate
If not stable or large or ruptured - surgical management
Braxton-Hicks?
Varying intensity, improve with rest, not associated with change of cervix
Timeline of delivery for nuliparous
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)
Time line for multiparous?
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
Management for Pre-term labour?
Admit, avoid repeated pelvic exams,
Can initiate: suppression of labour - tocolysis (nifedipine, indomethacin), cervical cerclage (before 24 wks), steroids for fetal lung maturity,
Postpartum hemorrhage think about?
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
Treatment for post partum hemorrhage?
Treat cause, uterine packing, ballon tamponade, compression sutures, hysterectomy.
Physiologic skin changes during pregnancy
Increased pigmentation of perineum, areola, chloasma, linea nigra, spider angiomas, palmar erythema due to increased estrogen
Striae gravidarum due to connective tissue changes
Physiologic CVS changes during pregnancy
- 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
Physiologic hematologic changes during pregnancy
- 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
Physiologic respiratory changes during pregnancy
- 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
Physiologic GI changes during pregnancy
- 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
Physiologic GU/renal changes during pregnancy
- 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
Physiologic endocrine changes during pregnancy
- 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)
Folic acid supplementation amounts
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
Hyperemesis gravidarum
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
Unstable hyperemesis gravidarum
- 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
Timing of prenatal visits
Uncomplicated pregnancies: q4-6 wk until 30wk, q2-3 wk from 30wk, and q1-2 wk from 36wk until delivery
SFH < dates
- Date miscalculation
- IUGR
- Fetal demise
- Oligohydramnios
- Early engagement
SFH > dates
- Date miscalculation
- Multiple gestation
- Polyhydramnios
- LGA (familial, DM)
- Fibroids
Assess at Every Prenatal Visit
- 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
Thalassemia high risk populations
Mediterranean, South East Asian, Western Pacific
CBC (MCV and MCH), Hb electrophoresis, or HPLC
Sickle cell high risk populations
African, Caribbean
CBC (MCV and MCH), Hb electrophoresis, or HPLC
Cystic fibrosis high risk populations
Family history of CF in patient or partner or medical condition linked to CF like male infertility
CFTR gene DNA analysis
Tay Sachs disease high risk populations
Ashkenazi Jewish, French Canadians, Cajun
Enzyme assay HEXA, or DNA analysis HEXA gene
Fragile X syndrome high risk populations
Family history – confirmed or suspected
DNA analysis: FMR-1 gene
> 10 weeks Screening Investigations
NIPT - Measures cell free fetal DNA in maternal circulation
10-12 weeks Screening Investigations
CVS
11-14 weeks Screening Investigations
FTS
IPS part 1
Measures
- Nuchal translucency on U/S
- β-hCG
- PAPP-A
15-16 weeks to term Screening Investigations
Amniocentesis
15-20 weeks Screening Investigations
IPS Part 2 (or MSAFP only for patients who did FTS earlier)
Measures
- MSAFP
- β-hCG
- Unconjugated estrogen (estriol or μE3)
- Inhibin A
18-20 weeks Screening Investigations
U/S for dates, fetal growth, and anatomy assessment
- Number of fetuses
- GA (if no prior U/S)
- Location of placenta
- Fetal anomalies
24-28 weeks Screening Investigations
Gestational Diabetes Screen 50 g OGCT
28 weeks Screening Investigations
Repeat CBC
RhIG for all Rh negative women
35-37 weeks Screening Investigations
GBS screen
6 weeks postpartum Screening Investigations
Discuss contraception, menses, breastfeeding, depression, mental health, support
Physical exam: breast exam, pelvic exam including Pap smear (only if due as per provincial screening)
Summary of U/S screening for pregnancy
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)
Indications for diagnostic tests
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
Isoimmunization happens how?
Antibodies produced against a specific RBC antigen as a result of antigenic stimulation with RBC of another individual
Isoimmunization and relevance to pregnancy
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
Isoimmunization - etiology
- 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
Isoimmunization - investigations
- 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
Isoimmunization - prophylaxis
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)
Isoimmunization - treatment
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
Isoimmunization - complications
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)
Iron supplementation in Pregnancy
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)
Supplementation in pregnancy
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
Lifestyle in pregnancy
- 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
Medications in pregnancy
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
Immunizations in pregnancy
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
Tx for leiomyomas
GNRH agonists are first line, OCP/IUD are only for symptomatic control.
Tx for chlamydia when pregnant?
Can still give usual dose of azithromycin but second line is amoxicillin
Developed breasts but no secondary hair growth, and no vagina or uterus
Androgen insensitivity syndrome - child is XY but insensitivity to testosterone has lead to breast development
How long after ROM to induce labour
12 hours so long as the patient is past 34 weeks GA
Can you use erogots in pregnancy?
NO
Most important risk factor for endometritis?
C-section - post op day 2
Day of ovulation by temps?
Day before the switch to high temp - progesterone causes the rise right after ovulation
Benign appearing ovarian cyst in post menopausal woman
Get a CA 125 then just monitor
Tx for endometritis
Broad spectrum - Gentamycin, clindamycin if breastfeeding, Ctx or Levo and metronidazole if not.
Lactation is suppressed by
Estrogen
Combination OCP can worsen what common condition
HTN
