OBGyn Flashcards
Abruptio placentae Path: Pt: Dx: Tx: Complications:
Path: Separation of placenta from its site of implantation before delivery of the fetus
-Visible if blood between membranes and uterus -escapes through cervix
Concealed if blood is retained between detached placenta and uterus
-MC associated w/ Maternal htn (essential, gestational, preeclampsia)
Pt: Vaginal bleeding Uterine tenderness or back pain Fetal distress Preterm labor High-frequency contractions Hypertonus (inc resting tone) Dead fetus
Dx: Clx
Tx:
Maternal resuscitation w/ blood and crystalloid
Delivery
For viable fetus: cesarean section if vaginal delivery is not imminent
For abruption demise: start induction when mother is stabilized
Complications: Consumptive coagulopathy -> DIC Renal failure Fetal demise Couvelaire uterus: widespread extravasation of blood into the uterine musculature beneath uterine serosa
Breech presentation
Path:
Dx:
Tx:
Path:
Lie: long axis of fetus (longitudinal, transverse, oblique)
Presentation: fetal part that directly overlies pelvic inlet: vertex (head), breech
Dx:
Head is not palpated above symphysis pubis
U/S to confirm fetal position: Also assesses for maternal pelvic abnormalities, uterine abnormalities and placenta previa
Tx:
External version can be attempted at 37w
Active labor: C/S
Umbilical cord prolapse Path: Pt: Dx: Tx:
Path: Risk factors: Unstable lie, Footling breech, Polyhydramnios, Prematurity, FGR (Fetal growth restriction), Multiparity, Long umbilical cord, Multifetal gestation, Unengaged presenting part
Pt: Hx of malpresentation, PROM
Dx: Cord precedes presenting part increasing cord pressure leading to fetal anoxia
Tx:
Lift baby’s head and try to decompress (usually more cord comes out)
Emergent C/S
Tocolytic: terbutaline 0.25mg sub-q to decrease uterine contractions and alleviate pressure on the cord
If delay in c/s-> Trendelenburg position, knee-chest position, bladder filling, elevation of present fetal part
Dystocia
Path:
Dx:
Tx:
Path: Failure of the shoulders to spontaneously traverse the pelvis after delivery of the fetal head, requiring extra maneuvers to enable delivery of the fetal shoulders
Dx: Central traction on fetal head does not produce delivery of the shoulders
Tx:
McRoberts’ maneuver followed by suprapubic pressure to release impacted shoulder
-Flex one of mother’s legs until her thighs touch her abdomen thus fattening the sacrum and rotating the symphysis pubis cephalic ally
-Delivery of posterior fetal arm
Ectopic pregnancy Path: Pt: Dx: Tx:
Path: Zygote implants not in uterus
MC ampulla
Stricture
Risk factors: Hx of PID, Tubal ligation, Prior ectopic, IUD, Assisted reproductive techniques, In vitro fertilization
Pt:
Abdominal pain, Bleeding
UPT +
Dx: B-Quant >/=1500 w/ negative TV U/S <1500 -Too soon to tell -If B-HCG doubles in 48 hours-> normal pregnancy
Tx: Salpingostomy: no rupture Salpingectomy: + rupture Methotrexate (+/- leucovorin) ok if: -B-HCG <5000 -Gestation sac <3.5cm -No heart tones
Fetal distress
dx:
Fetal heart rate monitoring
- Absent variability with recurrent late decelerations
- Absent variability with recurrent variable decelerations
- Absurd variability with bradycardia or a sinusoidal pattern
Gestational diabetes
Dx:
Tx:
Complications:
Dx: Fasting >95 Screening between 24 and 28w w/ 50g glucose load >130-140 after 1hr 100g glucose challenge with >180 at 1hr >155 at 2hr >140 at 3hr
Tx:
Medical nutritional therapy -> diet and exercise routine
Insulin
Oral glyburide, metformin-> only if pt unwilling/unable to use insulin therapy to control glucose levels
Complications:
Fetal risks-> macrosomia, respiratory distress syndrome, neonatal hypoglycemia
Maternal risk-> inc DM-II
Gestational trophoblastic disease
Pt:
Dx:
Tx:
Molar pregnancy
Pt: N/V, abd pain, vaginal bleeding
New onset HTN <20w, suspect molar pregnancy
PE: uterine size larger than expected for dates
Labs: B-hCG higher than expected for dates
Dx: U/S: snowstorm/bag of grapes
Tx: D&C
Choriocarcinoma
Risk factors: extremes of maternal age, hx of previous mole, vitamin A deficiency
Pt: Vaginal bleeding, Pelvic discomfort, Hyperemesis gravidarum
Dx:
PE: uterus large than expected for gestational age
B-HCG usually high
Higher for complete moles than partial moles
TV-U/S: absence of an embryo or fetus and central heterogeneous mass w/ numerous discrete anechoic spaces -> “snowstorm” or “bag of grapes” appearance
Tx:
Uterine evacuation with suction curettage
Weekly hCG until undetectable
If levels remain elevated or rise-> gestational trophoblastic neoplasia tx with hysterectomy
Pregnancy induced hypertension Path: Pt: Dx: Tx:
Path: HTN no proteinuria after 20w gestation
Resolves 12w postpartum
Thought to be due to arteriolar vasoconstriction
Pt: Asx
Dx:
BP >/=140 / >/=90
No proteinuria
Tx:
May withhold meds
+/- hydralazine, labetalol
Monitor for preeclampsia
Preeclampsia Path: Pt: Dx: Tx:
Path:HTN + proteinuria +/- edema AFTER 20w gestation (earlier in multiple gestation or molar pregnancy)
Without severe features Pt: Asx Dx: BP >/=140 / >/=90 sustained, starting after 20w Urine: 300mg/dL proteinuria (1+ dip stick) Tx: >37w deliver urgently (induce) <37w bed rest
With severe features Pt: Sx of HTN: HA, visual sx Fetal growth restriction Edema caused by proteinuria (dec oncotic pressure)
Dx:
BP >160 / >110 sustained, starting after 20w
Proteinuria 5g/24h (3+ dip stick)
Oliguria (<500ml/24h)
Thrombocytopenia, +/- DIC
HELLP syndrome: (Hemolytic anemia, Elevated liver enzymes, Low Platelets)
Tx:
Prompt delivery
Magnesium sulfate (seizure prevention)
BP meds in acute severe HTN: Hydralazine, Labetalol, Nifedipine
Eclampsia Path: Pt: Dx: Tx:
Path: Seizures or coma in pts who meet preeclampsia criteria
Pt:
Abrupt tonic-clonic seizures
HA, visual changes, cardiorespiratory arrest
Dx:
Same at preeclampsia + seizures
Hyperreflexia
Tx: ABCD’s 1st Magnesium sulfate for seizures (lorazepam if refractory) Delivery of fetus once mom is stabilized BP meds: hydralazine, labetalol
Incompetent cervix Path: Pt: Dx: Tx:
Path: Inability to maintain pregnancy 2/2 premature cervical dilation (esp in 2nd trimester)
Risk factors: Previous cervical trauma or procedure (tx for CIN), Uterus defects, DES exposure in utero, Multiple gestations
Pt: bleeding, vaginal discharge especially in 2nd trimester
Dx: painless dilation and effacement of cervix
Tx:
Cerclage (suturing of cervical os) and bed rest especially if prior hx
If not performed initially, cerclage can also be performed for women who develop a short cervix (=25mm) before 24w as determined by U/S surveillance
+/- weekly injection of 17 alpha-hydroxyprogesterone in some women with preterm birth hx
Multiple gestations
Monochorionic: share placenta
At risk for twin-twin transfusion syndrome
Quintero system:
-Stage I: manage expectantly w/ weekly Doppler blood flow studies; poly/oligohydramnios (recipient poly; donor oligo); Visualize bladder in both fetuses; Normal umbilical doppler flow
-Stage II: Bladder of donor fetus is not visualized on U/S
-Stage III: abnormal doppler flow to either fetus
-Stage IV: Signs of hydrops
-Stage V: Death of one or both fetuses
16-26w stage II-IV: fetoscopic laser ablation of placental anastomoses
>26w: amnioreduction
Monoamniotic: share amniotic sac
-Highest risk for complications
Diamniotic/Dichorionic: inhabit separate amniotic sacs/own placenta
Placenta previa Path: Pt: Dx: Tx:
Path: placenta is located over/very near internal os
- Complete previa: covers entire os
- Incomplete previa: placenta at the edge of/partially covers os
- Low-lying: placenta is within 2cm of internal os
Risk factors: Prior cesarean delivery, Advanced maternal age, Multiparity, Smoking
Pt: Painless hemorrhage occurring at end of 2nd trimester or later in pregnancy
Dx:
Doppler TV U/S @20w (early in pregnancy may resolve by term from placental migration)
Speculum exam visualize bleeding is from above the os
Tx:
Ideal: term fetus or fetus w/ documented lung maturity can be scheduled for routine cesarean
Less ideal: pt w/ known previa presents in labor and receives emergent cesarean
Least ideal: severe hemorrhage preterm mandating stat cesarean
Postpartum hemorrhage
Path: Bleeding from placental implantation site
Atony: Uterus unable to contract to stop bleeding Retained placental products Trauma to the genital tract Rupture uterus Coagulation defects
Atony
Path:
Pt:
Tx:
Path: Uterus unable to contract to stop bleeding
Risk factors: (additive)
- Over-distended uterus: Large fetus, Multiple gestation, Hydramnios
- Rapid labor
- Prolonged labor
- Use of labor augmentation agents: Pitocin
- Chorioamnionitis
- Hx of uterine atony
Pt: Postpartum hemorrhage
Tx:
1. First: Vigorous massage: bimanual exam and massage of uterine fundus; Oxytocin infusion; Manual exploration of uterine cavity for retained placental products
- Second: Pharmacological agents: Prostaglandins F2alpha (prostin, carboprost), Ergot derivatives (methergine), Prostaglandin E1 (misoprostol, cytotec)
- Third: Surgical management: Hypogastric artery ligation, Uterine compression sutures (B-lynch), Uterine packing, Peripartum hysterectomy
Retained placental parts
Path:
Pt:
Path:
- Accreta: abnormal Adherence to the uterine wall
- Increta: Invade the myometrium
- Percreta: Penetrates the uterine serosa and can invade surrounding organs such as bladder or rectum
Risk factors:
- Placenta previa: placenta located over/near the cervical os
- Prior cesarean delivery
- Prior uterine curettage
- Grand multiparity: women who has had >/= 5 births at >/=20w
Pt: postpartum hemorrhage
Trauma to the genital tract postpartum hemorrhage
Path:
Dx:
Path:
Episiotomy
Vaginal or cervical lacerations
Dx:
bleeding despite a well-contracted, firm uterus, hemorrhage is likely from a laceration
Bright red blood suggests laceration
Seen on careful inspection of vagina and cervix
Ruptured uterus
Path:
Pt:
Path:
MC is separation of the previous cesarean hysterotomy scar
Others: trauma, congenital abnormality, prior uterine surgery (myomectomy)
Pt: postpartum hemorrhage
Premature rupture of membranes Path: Pt: Dx: Tx:
Path:
Normal vaginal fluid is acidic (3.5-6)
Amniotic fluid is alkaline
Pt: Rupture of membranes <37w
Dx:
- Nitrazine paper color change to blue
- Ferning: distinctive pattern of amniotic fluid as it crystallizes on glass slide
- Assess cervix for effacement and dilation
Tx:
Admission + OB consultation
Tocolytics-> prolong pregnancy to allow continued time for fetal development
Antenatal administration of corticosteroids if <34w
It’s Not My Time:
- Indomethacin (not given at 33w due to risk of PDA closure)
- Nifedipine
- Magnesium sulfate
- Terbutaline
Rh incompatibility Path: Pt: Dx: Tx:
Path:
Maternal antibodies that bind to fetal RBCs -> neonate hemolytic disease
Occurs if Rh negative (rhesus factor) mother carries an Rh positive fetus w/ exposure to fetal b mood mixing:
-C/S
-Abruptio placentae
-Placenta previa
-Amniocentesis
-Vaginal delivery
The mixing causes maternal immunization -> maternal anti-Rh IgG antibodies. During subsequent pregnancies, if she carries another Rh + fetus, the antibodies may cross the placenta and attack the fetal RBCs -> hemolysis of fetal RBCs
Pt (newborn):
Hemolytic anemia, jaundice, kernicterus, hepatosplenomegaly
Fetal hydrops: fluid accumulation in 2 spaces: pericardial effusion, ascites, pleural effusion, subcutaneous edema; CHF
Dx: Pregnant women: -ABO blood group, RH-D type -Indirect erythrocyte antibody screen: 1:8 - 1:32 associated w/ fetal hemolysis -Indirect Coombs
Fetus monitoring in 2nd trimester:
- If present -> amniotic fluid: inc bilirubin
- U/S of middle cerebral artery (inc flow 2/2 decreased viscosity of blood in anemia)
- Percutaneous umbilical blood sampling: decreased hematocrit
Tx:
Prevention in mother: RhoGAM
-MOA: Rh immunoglobulin-pooled anti-D IgG binds to fetal RBCs to prevent maternal mixing
3 indications:
-Given at 28w gestation AND
-72h of delivery OR
-After any potential mixing of blood: SAB, vaginal bleeding, etc.
Endometriosis Path: Pt: Dx: Tx:
Path:
Endometrial glands and stroma which occur outside of the uterine cavity
MC site: ovaries (endometriomas)
Risk factors: nulliparity, prolonged exposure to endogenous estrogen, exposure to diethylstilbestrol in utero, lower BMI
Pt: Reproductive women w/ pelvic pain (dysmenorrhea, dyspareunia) , Infertility, Ovarian mass
Dx:
PE: immobility or lateral displacement of cervix or uterus
Eval w/ TVU/S or MRI
DDx: histologic analysis of lesions
Tx:
Continuous hormonal contraceptive + NSAIDs
Laparoscopic excisions
Leiomyoma
Path:
Pt:
Tx:
Path: Benign fibromuscular tumors of the myometrium
Proposed etiology: venous congestion within uterus
Types: Pedunculated Intracavitary Submucosal Intramural Subserosal
Pt: When symptomatic, AUB MC sx
Tx: Observation Medical therapy Myomectomy Hysterectomy Alternatives: uterine artery embolization, high intensity focused U/S
Uterine prolapse
Path:
Pt:
Tx:
Path:
Uterine herniation into the vagina
Risk factors: (weakness of pelvic support structures)
MC after birth (especially traumatic)
Inc pelvic floor pressure: Multiple vaginal births, Obesity, Repeated heavy lifting
Grades: I: decent into upper 2/3 of vagina II: cervix approaches introitus III: outside introitus IV: entire uterus outside of vagina- complete prolapse
Pt:
Pelvic or gain fullness, heaviness “falling out” sensation
Lower back pain (esp w/ prolonged standing)
Vaginal bleeding, purulent discharge
Urinary frequency, urgency, stress incontinence
Tx:
Prophylactic: Kegel exercises (strengthens pelvic floor muscles), weight control
Nonsurgical: pessaries (sx relief); Improves atrophy
Surgical:
-Hysterectomy
-Uterosacral or sacrospinous ligament fixation
Polycystic Ovarian Syndrome Path: Pt: Dx: Tx:
Path: Inc insulin -> inc LH-driven inc ovarian androgen production
Pt:
Amenorrhea
Obesity
Hirsutism
Dx: LH:FSH ratio >3:1 Pelvic U/S: “string of pearls” Ovarian volume >10cm3/mL >/= 12 antral follicles
Tx: OCPs Spironolactone Infertility-> clomiphene Lifestyle changes
