OBGYN Nagy Questions Flashcards
Definition of Preeclampsia and Eclampsia
After 20th week of gestation
Preeclampsia - BP > 140/90
proteinuria >300mg/24hr
Eclampsia - tonic-clonic seizures
Gestational Diabetes
Done in all pregnancies - screen between 24-28 weeks
Healthy = Fasting glucose < 5.6 mmol/L
FG 5.6 - 7.0 mmol/L - Do OGTT
FG > 7.0 mmol/L on 2 separate occasions - GDM
Oral Glucose Tolerance Test
OGTT - consume 25g of glucose after fasting
minute 0 <7.0 mmol/L
If <7.8 - 11.1 mmol/L - Impaired Glucose Tolerance (IGT)
If > 11.1 mmol/L - DM
Indications of C- section
Maternal-Fetus perspective
- cephalopelvic disproportion
- failed induction of labor
Maternal Perspective
- eclampsia
- cerival cancer
- fibroids, tumor
- herpes
Fetal
- “non-reassuring” fetal HR - bradycardia
- cord prolapse
- Malpresentation
- Multiple gestations
Fetal abnormalities
- hydrocephalus
Placenta
- previa
- abruptio
When is US in pregnancy done
week 6-7 - confirm pregnancy
- gestational sac, HR
Location: intra/extrauterine
week 11-13
- congenital malformations
- nuchal translucency (Down’s)
- Neural Tube defects
- Biometrics
week 18-20
- congenital malformations
week 30-31
- IUGR
- late congenital malformations
week 36-38
- fetal presentation
- fetal weight
- information for prep of delivery
Approach to Placental abruptio
and Placental previa
use hands to palpate the uterus
abruptio - painful, hard uterus –> C-section
previa - painless, CTG is normal
Post-partum hemorrahge
tissue - retain placenta
trauma - vaginal lacerations
thrombin - coagulopathy (DIC)
Tone - uterine atony (need to exclude other causes)
Stages of Birth
- onset of labor - longest stage
- latent (3cm)
- active (3-10 cm) - baby: 30-90 mins
- propulsive phase - full dilation, descend to pelvic floor
- expulsion phase - ends with delivery of baby - placenta: 5-30 mins, separation
- expulsion of placenta
- expulsion of membranes - Recovery: 2 hours, after expulsion of placenta
- inc. risk of bleeding
- repair lacerations
- RhoGAM - a medicine that stops your blood from making antibodies that attack Rh-positive blood cells
Techniques of C-section
Abdominal Wall
- transverse, pfannenstiel
- vertical, midline
Uterus
- lower segment incision - transverse
- classical - vertical
Pearl Index
number of pregnancies in 100 females/year with chosen contraceptive
- OCP: 0.1-2.5
- Plan B: 0.5 - 2.5
- IUD 0.5-5
- Condom 3-28
- Sterilization 0.3-6
Routine Examiations
colposcopy
cytology
bimanual exam
breast exam
Long term OCP use
GOOD:
- dec ovarian/endometrial cancer
- dec bone loss
- dec dysmenorrhea
- dec acne
- dec risk of trisomies with inc in maternal age
- regulates cycle
BAD:
- inc DVT/stroke
- inc BP
- inc weight
Endometriosis
endometrial like tissue outside the uterine cavity
DX - Gold standard - Laparscopic visualization
TX - surgery
- pseudopregnancy
- pseudomenopause - GnRH analogue
Urinary incontinence
irritative:
- urinalysis – cystitis/tumor/foreign body
stress:
- loss of bladder support – cough – urge
- hypertonic – inc detrusor
TX - anticholinergics
overflow/neurogenic:
- hypotonic w/ dribbles
TX - cholinergics
bypass/fistula
Main Vaginal infections
bacterial vaginosis
trichomonas
mycosis (Candida)
Condyloma
Spontaneous abortion
pain and bleeding
DX: cervix, US, hCG
Contraindications to Tocolysis
Obstetric:
- severe abruption
- ruptured membranes
- chorioamnionitis
Fetal:
- lethal anomaly
- fetus has died
- fetal jeopardy
Maternal
- eclampsia
- advanced dilation
Leopold maneuvers
- Fundal grip
- Umbilical grip
- Pelvic Grip (first)
- Pawlick grip (2nd pelvic grip)
Leopold maneuver - 1. Fundal grip
- Fundal grip - palpate upper abdomen with both hands
Leopold maneuver - 2. Umbilical grip
- Umbilical grip - palpate to localize fetal back. One palm fixed, while the other explores one side then change
Leopold Maneuver - 3. Pelvic Grip (first pelvic grip)
- Pelvic Grip (first) - determine what fetal part is lying above the inlet. grasp the lower portion of the abdomen just above the pubic symphysis with thumb and fingers of the right hand
Leopold Maneuver - 4. Pawlick grip (2nd pelvic grip)
- Pawlick grip (2nd pelvic grip) - face woman’s feet, attempt to locate fetus’ brow. Fingers of both hands move gently down the sides of the uterus to pubis. The side where there is resistance to the descent of the fingers is greatest where the brow is located.
How to stop uterine bleeding
Old - D&C
Young - progesterone – preserve fertility
What is Mayer-Rokitansky-Kuster-Hauser Syndrome
i.e. Mullerian agenesis
congenital malformation where the mullerian duct fails to develop
has missing uterus, cervix, vagina
there is a variable degree of upper vaginal hypoplasia (shortened)
causes 15% of primary amenorrhea
ovarias are still intact so ovulation occurs - will enter puberty and have secondary sex characteristics
Pap Smear
P0 - improper sample
P1 - Negative, superficial cells on slide
P2 - Superficial cells and WBC
P3 - unsure
P4 - atypical cells – suspect malignancy
P5 - malignancy
Bethesda System
Results - reporting of cervical or vaginal cytology from Pap Smear
steps:
1. quality of slide
2. whether the result is positive or negative
3. details of the slide - types of cells, LSIL/HSIL
4. physician recommendation on how to proceed
Prenatal care
starts before pregnancy
Puerperium
period beginning immediately after the birth of child and extends for 6 weeks
Neonatal mortality rate
number of neonatal deaths during the first month/1000 live births
Early NMR is the first week
Late NMR weeks 2-4
Perinatal Mortality Rate
number of perinatal deaths (stillbirths and neonatal deaths) from 22 w gestation to 7 w postpartum/1,000 live births
How to exclude ectopic pregnancy
measure beta-hCG:
1000 U/L - gestational sac
7,000 U/L - Yolk sac
10,000 U/L - Embryo
brown spotting and abdominal pain indicates ectopic pregnancy
Check Fallopian tubes
beta-hCG doubles every 2nd day of pregnancy
Important questions for history taking
previous operations
allergy to meds
obstetric anamnesis
illness, drugs
first day of last period
- Naegele Rule
Naegele Rule
used to calculate the expected date of delivery (due date)
First day of the last menstrual period + 7 days + 1 year - 3 months
can only be applied if menses are regular and cycle is 28 days
Inaccurate if:
- The date of the last menstrual period is uncertain or unknown
- The patient has irregular menstruation cycles
- The patient conceived while taking contraceptive pills
Signs of pregnancy
Presumptive Signs
Presumptive sign -
Chadwick’s sign - bluish discoloration of the cervix and vagina due to pelvic vascular engorgement (6th week)
Signs of Pregnancy - Probable signs
Probable signs - positive home preg test, uterine and breast engorgement
Piskacek sign - soft prominence over the site of implantation
Goodell sign - softening of the cervix
Hegar sign - softening of the cervical isthmus
Signs of Pregnancy - Positive Signs
Positive sign - detection of fetal hemoglobin
recognition of fetal movement
Location of Bartholin’s Cyst
lower 1/3 of labia major
Marsupialization of Bartholin’s Cyst
cyst opened at the edges and sutured- forming an open pocket
Ashermn’s Syndrome
adhesions/fiborsis of the uterine cavity
usually from D&C
reversible infertility
Types of anesthetics used in C-Section
determined by urgency of situation
vaginal - epidural
intrathecial narcosis - emergency c-section
Vitamin supplements
preconception - folic acid up to 6 weeks before - 400 microgram/day
2nd trimester - low dose iron and iodine 250 microgram/day
FIGO staging for Endometrial cancer
0-I
0: CIS (Carcinoma in situ)
I: Limited to the uterus
Ia: < 50% myometrial invasion
Ib: > 50% myometrial invasion
FIGO staging for Endometrial cancer
II - III
II: Cervical involvement
III: Local spread
IIIa: Adnexa/uterine serosa
IIIb: Vagina/parametrium
IIIc1: Pelvic nodes
IIIc2: Paraaortic nodes
FIGO staging for Endometrial cancer
IV
IV: Metastasis
IVa: Bladder/rectal mucosa
IVb: Distant metastasis, ascites, peritoneum
FIGO staging for Endometrial cancer
0: CIS (Carcinoma in situ)
I: Limited to the uterus
Ia: < 50% myometrial invasion
Ib: > 50% myometrial invasion
II: Cervical involvement
III: Local spread
IIIa: Adnexa/uterine serosa
IIIb: Vagina/parametrium
IIIc1: Pelvic nodes
IIIc2: Paraaortic nodes
IV: Metastasis
IVa: Bladder/rectal mucosa
IVb: Distant metastasis, ascites, peritoneum
Vulvar cancer Staging
0 - I
0: VIN
I: Limited to vulva/perineum < 2cm
Ia: < 1mm stromal invasion
Ib: > 1mm stromal invasion
Vulvar cancer Staging
II - III
II: Extension to adjacent perineum
III: Any size + extension to perineal structures with
positive inguinofemoral LN
IIIa1: 1 LN > 5mm
IIIa2: 1-2 LN < 5mm
IIIb1: > 2 LN > 5mm
IIIb2: > 3 LN < 5mm
Vulvar cancer Staging
IV
IV: Metastasis
IVa: Bladder, urethra, rectum, bone
IVb: Distant metastasis (Pelvic LN)
Vulvar Cancer Staging
0: VIN
I: Limited to vulva/perineum < 2cm
Ia: < 1mm stromal invasion
Ib: > 1mm stromal invasion
II: Extension to adjacent perineum
III: Any size + extension to perineal structures with
positive inguinofemoral LN
IIIa1: 1 LN > 5mm
IIIa2: 1-2 LN < 5mm
IIIb1: > 2 LN > 5mm
IIIb2: > 3 LN < 5mm
IV: Metastasis
IVa: Bladder, urethra, rectum, bone
IVb: Distant metastasis (Pelvic LN)
Vaginal cancer Staging
0: VAIN
I: Limited to vagina
II: Paravaginal invasion w/out extension beyond
pelvic side walls
III: Invasion of pelvic side wall
IV: Metastasis beyond pelvis
IVa: Bladder, rectum
IVb: Distant metastasis
Cervical cancer Staging
0-I
0: CIN
I: Limited to cervix
Ia: Invasion dx by microscopy
Ia1: Stromal invasion < 3mm depth, < 7mm extension (microinvasive)
Ia2: Stromal invasion 3-5mm depth, > 7mm extension
Ib: Clinically visible lesion
Ib1: < 4cm
Ib2: > 4cm
Cervical cancer Staging
II
II: Beyond cervix, NOT pelvic side walls, NOT lower 1/3 of vagina
IIa: Involved upper 2/3 of vagina, NO parametrial involvement
IIa1: < 4cm
IIa2: > 4cm
IIb: Parametrial invasion
Cervical cancer Staging
III
III:
IIIa: Lower 1/3 of vagina, NO pelvic wall
extension
IIIb: Pelvic side wall extension, obstructive
uropathy
Cervical cancer Staging
IV
IV: Metastasis
IVa: Bladder, rectum
IVb: Distant organs
LSIL: Condyloma
CIN I
HSIL: CIN II
CIN III –> In situ –> invasive cc
Ovarian cancer Staging
I
I: Ovary/fallopian tube
Ia: 1 ovary/fallopian tube
Ib: 2 ovaries/fallopian tubes
Ic: a/b +
Ic1: Surgical spill
Ic2: Capsule rupture before surgery, tumor
on ovary/fallopian tube surface
Ic3: Malignant cells in ascites/peritoneum
Ovarian Cancer Staging
II
II: Pelvic extension/primary peritoneal cancer
IIa: Uterus/fallopian tubes
IIb: Other pelvic tissues
Ovarian Cancer Staging
III
III: Cytologically/histologically confirmed spread to peritoneum and retroperitoneal LN
IIIa: Retroperitoneal LN, microscopic
metastasis beyond pelvis
IIIa1(i): Retroperitoneal LN < 10mm
IIIa1(ii): Retroperitoneal LN > 10mm
IIIa2: Microscopic extrapelvic peritoneal
metastasis
IIIb: Macroscopic peritoneal metastasis < 2cm
IIIc: Macroscopic peritoneal metastasis > 2cm
Ovarian Cancer Staging
IV
IV: Metastasis
IVa: Pleural effusion with positive cytology
IVb: Distant metastasis
Breast cancer (TNM) Staging
T
Tis: DCIS (Ductal Carcinoma in situ), LCIS
(Lobular Carcinoma in situ)
T1: 2cm
- T1mi: 0.1cm
- T1a: 0.1cm – 0.5cm
- T1b: 0.5cm – 1cm
- T1c: 1cm – 2cm
T2: 2-5cm
T3: > 5cm
T4: Metastasis
T4a: Chest wall
T4b: Skin
T4c: Chest wall + Skin
T4d: Inflammatory cc
Breast cancer (TNM) Staging
N
N: Lymph nodes
Nx: LN cannot be assessed
N0: NO Cancer cells
N1: Cancer cells in armpit LN but not stuck to
surrounding tissues
N2: Stuck to surrounding tissues
N3: Cancer cells in LN below collarbone,
behind breast bone, above collarbone
Breast cancer (TNM) Staging
M
M: Metastasis
M0: No metastasis
M1: Metastasis
