OBGYN Precision & Pearls #3 Flashcards
name and describe the four stages of labor
Stage 1: onset of labor to full dilation of cervix
–Latent Phase: onset to 4-6 cm
–Active Phase: rapid dilation to completion
Stage 2: 10 cm to delivery of baby
–Passive: dilation to active efforts
–Active: active effort to delivery
Stage 3: Postpartum to delivery of placenta
–0-30 minutes usually
–examine for three vessels and make sure intact
Stage 4: 1-2 hours after delivery
What testing is done in the first trimester (weeks 1-12)
Biochemical screening - free beta-HcG, PAPP-A
Antibody titers (HepB, HIV, sickle cell, rubella, CF)
Nuchal translucency US (for Trisomy 13, 18, 21)
Chorionic villous sampling
Others:
-Fetal heart tones by doppler at 10-12 weeks
-Transvaginal US heart tones by 5-6 weeks
-PAPP-A low in Down Syndrome
-STI testing
What testing is done in the second trimester (weeks 13-27)
-Gestational DM screen (24-28 weeks)
-Amniocentesis at 15 weeks if high risk
-Triple Screening (a-fp, beta HcG, and unconjugated estriol, inhibin A if Quad Screen)
What is quickening and when is it seen?
Moving of the fetus at 18 weeks
at 20 weeks, where is the fundus of the baby?
At the level of the umbilicus
Regarding the Quad Screen, explain what is seen in Trisomy 18
All low
Regarding the Quad Screen, explain what is seen in Down Syndrome (Trisomy 21)
High inhibin A & BhCG
Low Estriol and AfP
2 high, 2 low
If Afp is high on Quad Screen, what should you suspect?
Neural Tube Defect (spina bifida or anencephaly)
What testing is done in the third trimester (weeks 28-birth)
-DM screening at 24-28 weeks
-Group B Strep Screen at 36-37 weeks (retrovaginal culture) –> give IV Pen G during labor
-Antibody titers
-Biophysical profile (2 pts each for fetal tones, breathing, movements, etc.)
-Nonstress testing
-Contraction stress testing
-Counseling
What counseling is given to mothers during the third trimester?
No airline travel > 35 weeks
Postpartum birth control
Birth plan discussion
Explain what is seen on a non stress test and what does each option mean?
Baseline fetal HR is 120-160 bpm
Reactive (fetal well being): > 2 accelerations, rate >15 from baseline
Nonreactive (sleeping or immature fetus): no accelerations or < 15 from baseline
What is premature labor defined as?
Regular contractions (>4-6/hr), progressive cervical dilation and effacement < 37 weeks
Premature labor is the #1 cause of fetal morbidity and mortality. What is the definition (dilation and effacement).
Dilation of 3 cm or greater
80% effacement or greater
What are some diagnostics that are highly suggestive of preterm labor?
Nitrazine paper test: turns blue (suggestive of amniotic fluid because pH > 6.5)
Presence of fetal fibronectin between 20-34 weeks
L:S ratio < 2:1 = fetal lung immaturity
Treatment for preterm labor
-< 34 weeks: Delay delivery with tocolytics (Mag Sulfate, Indomethacin, Nifedipine) and give Dexamethasone to improve lung maturity
->34 weeks: admit for delivery
How does Plan B work.
Emergency Contraception pill - Uses protesting to stop ovaries from releasing an egg. Most effective if taken within 72 hours after unprotected sex
Explain how combination OCPs work
Prevent ovulation by inhibiting mid-cycle LH surge, thicken cervical mucosa and thins endometrial lining.
Combination (estrogen + progesterone) OCPs protect against 5 things, name them.
What are some contraindications to using combo OCPs?
Osteoporosis, cervical cancer, ovarian cancer, ovarian cysts, ectopic pregnancy
History of breast cancer, smoking, >35 years old, DVT/PE, severe HTN.
What are some Progestin-only OCP’s?
Depo = increases risk of osteoporosis
Nexplanon = increases risk of HA, menstrual irregularities
IUD (Mirena = 5 years, Kyleena = 5 years, Skyla = 3 years). Risk of perforation and ectopic pregnancy, PID
Copper IUD = Paragard (10 years). Increased risk of PID
What is the most effective Progestin only OCP besides abstinence
IUD = however, there is an increased risk of PID
True or False: Progestin only OCPs are safe during lactation?
True
Ovarian torsion is ________ and some symptoms include what?
compromised ovarian blood flow
-Sudden onset of acute, unilateral pelvic pain.
-Nausea, vomiting
-Abdominal tenderness or adnexal mass
Diagnostics done for ovarian torsion
-US with Doppler: shows decreased ovarian blood flow
-Surgical exploration = definitive diagnostic
Treatment for ovarian torsion
-Laparoscopy with detorsion
What is the pathophysiologic triad for polycystic ovarian syndrome (PCOS)? There are actually four things…
-Bilateral cystic ovaries + oligo/anovulation + hyperandrogenism + insulin resistance
Symptoms of PCOS
-Menstrual dysfunction
-Hirsuitism (from high androgen)
-DM, obesity, HTN
-Bilateral, smooth, enlarged ovaries
-Acanthosis nigricans
Labs for PCOS shows
-Increased testosterone (DHEA)
-Increased LH:FSH ration
What diagnostic is done for PCOS?
Pelvic US: multiple ovarian cysts with a “string of pearls” appearance
Treatment for PCOS
-Lifestyle modifications (for insulin resistance)
-Combo OCP’s (Mainstay)
-Spironolactone (blocks testosterone)
What are two risks of PCOS?
Increases risk of infertility and endometrial cancer
Atrophic vaginitis occurs MC in postmenopausal women. What is it?
Drying due to decreased estrogen
What are some symptoms of atrophic vaginitis?
Dryness, dyspareunia, pruritus, bleeding due to irritation
Treatment for atrophic vaginitis
-Topical vaginal estrogen
-Moisturizers
-Alcohol free products
What is Fitz-Hugh Syndrome?
Perihepatitis in RUQ with pelvic inflammatory disease
Symptoms of Fitz-Hugh Syndrome
RUQ pain (may radiate to shoulder)
What diagnostic should be done if you suspect Fitz-Hugh Syndrome?
Laparoscopy: violin string adhesions on liver
Toxic Shock Syndrome occurs due to a ________. What is the pathophysiology of this condition?
Staph Aureus toxin
-Superantigen that releases inflammatory mediators –> multi organ failure
What is the MC risk factor for Toxic Shock Syndrome?
Tampon Use (Infrequent removal)
Symptoms of Toxic Shock Syndrome
-Abrupt onset of high fever
-Erythroderma (diffuse erythematous rash) resembling sunburn
-Hypotension, headache, myalgias, n/v, diarrhea (symptoms of shock)
Treatment for toxic shock syndrome
-Hospital admission
-IV rehydration
-ABX (Clinda + Vanco or Linezolid)
What is congestive mastitis?
Bilateral breast enlargement 2-3 days postpartum due to milk stasis.
What is the treatment of congestive mastitis?
Breast drainage (manual or pump)
What is polyhydramnios?
> 25cm fluid around the baby
What are two symptoms of polyhydramnios?
-Uterine size large for dates
-Low fetal activity
Polyhydramnios is associated with what conditions?
Maternal DM, multiple gestations, fetal issues with breathing or chromosome abnormalities
On the contrary, what is oligohydramnios?
<5 cm of fluid around the baby
Symptoms of oligohydramnios?
-Uterus size small for date
-Low fetal activity
Explain what macrosomia is, what a common cause is, and what two risks associated with this condition are.
Macrosomia: birth weight > 95%ile
Common cause: Maternal DM
Risks: Shoulder dystocia & maternal trauma
Treatment for macrosomia
-Plan C-section if estimated weight >5,000g without DM and >4,5000g with DM
What is an APGAR score, what is normal, when is it done, and what are the components?
Done at 1 and 5 minutes
7 or above is normal
Appearance (Pink normal)
Pulse (>100 normal)
Grimace (cry is normal)
Activity (movement of all limbs normal)
Respiration (strong cry normal)
A spontaneous abortion is ____________. 80% of these occur in which trimester?
What is the only type of spontaneous abortion that is potentially viable?
Loss of pregnancy < 20 weeks
First trimester
Threatened is the only potentially viable one
Explain a threatened abortion
-Cervical OS closed
-POC intact
-Supportive tx
MCC of spontaneous abortion
-Chromosomal abnormalities
Explain an inevitable abortion
-Os DILATED
-POC intact
-D&C or Misoprostol evacuation
Explain an incomplete abortion
-OS dilated
-Some POC expelled
-D&C or Misoprostol
Explain a complete abortion
-Os closed
-All POC expelled
-Supportive, RhoGAM given
Explain a missed abortion
-OS closed
-POC intact, non viable fetus
-D&C, Misoprostol
Explain a septic abortion
-OS closed, Cervical motion tenderness
-POC retained, foul brown discharge
-D&C And ABX (Levo + Metro)
What is vasa previa?
Complication of placenta previa
-Fetal vessels crossing over the os
Symptoms of vasa previa
-painless vaginal bleeding + fetal distress (bradycardia) + rupture of membranes
What should be done if you suspect vasa previa?
Deliver the baby
MCC of postpartum hemorrhage
Uterine atony
Symptoms of postpartum hemorrhage (what does the patient look like?)
-Soft, flaccid boggy uterus with dilated cervix
-Bleeding with hypovolemic shock
Treatment for postpartum hemorrhage
-Bimanual uterine massage and compression (1st line)
-IV Oxytocin
-Artery embolization if ineffective
Prelabor Rupture of Membranes (PROM) is? It occurs prior to when? Symptoms of this condition.
PROM: rupture of amniotic membranes prior to onset of labor
Occurs after to 37 weeks
Gush of fluid or persistent leakage
What are some diagnostics that can be done for PROM?
-Nitrazine paper test: turns blue if pH > 6.5 (amniotic fluid)
-Fern test: amniotic fluid dries in a fern pattern
-NO DIGITAL EXAM!
Treatment for PROM
-Admit and await spontaneous labor
-Induce labor with Oxytocin or Prostaglandin gel is no labor within 18 hours
What is Preterm Prelabor Rupture of Membranes?
occurs prior to 37 weeks
If under 34 weeks and you are dealing with PPROM, what should you do?
Give Betamethasone to improve fetal lung maturity
-Delivery if signs of maternal or fetus distress/infection
