Obsgyn Flashcards
Most common cause of anovulatory infertility?
PCOS!
How do you dx PCOS?
Rotterdam criteria: 2 out of the following 3 1. Oligo/ anovulation 2. Clinical or biochem hyperandrogen 3. Sonographic PCOS - 12 or more follicles in each ovary measuring 2-9mm in d AND/OR increased ovarian volume - cant use this def if on ocp
Clinical: oligo/amenorrhea , hirsute, obese, acne, alopecia, acanthosis nigricans,
Biochemical: increased lh:fsh ratio >2, estrone>estradiol, androstenedione and testosterone upper normal or increased
Sonographic: see above
Most frequent biochem marker detected in PCOS?
Serum testosterone
Free androgen index in PCOS?
> 5
LH:FSH in PCOS
> 2
Options for mx anovulatory infertility in PCOS women
1-weight reduction 2-clomifene citrate 3-metformin 4-gonadotropin therapy 5-LOD
Talk about LNG IUD
How its put in Bimanual exam first Any time , -ve preg test 5y Come in after first menses and Check threads self after menses Mode of action - LNG prevents implantation Failure rate - LNG <1% Risk of uterine perforation 2/1000 Expulsion - 1/20 first 3 months Risk of ectopic less than no IUD Condoms Return to fertility Pelvic infection Bleeding and pain 6-9 m spotting Hormonal ses 90% of women happy at 9m
Chancroid caused by:
Haemophillus ducrei
Features of chancroid
Painful
Soft ulcer
Usually on vestibule of vulva
Epidermis must be compromised to transmit infection
Treat chancroid:
Azithromycin 1gm po
School of fish app on gram stain
H ducrei
Does hsv2 protect against 1?
Yes but not vice versa
What’s pH of normal vagina
4
Amsels criteria for BV ?
3 of 4: >20% CLUE CELLS Thin watery dc PH >4.5 \+ whiff
Clue cells
BV
Nugents criteria for BV
Need gram stain
Looks at lactobacillus count etc
Treat BV
Metronidazole 500 bidx7
What causes BV?
Shift in vaginal flora from lactobacillus to gardnarella and anaerobes
What’s classic in trichomoniasis?
Frothy dc
Strawberry cervix in 10%
Might look and smell like BV
DO A WET MOUNT look quick!!
Treat trichomoniasis
Like BV but more metronidazole 2gm po
TREAT PARTNERS
MALE HAS NO SYMPTOMS!
If they come back with symptoms again prob reinfected as resistance is rare!
Best test for chlamydia
NAAT like pcr
Treat chlamydia
Azithromycin 1gm po
Treat partners
Retest at 3m
Treat gonorrhoea
Ceftriaxone IM 250mg
Menorrhagia >?ml ?
80
Causes of menorrhagia?
- Disorders of coagulation
- Hypothyroidism
- Fibroids
- Endometrial polyps
- Pelvic inflammatory disease
- Foreign bodies/ intrauterine devices
- Endometriosis
- Adenomyosis
Investigating menorrhagia who should have pelvic u/s?
- the uterus is palpable abdominally
- vaginal examination reveals a mass of uncertain origin
- pharmaceutical treatment has failed.
Who definitely doesn’t get depo provera?
> 45
Common sites of Endometriosis
Commonest sites of endometriosis order of frequency are: ¨Ovaries- 55% ¨Posterior leaf of broad ligament-35% ¨POD- 35% ¨Uterosacral ligament- 30% ¨The rectum, urinary tract or lungs may occasionally be involved
Describe usual pattern of dysmenorrhea in endometriosis?
pain starts before menstruation as an ache or discomfort
worsens and becomes spasmodic with the start of the menstrual flow, and continues throughout the period until it gradually lessens towards the end of the flow.
untreated patients, dysmenorrhoea progressively increases in duration
Most common symptom in endometriosis
Dysmenorrhea
Signs suggestive of endometriosis
Signs
nNo specific clinical signs can be detected on abdominal or pelvic examination in most patients with endometriosis.
nSigns suggestive of endometriosis include
¨tenderness on cervical movement
¨thickening and tenderness of the uterosacral ligaments
¨fullness or mass in the pouch of Douglas (POD)
¨fixation and retroversion of the uterus
nIn women with large endometriomas, an adnexal (or even a pelvi-abdominal) mass may be palpated.
Gold standard for dx endometriosis ?
Laparoscopy!
Ses of progesterone
nausea, bloatedness, acne, fluid retention, mood changes, depression, breast tenderness and irregular uterine bleeding.
Major problem of GnRH analogues?
the spine, ∼5% loss of BMD has been reported. This BMD loss recovers 6–12 months after treatment discontinuation.
Criteria for instrumental delivery
- Expertise
- Consent
- Analgesia
- Fully dilated / membranes ruptured
- Bladder empty
- Position known
- Fully engaged (no fetal head palpable abdominally)
- Station @/below spines
Causes of pph
4 T’s!
How does clomifene citrate work?
Binds to oestrogen receptors at HP level and inhibits negative feed back allowing the GnRH pulse to occur and so u get more FSH and normal ovulation! Once ovulation confirmed continue for 6-12 m taking it day 2-6!
What’s the risk of using GnRH for tx PCOS
Risk ovarian hyper stimulation
How to treat hirsutism?
1st line : cocp alone x 6m, if no good response add spironolactone as an antiandrogen!
Explain PCOS to pt:
Condition that can cause women to have irregular periods, oily skin, acne, hair growth in male pattern, hair loss in male pattern, weight gain, and problems getting pregnant.
Called PCOS - very common, about 5% of women
What’s gone wrong? Ovaries not making one big follicle but lots of small ones, hormones out of balance, ovulation doesn’t occur
More likely to end up with other health problems - dm, hyper cholesterol, heart disease
What tests? Blood tests measuring hormone levels, blood sugar, cholesterol, PREG test, pelvic u/s
Then go into mx - ocp, antiandrogens, facial hair removal, lose weight - at least 5%of body weight if over weight! Talk about pregnancy.
How does spironolactone control hirsutism?
Directly inhibits 5alpha reductase
Competes with androgen at hair follicle
Inhibits ovarian and adrenal biosynthesis of androgens!
How does cocp work in tx hirsutism?
Hyperandrogenism usually LH dependent!
Therefore progestin part suppresses LH production and inhibits 5alpha reductase in skin and the oestrogen part increases SHBG
Thus less free testosterone
What’s deficient in CAH?
21 hydroxylase
Which ovarian tumours are ass w androgen excess?
- Arrhenoblastomas
- Leydig hilar
- Thecal cell
- Luteomas of preg
Inheritance of CAH?
Auto recessive
Monozygotic twins arise From….? And can be…?
Splitting of single fertilised egg in the 1st 14 days after fertilisation... Can be DCDA d1-3 MCDA d3-8 MCMA d9-12 Conjoined after d12
Signs of dichorionicity on u/s?
Lambda
Twin peak
At 10-14weeks gestation
Signs of monochorionicity on us?
T sign
Intertwin membrane thickness of < 2mm suggestive
Types of twins in order of frequency?
Dizygotic
DCDA 60
Monozygotic
MCDA 30
MCMA 5
DCDA 5
MCMA twins electively delivered at
32w after steroids
DDx for large for dates?
- Multiple fetuses.
- Inaccurate menstrual history.
- Hydramnios.
- Hydatidiform mole.
- Elevation of the uterus by distended bladder.
- Uterine myomas.
- A closely attached adnexal mass.
- Fetal macrosomia (late in pregnancy)
When is twin to twin transfusion syndrome dx?
12-18 w gestation
Majority of monochorionic miscarriages are due to
TTTS
FHR is vasa praevia:
Bradycardia!
How is pre GDM managed?
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 18-20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Some potential complications of hrt
increased risk of breast cancer: increased by the addition of a progestogen
increased risk of endometrial cancer: reduced by the addition of a progestogen but not eliminated completely. The BNF states that the additional risk is eliminated if a progestogen is given continuously
increased risk of venous thromboembolism: increased by the addition of a progestogen
increased risk of stroke
increased risk of ischaemic heart disease if taken more than 10 years after menopause
Potential complications of chlamydia
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)
Main indicator for hrt?
Main indication for HRT: control of vasomotor symptoms
Absolute contraindications to ocp use:
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
breast cancer
major surgery with prolonged immobilisation
Features of levonorgestrel as emergency contraception?
should be taken as soon as possible - efficacy decreases with time
must be taken within 72 hrs of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
mode of action not fully understood - acts both to stop ovulation and inhibit implantation
84% effective is used within 72 hours of UPSI
levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle is seen in a significant minority of women. Vomiting occurs in around 1%
if vomiting occurs within 2 hours then the dose should be repeated
can be used more than once in a menstrual cycle if clinically indicated
Need to rapidly stop heavy menstrual flow- use:
Norethisterone 5 mg tds can be used as a short-term option to rapidly stop heavy menstrual bleeding.
Mx GDM
responds to changes in diet and exercise in around 80% of women
oral hypoglycaemic agents (metformin or glibenclamide) or insulin injections are needed if blood glucose control is poor or this is any evidence of complications (e.g. macrosomia)
there is increasing evidence that oral hypoglycaemic agents are both safe and give similar outcomes to insulin
hypoglycaemic medication should be stopped following delivery
a fasting glucose should be checked at the 6 week postnatal check
Causes of puerperal pyrexia
Puerperal pyrexia may be defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes: endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism
Most common cause of primary amenorrhea
Gonadal dysgenesis - turners
causes of primary amenorrhea
Turner’s syndrome
testicular feminisation
congenital adrenal hyperplasia
congenital malformations of the genital tract
Rfs for endometrial cancer?
obesity nulliparity late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome
1st line ix for post menopausal bleeding
first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value
hysteroscopy with endometrial biopsy
Is the ocp protective for endometrial ca?
Yes!
If hormonal contraceptives aren’t started day 1 of cycle how long do they take to become effective?
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
Counselling on ocp
What how
the COC is > 99% effective if taken correctly
Nausea breast tender bloating weight gain headache breakthrough bleeding
small risk of blood clots up to 3x
very small risk of heart attacks and strokes
increased risk of breast cancer and cervical cancer
Advice on taking the pill, including
if the COC is started within the first 5 days of the cycle then there is no need for additional contraception. If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
should be taken at the same time everyday
taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
advice that intercourse during the pill-free period is only safe if the next pack is started on time
Discussion on situations here efficacy may be reduced*
if vomiting within 2 hours of taking COC pill
if taking liver enzyme inducing drugs
Other information
discussion on STIs
What’s a blighted ovum?
when the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
What’s a partial mole?
In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
Failure rate of implanon?
highly effective: failure rate 0.07/100 women/year
Counsel someone for pop
Progestogen only pill: counselling
Potential adverse effects
irregular vaginal bleeding is the most common problem
Starting the POP
if commenced up to and including day 5 of the cycle it provides immediate protection, otherwise additional contraceptive methods (e.g. Condoms) should be used for the first 2 days
if switching from a combined oral contraceptive (COC) gives immediate protection if continued directly from the end of a pill packet (i.e. Day 21)
Taking the POP
should be taken at same time everyday, without a pill free break (unlike the COC)
Missed pills
if < 3 hours* late: continue as normal
if > 3 hours*: take missed pill as soon as possible, continue with rest of pack, extra precautions (e.g. Condoms) should be used until pill taking has been re-established for 48 hours
Other potential problems
diarrhoea and vomiting: continue taking POP but assume pills have been missed - see above
antibiotics: have no effect on the POP**
liver enzyme inducers may reduce effectiveness
Other information
discussion on STIs
*for Cerazette (desogestrel) a 12 hour period is allowed
**unless the antibiotic alters the P450 enzyme system, for example rifampicin
Mx hot flushes/night sweats
Management options for hot flushes or night sweats
lifestyle advice: exercise, avoiding caffeine/spicy foods, lighter clothing
hormone replacement therapy: most effective
tibolone: unsuitable for use within 12 months of last menstrual period as may cause irregular bleeding
clonidine: use is often limited by side-effects such as dry mouth, dizziness and nausea
selective serotonin reuptake inhibitors: only small trials have been completed to date
Vaginal atrophy
topical oestrogens
Causes of recurrent miscarriages
antiphospholipid syndrome = most common cause
endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
uterine abnormality: e.g. uterine septum
parental chromosomal abnormalities
smoking
What’s the failure rate of male sterilisation?
Male sterilisation - failure rate = 1 in 2,000
doesn’t work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks
Failure rate of female sterilisation
failure rate: 1 per 200*
Who should be urgently referred to the breast clinic
Urgent referrals (i.e. within 2 weeks)
any breast lump with features suggestive of cancer (hard, tethered etc)
any breast lump in a post-menopausal woman, regardless of features suggestive of cancer
any breast lump in a women more than 30 years old without features suggestive of cancer but which persists after her next period
if there is past history of breast cancer any breast lump should warrant urgent referral
spontaneous unilateral bloody nipple discharge
unilateral eczematous skin or nipple change that does not respond to topical treatment, or with nipple distortion of recent onset
Non-urgent referrals
women < 30 years old who present with a breast lump with no features suggestive of cancer, no relevant family history and no change in the size of the lump
What are soe features of severe pre eclampsia
hypertension: typically > 170/110 mmHg
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome
Rfs for pre eclampsia
> 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre-eclampsia previous history of pre-eclampsia pre-existing vascular disease such as hypertension or renal disease
Secondary causes of dysmenorrhea
endometriosis adenomyosis pelvic inflammatory disease intrauterine devices* copper fibroids
What happens at booking visit? At 8-12 weeks (best <10)
Booking visit
general information e.g. diet, alcohol, smoking, folic acid, vitamin D, antenatal classes
BP, urine dipstick, check BMI
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis, rubella
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
Neonatal complications of dm in PREG
macrosomia (although diabetes may also cause small for gestational age babies)
hypoglycaemia
respiratory distress syndrome: surfactant production is delayed
polycythaemia: therefore more neonatal jaundice
malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy)
stillbirth
hypomagnesaemia
hypocalcaemia
shoulder dystocia (may cause Erb’s palsy)
When hyperemesis gravidarum most commonly occurs
Weeks 8-12 but may persist til w30
Risk of ds at different maternal ages
Down’s syndrome risk - 1/1,000 at 30 years then divide by 3 for every 5 years
risk at 30 years = 1/1000
35 years = 1/350
40 years = 1/100
45 years = 1/30
Px of endometrial ca
Usually good
Late taking pop by more than 3h
take missed pill as soon as possible continue with rest of pack extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Causes of oligohydramnios <500ml @ 32-36 w
premature rupture of membranes fetal renal problems e.g. renal agenesis intrauterine growth restriction post-term gestation pre-eclampsia
Symptoms of endometriosis
chronic pelvic pain
dysmenorrhoea - pain often starts days before bleeding
deep dyspareunia
subfertility
Less common features
urinary symptoms e.g. dysuria, urgency
dyschezia (painful bowel movements)
The most common type of epithelial cell tumour
Serous cystadnoma
If ruptures may cause pseudomyxoma peritonei
Mucinous cystadenoma
Causes of 2* amenorrhea
hypothalamic amenorrhoea (e.g. Stress, excessive exercise) polycystic ovarian syndrome (PCOS) hyperprolactinaemia premature ovarian failure thyrotoxicosis*
Tx DVT in PREG
Subcutaneous lmwh
Disadvantages of depo provera
Disadvantages include the fact that the injection cannot be reversed once given. There is also a potential delayed return to fertility (maybe up to 12 months)
irregular bleeding
weight gain
may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
not quickly reversible and fertility may return after a varying time
Cocp and risk of ca
Combined oral contraceptive pill
increased risk of breast and cervical cancer
protective against ovarian and endometrial cancer
White cells in pueperium?
Leucocytosis - lymphocytosis, eosinophils up
If bf - when do u begin to ovulate
Many ovulate at 6m
Hormonal contraception while BF
- POP to be started 2–3 weeks postpartum
- Depot medroxyprogesterone acetate initiated at 6 weeks postpartum
- Hormonal implants inserted at 6 weeks postpartum
- The LNG IUS can be inserted at 4-6 weeks postpartum
- COCP should not be started before 6 weeks postpartum.
Contraindications to bf
- Maternal use of street drugs or xs alcohol
- Infant with galactosemia
- HIV
- Active untreated TB
- Certain meds
- Breast cancer Tx
Normal emo changes in puerperium
D3-5 x48 h
Onset of puerperal psychosis?
Most common day 5
•Manic state should improve within 2 weeks and the depressive psychosis by 6–8 weeks.
Mx pph
Abc 2 wide bore IV cannulae, take bloods.
•Resuscitate
•Crystalloids, colloids, blood transfusion, FFP, other blood products (reverse coagulopathy)
•Diagnose
•Atony
•Laceration, ruptured uterus
•Retained placenta
•Treat
•Drugs (oxytocin, ergometrine, carboprost)
•Embolization, balloons, internal iliac artery ligation
•EUA, laparotomy, hysterectomy
•Reverse coagulopathy
Neo herpes most commonly because ..->
Neonatal Herpes most commonly results from subclinical shedding due to first episode infection at the time of labor.
If mama has genital herpes
_Scalp electrodes, AROM and obstetrical instruments INCREASE the risk of neonatal transmission with asymptomatic shedding
Features of hsv 1 in PREG compared with hsv2
_HSV-1 transmits MORE readily to the newborn.
_HSV-1 is MORE likely to cause skin, eye and mucous membrane infection in the newborn.
_HSV-1 is LESS LIKELY to cause an encephalitis and neurodevelopmental disability.
Which HIV + women should have cs
§Scheduled C/S at 38 weeks to reduce risk of transmission:
•For women with HIV RNA levels >1000 copies/mL
•For women with unknown HIV RNA levels
•Benefits of C/S not clear after rupture of membranes or onset of labor
DDx for fetal tachycardia
TACHYCARDIA>160 nExcessive fetal movement nMaternal anxiety nGestation <32 weeks nMaternal pyrexia nFetal infection nChronic hypoxia
DDx fetal bradycardia
BRADYCARDIA 40 weeks nCord compression nCongenital heart malformations nCongenital heart block (including SLE) nDrugs eg.benzodiazepines
•Presence is the single best indicator of fetal
well-being
Accelerations
How many fhr accelerations should u see
2 of 15bpm for 15 secs in 20 mins
Hpv 16
Sixteen - squamous
Eighteen - adeno
Cervical ca nodes
nInvolved regional pelvic lymph nodes
- parametrial - obturator - internal and external iliac - sacral
DDx for pmb
nExogenous estrogen use: ie tamoxifen nAtrophic endometritis/vaginitis nEndometrial/cervical polyps nEndometrial hyperplasia nEndometrial Cancer nOther gynecologic cancers
Features of mittelshmerz
•Simple cysts less than 4 cm are NORMAL
•May cause intermittent pain
•Worse with ovulation
–Serous fluid and small amount of blood leaks into peritoneal cavity, causes irritation
•Treatment – manage pain, suppress ovulation
Prognosis of breech
■Perinatal morbidity and mortality higher than cephalic presentation because
¨Prematurity
¨congenital malformations
¨ birth asphyxia
nCord prolapse
nDifficulty with delivering the after coming head
¨trauma
nPerinatal mortality is 5 times that of cephalic presentation.
Predisposing factors to breech
Predisposing factors ■Prematurity ■Uterine abnormalities ■Malformation ■Fibroids ■Fetal abnormalities ■CNS Malformations ■Neck Masses ■Multiple gestations ■Previous breech delivery
University of Limerick
Most common type of breech
1.Frank (65%) – lower extremities are flexed at the hips, and extended at knees,
and the feet lie in close proximity
to the head
Indications for ecv
nBreech presentation
nFrom completed 36 wks GA in primiparous
nIn multiparous- from 37 completed weeks
Absolute contraindications to ECV
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy (except delivery of second twin)
Predictors of successful ecv
nParous (52-95%) nN/I amniotic fluid nTransverse/Oblique lie nPresenting part unengaged, mobile nPalpable fetal head
Advise mamma on the delivery options of breech babe
Mode of delivery
Women should be informed of the benefits and risks, both for the current and for future pregnancies, of planned caesarean section versus planned vaginal delivery for breech presentation at term.
¨caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies
¨no evidence that the long term health of babies is influenced by how the baby is born
¨
caesarean section carries a small increase in serious immediate complications for the mother
University of Limerick
BP IN PREG AT LOWEST AT HOW MANY WKS
22-24
CO in preg increases by
40%
Itll be up by 20% at 8 wk
And 40 by 20-28
Normal findings on cvs exam in preg
Bounding pulse Increase splitting of mitral and tricuspid comps of s1 Ejection systolic murmur in 90% !! 3rd heart sound Rel. sinus tach Transient diastolic murmur 20% Continuous murmur 10%
Ecg findings normal in preg
Ectopics
lead III Qwave and inverted t
St dep and t imversion in lat and inf leads
Left axis shift
What happens pco2 in preg
Blown off! Hyperventilation
Resp alkalosis
In lung capacity pic what increases in preg
Tidal vol and insp cap
In lung capacity in preg what decreases
The functional residual capacity, expiratory reserve, residual vol
What happens o2 consumption, met rate, resting minute ventilation, tidal vol, rr, func residual cap, vital cap, fev1 and pefr, pao2, paco2, ph In preg
02 up by 20% Met rate up by 15% Resting minute vent up by 40-50% !!!! Tidal vol up Func residual cap down in t3 Vital cap. Same Fev abd pefr same Pao2 up Paco2 down pH up
WhAt does hb go down to by 36 weeks
10.6g/dL
At 36 weeks gestation woman needs how much more iron and folat
3 times more fe
20 times more folate
What happens to
Plasma vol, red cell mass, hb, hematocrit, rcc, mcv, mchc in preg?
Up
Slightly up
Down down down
Same same
What happens wcc, plts, esr, in preg
Wcc up, esp pmn cells
Esr up
Plts lower range normal
Describe changes in renal system in preg
By t2 you have increase in flow to renal system by 60-80%
This drops in t3 but. At term its still up by 50%
Gfr up by 50%
More clearance of urea cr and uric acid
More protein excreted but should be less than .3g/d
What does progesterone do with na+
Inhibits its reabsorption
Which coag factors up in preg?
8 9 10
Fibrinogen is ____ by ____
Up by 50% leading to increase esr
Whats normal weight gain in preg
20lbs
What happens to thyroid hormones in preg
Tsh down in t1 coz of the hcg!
Less tbg made by liver therefore increase in total t3t4 to compemsate
But free t4 drops in t2 and 3
What is colposcopy
•Diagnostic test for Cervical Dysplasia
•5% acetic acid applied to cervix
•Cervix viewed through binocular magnifier
•Careful attention to Transformation Zone
•Stains abnormal areas white (Aceto-White Epithelium)
–Result of decreased glycogen content of dysplastic cells
•Can also visualize areas of abnormal vascularization
Talk about hpv vac
•New class of vaccine Virus Like Particle (VLP)
•Mimics the L1 and L2 capsid proteins of HPV
•Basically an empty shell of a virus, microscopically indistinguishable from an active HPV virion
•Produced by recombinant DNA technology
•Current vaccines
–Cervarix Types 16, 18 (not used in USA)
–Gardasil Types 6,11 (genital warts), 16, 18
- Given in 3 doses Month 0, Month 2, Month 6
- If doses are missed by more than a few weeks, must restart series
- Currently no test to determine immunity
- Pap smear guidelines for vaccinated individuals are the same
- May be given to individuals with history of abnormal pap/dysplasia or warts, but it is likely to be less effective compared to non-exposed individuals
- Has been demonstrated to prevent cervical dysplasia
- Cross effectiveness with other viral types still unknown
- Most widely studied among women, though it has been demonstrated to prevent warts in men
- Essential to vaccinate BEFORE coitarche to achieve maximum effectiveness
What are some features of sever pre eclampsia
Headache Visual disturbance Pulm oedema Liver dysfn Ruq or epigastric pain Raised cr Protein >5g in 24 h Oliguria Syst bp > 160 Diasto bp>110 Thrombocytopenia
Rfs for pre eclampsia
Nulliparous Age more than 40 Fam hx Renal disase Dm Twins Hx of htn Anti phospho syn
Serious clinical course of pre eclampsia Eyes Liver Lungs Kidneys Brain Uteroplacental Hematopoeitic
Rem the pic!
3 main tx goals in pre eclampsia mx?
1 prevent seizure
2 lower bp to prevent hem
3 expedite delivery balance mama condition and fetal maturity
Manage pre eclamsia
Abc Vitals neuro dtrs q 15 mins Iv cannula Catheter Dipstick protein q1hr Monitor fetus NST Labs Fbc, u+e BUN Cr LDH lft's Meds
How does mgso4 work,how do u giveit, whats therapeutic dose, what do u give if it becomestoxic
Slows neuromusc conduction
Decreases cns irritability
Give it by iv load 4-6g followed by infusion of 1-3g/h
Therapeutic dose is 4-8
If itgoes higer you lose reflexes, somnelent, resp dep, cardiac arrest
Antidote is ca gluconate 1g over 3m
If mum has severe pre eclamsia when do u absolutelydeliver within 24 h
>34w Mum deteriorating In labour Sever iugr Fetal compromise
Whats the clinical presentation of help?
Variable
Most are hypertensive
Nausea vomiting ruq pain epigastric pain
Mostly mid t2 to several days postpartum
Labs in hellp
Haemolysis
- abnorm peripheral smear
- total bili >1.2mg/dL
- LDH
LIVER ENZ ast >70
Platelets <100000/mm3
3 meds in hellp
Mgso4
Dexamethasone iv
Platelets if <100000
What are labs like in DIC
Increase pt aptt
Increase fibrin split products and d dimer
Decrease fibrinogen
Decrease plts
4 big issues with prom
Prematurity in pprom
Lung hypoplasia in pprom
Corioamnionitis.. Sepsis
Cord prolapse
4 big qs to ask about in pprom
Is it normal history for rom? Sudden gush large amt fluid from vagina, still trickling
Colour of fluid?
Pains?
Fever or chills?
Pprom examination?
nVitals
¨Signs of infection should be excluded, particularly tachycardia and pyrexia
nAbdomen
¨Reduction of liquor may be clinically obvious
¨SFH may be reduced
¨Palpate for tenderness/ contraction
¨Presentation- higher incidence of cord prolapse in non cephalic
¨FH auscultation
nSpeculum examination- Pool of fluid in the vagina is highly suggestive
Investigate a Pprom
nRange of tests used to confirm ROM
¨Nitrazine test, which detects pH change
nFalse-positive rate 17% owing to contamination with urine, blood or semen
¨Microscopic examination of the vaginal fluid
nFalse positive 6% due to contamination with cervical mucus
nRapid immunoassay- Amnisure
¨accurate in the diagnosis of ruptured membranes
¨sensitivity and specificity of 98.9% and 100%
nHVS
nFBC
nCRP
nCTG
She asked me this
nU/S- AFI, presentation, EFW, BBP, doppler, placental location
U have a pt 32 weeks gestation with pprom and delivery is not imminent.. Mx.?
Delivery not imminent
Admit to hospital
EXAM daily assessment - pains? unwell? tender?
VITALS 4hourly T, P, FH
FETUS Daily CTG
BLOODS twice weekly FBC, CRP
SWABS vaginal for c and s
ULTRASOUND- presentation, BPS, liquor, growth
MEDS
nBetamethasone - 2 doses
nAntibiotics- erythromycin 250 mg QDS for 10 days
nTimely delivery - aim for after 34 weeks
nInsufficient evidence to recommend the use of amniocentesis in the diagnosis of intrauterine infection.
7 ddx for t1 bleed
Miscarriage Ectopic Trophoblast disease Trauma Cerv ca Cerv polyps Friable cervix
Calculate menstrual age in wks based on crl
Weeks menstrual age = crl cm +6.5
Ueful between wks 8-13
