OBSGYN OSCE review Flashcards
what is included in a general gynecological history
- ID–> age, occupation, relationship status
- CC
- HPI–> onset, course, duration, OPQRST
- Menses
- Sexual history
- contraception
- PAP and mammography
- general gyne history
- PMH/past surgical history, meds, allergies
- social history
- family history
- obstetrical history
what questions do you ask on a menses history
LMP
menarche
regularity
frequency
interval
flow
spotting
PMS/dysmenorrhea
what should you ask on a sexual history
active?
age of coitarche
number of partners and gender
STI/blood born disease work up before?
what should you ask on history about contraception
method
duration
side effects
plans for future
what should you ask on a general gyne history
discharge
itching
dyspareunia
post coital bleeding
what is an outline for an obstetric history
- ID
- EDD my US/LMP, GA
- US dates
- LMP dates
- CC
- HPI–> 4 cardinal questions
- current OB history –> complications (diabetes, HTN), GBS status, blood type
- Past OB history –> SVD or C/S, reasons for C/S, miscarriages and abortions and their management and complications, PPH, transfusion required?
- past gyne history–> STI, paps etc
- PMHx, meds, allergies
- social history, family history
describe an approach to a focused gynecological physical exam
- inspection, vitals, stigmata of disease
- quick screen of HEENT, CV, Resp
- abdo exam–> IAPP, special maneuvers
- pelvic exam–> inspection, speculum exam, special swabs/pap, bimanual exam, rectovaginal exam
- testing for cervical/vaginal infections
- -GC/chlamydia culture testing (endocervical)
- -general swab for all other infections (posterior fornix) for gram stain (intracellular diplococci are gonorrhea and large gram positive rods are lactobacilli)
- -pH paper test (lateral vaginal walls)
- -whiff test with KOH
- -vaginal saline wet prep (trich vs BV)
- -vaginal saline wet prep plus KOH - bimanual exam–> vaginal walls, cervix, CMT, uterus (size, mobility), adnexa, uterosacral nodularity
- rectovaginal exam
what does large gram positive rods on endocervical swab indicate
lactobacilli
what does intracellular diplococci indicate on endocervical swab indicate
gonorrhea
what does a vaginal saline wet prep test for
trich vs BV
what does a vaginal saline wet prep plus KOH test for
yeast
describe an approach to the pelvic exam
- introduction and detailed explanation–> empty bladder–> abdo exam
- wash hands, sterile gloves, get all equipment ready
- give notice
- inspection–> vesicles, lacerations, rash etc
- speculum exam–> use hot water as lubricant instead of lube, comment on anatomy
- pap–> SHORT end of spatula and cytobrush (NEVER in pregnant women) –> wipe on slide and then fix
describe an approach to a focused obstetrical exam
- inspection, vitals, stigmata of disease
- quick screen of HEENT, CV, resp
- abdo exam–> IAPP
- -intro and explanation, empty bladder
- -examine on right side of patient
- -palpate the fundus for contractions
- -SFH
- -leopolds maneuvers - FHR–> baseline, variability, accels, decels
- sterile speculum exam
- vaginal exam (confirm no previa beforehand)
what are leopolds maneuvers
presentation–>
- fundus for whether head or bum
- lie–> longitudinal, oblique or transverse
- engagement
- attitude–> flexion/extension–cant assess unless head is engaged in pelvis
what are the cardinal movements of labour
- engagement and descent
- flexion
- internal rotation
- extension
- restitution/external rotation
- expulsion
describe the cardinal movement of labour:
engagement and descent
biparietal diameter (largest transverse diameter) of the fetal head passes through the pelvic inlet–> most commonly assumes OT position
describe the cardinal movement of labour:
flexion
descending fetal head meets resistance of pelvic floor and passively flexes to allow smallest diameter to present to the pelvis–> posterior fontanel in the center of the birth canal
remains OT
describe the cardinal movement of labour:
internal rotation
occiput rotates anteriorly to come under the symphysis–> OT into oblique position, OA or OP (OA most common)
describe the cardinal movement of labour:
extension
occiput comes into direct contact with inferior part of maternal symphysis and swivels under the bone, extending the head as it comes clear… chin delivers last
check nuchal cord after this
describe the cardinal movement of labour:
restitution
head restitutes to the original position before internal rotation–> transverse position to bring fetal shoulder in line with AP diameter of pelvic outlet
describe the cardinal movement of labour:
expulsion
anterior shoulder comes under symphysis, folloed by posterior shoulder, distends peritoneum
what is the shortest diameter of the pelvis
interspinous diameter
how do you manage the placenta after expulsion of the neonate
signs: sudden gush of blood, lengthening of the cord, uterus is globular and firm
check for 3 vessels, attachment point of cord, succenturiate lobe, is it complete
describe an approach to a vaginal exam in labour
general inspection
assess cervix
- -location
- -consistency
- -effacement
- -dilation
- -membranes
assess fetus
- -presenting part (cephalic/breech)
- -position (triangle is OA)
- -station (NOT assessable in blue box)
- -caput (NOT assessable in blue box)
what are the causes and risk factors for PPH
PREVIOUS history of PPH
tone
tissue
trauma/tears
thrombosis
what kinds of things can cause uterine atony leading to PPH
inversion
overdistended uterus–> macrosomia, multiples, poly, multiparity
exhausted uterus from prolonged labour, rapid labour, augmentation, chorioamnionitis
what kinds of tissue problems can cause PPH
retained POC
incomplete placenta
invasive placenta–accreta
what kinds of trauma and tears can cause PPH
hematoma
uterine rupture
lacerations (cervix, vagina, episiotomy)
assisted delivery
what kinds of thrombotic events can cause PPH
coagulopathy
anticoagulant tx
intravascular hemolysis and DIC
severe preeclampsia/eclampsia
how would you manage a PPH
- call for help
- ABCs, vitals
- two large bore IVs, start NS
- lab–> group and screen, crossmatch and coag profile
- foley catheter to monitor urine volume
- assess and manage TONE
- -bimanual massage
- -oxytocin 40 U IV in 1 L NS–> fast infusion
- -misoprostol suppository/hemabate/ prostin/ methergine/ ergotamine - assess and manage TISSUE
- -check placenta–manual removal of retained
- -express uterus for clots - assess and manage trauma/tears
- -repair - assess and manage thrombosis
- -replace missing factors according to coag results
- -packed RBCs, platelets - surgical management
- -Bakri balloon insertion
- -D and C
- -ligation of uterine/ovarian artery (main branches of internal iliac)
- -embolization
- -hysterectomy
how much/how would you administer oxytocin in the context of a PPH
40 U IV in 1 L NS fast infusion
what are some ways to prevent PPH
10 U of oxytocin IM after anterior shoulder delivery
breast feeding ASAP to cause uterine contraction
if has risk factors, be ready with IV etc
what are complications from PPH
anemia
Sheehans–> unable to breastfeed due to low PRL–> check other hormones
what is the ddx for AUB/menorrhagia that presents as a heavier than normal period
fibroid
adenomyosis
endometrial polyp
coagulopathy
could also be…
endometrial hyperplasia or cancer
cervical polyps or cancer
what is the ddx for AUB/menorrhagia that presents as intermenstrual bleeding
breakthrough bleeds from OCP/IUD
cervical polyp/ectropion
infection (endometrial, cervical or vaginal)
endometrial hypertrophy or cancer
what is the ddx for AUB/menorrhagia that presents as post coital bleeding
cervical polyp
cervical friable lesion
cervical cancer
what are some “other” causes for AUB/menorrhagia
trauma
lacerations
instrumentation
thyroid problem/prolactin problem
what history should you ask, beyond normal gyne history, in the setting of AUB/menorrhagia
intermenstrual, menstrual or post coital?
associated symptoms–fever, pain, discharge?
pregnancy?
family history of coagulopathy or cancers?
constitutional sx?
menopausal sx?
risk factors for endometrial cancer
what are the risk factors for endometrial cancer
early onset of menarche
late menopause
nulliparity
diabetes
obesity
exogenous estrogen use
chronic anovulation (irregular periods)
personal history
family history
lack of OCP use
HTN
what physical exam should you do for AUB/menorrhagia
inspection/vitals
height and weight
signs of anemia?
stable?
quick HEENT/CV/RESP/GI screen (rule out other sources of bleeding
abdo exam–> IAPP and special maneuvers
pelvic exam–> inspection, speculum, bimanual
what labs should you do for AUB/menorrhagia
pregnancy test
CBC
TSH, PRL, FSH
coagulation workup–> INR, PTT, fibrinogen
androgen workup if hirsutism suspected
pap smear
cultures for STI
endometrial biopsy
hysteroscopy if you have one
pelvic U/S or transvaginal U/S for endometrial thickness
HSG (MRI)
treatment for uterine bleeding due to fibroids
NSAIDS
provera
danazol
GnRH agonists for 3-6 mo to shrink fibroids
uterine artery embolization
hysteroscopic/lap/abdo myomectomy
hysterectomy
treatment for uterine bleeding due to adenomyosis
hormonal regulation
endometrial ablation
hysterectomy
treatment for uterine bleeding due to endometrial hyperplasia
progestin therapy
D and C
hysterectomy
treatment for uterine bleeding due to endometrial cancer
TAHBSO
how do you manage mild to moderate uterine bleeding
OCP
how do you manage severe uterine bleeding
admit
stabilize
premarin IV then to oral estrogen when bleeding stops
NSAIDS, OCPs, progestin, danazol, IUD, D and C, endometrial ablation, hysterectomy
ddx for oligomenorrhea
PCOS
pregnancy
anovulation
hypothyroid/
hyperprolactinemia
hypo hypo–> stress, anorexia, exercise
anovulatory
ddx of PCOS/hirsutism
PCOS
metabolic syndrome
cushings
androgen secreting tumour
CAH
androgen drug exposure
theca lutein cysts
stromal hyperplasia/
hyperthecosis
idiopathic hirsutism due to high 5 alpha reductase activity
history to ask for PCOS/hirsutism
onset and signs of hyperandrogenism –> if rapid with virilization–> consider androgen secreting tumour
signs of virilization
physical exam for PCOS and hirsutism
focus on clinical signs of virilism/hirsutism –>
male pattern balding
acne
oily skin
truncal obesity
acanthosis nigricans
pubic hair distribution
deepening of voice
increased muscle mass
clitoromegaly
breast atrophy
male body habitus
cushinoid features
labs to order for PCOS/hirsutism
CBC
serum testosterone
DHEA-S
serum 17-OHP
dexamethasone suppression test and 24 hour urine cortisol
FSH, LH, PRL, TSH, beta hCG
cholesterol panel
DM screen
pelvic U/S or transvaginal U/S
endometrial biopsy
treatment for PCOS
lifestyle mods
screening/monitoring for endometrial cancer, HTN, dyslipidemia, DM, sleep apnea
if trying to conceive–> weight loss, clomiphene citrate, metformin, FSH injection, ovarian drilling or IVF
if not trying to conceive–> weight loss, OCP/progestin and anti-androgens
how do you diagnose gestational DM
SCREEN with 50 mg glucose load at 24-28 weeks–> measure 1 hour later
- -if above 7.9 mmol/L, confirm with 75 g OGTT test
- -if above 10.3 mmol/L, diagnosis is made
DIAGNOSE with 2 hr 75mg OGTT after overnight fast–2 or more abnormal values is diagnostic
- -fasting above 5.1 mmol/L
- -1 hour above 10 mmol/L
- -2 hour above 8.5 mmol/L
if GDM is diagnosed, then have to do a 75g OGTT at 6-12 weeks post partum
what complications are associated with GDM
fetal macrosomia
birth injury
neonatal hypoglycemia
hypocalcemia
hyperbilirubinemia
polycythemia
how do you manage GDM
- nutritional counseling
- -BG self monitoring
- -count carbs (200-220 g carbs per day)
- -aim for fasting BG less than 5.3, post prandial less than 7/8 - start insulin therapy if targets not reached within a matter of 1-2 weeks
- serial assessment of fetal wellbeing especially if insulin treatment
- -fetal movement counting daily
- -U/S for growth, fluid, dopplers, NST, BPP
what is the starting dose of insulin for GDM
4U short acting/rapid acting insulin before meals
4U intermediate acting at bedtime (NPH)
total daily doses–> 0.6U/kg before 6 weeks, 0.7U/kg 6-18 weeks, 0.8U/kg from 18-26 weeks, 0.9U/kg from 26-30 weeks, 1U/kg from 36-40 weeks
how do you manage delivery in GDM
check level q1-2 hours and give IV insulin infusion/dextrose infusions if glucose levels exceed 6.5mmol/L
early induction of labour at 38-40 weeks
avoid forceps/vacuum due to increased risk of shoulder dystocia
prophylactic C/S for macrosomia (i.e above 4500-5000 g)
how do you manage GDM post partum
6-12 weeks post partum, do 75g 2 hour OGTT
annual fasting glucose to screen for T2DM
lifestyle mods
what is the workup for HELLP
CBC–platelets, HgB– plus diff
lytes
AST, ALT
albumin
bilirubin
workup for DIC/hemolysis
INR
PTT
fibrinogen
LDH
peripheral smear
renal workup
Cr
Uric acid
BUN
UA
24 hour protein urine
how do you manage an acutely elevated BP in a pregnant woman (including dosages)
treat immediately if sBP above 160 or dBP above 110 –> try and get it below this
- nifedipine (10 mg q45 min)
- labetalol (20 mg IV q 30 min)–contraindicated in asthma or heart failure
- hydralazine (5 mg IV q 30 min)
4 for seizure prophylaxis–> MgSO4 4g STAT over 20 min then 1g/hr–> antidote is calcium gluconate
how do you manage chronically elevated BP in a pregnant woman
goal is sBP 130-135 and dBP 80-105
- methyldopa
- labetolol/nifedipine XL 30 mg daily at 18:00
- diuretics if have special indications
avoid ACEi, angtiotensin II receptor antagonists, atenolol
how do you manage HELLP acutely
- order blood products, including platelets
- platelet transfusion prior to vaginal delivery/C section if count is below 20
- consider corticosteroids if count is below 50
- Mg prophylaxis (4 g stat over 20 min then 1g/hr)
- stabilize and deliver at all GA
how do you manage eclampsia acutely
call for help
ABC
stabilize
deliver
MgSO4 2g IV STAT to control seizures then 1.5g/hr plus valium
what BP meds are safe for breastfeeding (to control HTN post partum)
nifedipine
labetalol
methyldopa
captopril
non gyne ddx for PID
appendicitis
diverticulitis
bowel perf
inflammatory bowel disease
gyne ddx for PID
ectopic
ovarian torsion
tubo-ovarian abscess
hemorrhagic cyst rupture
TB salpingitis
what should you ask on history for PID
- how old are you (15-25 yo is highest risk)
- age at first coitus
- form of contraception
- sexual history–how many sexual partners recently?
- new partner?
- prior history of PID/pelvic infections or STDs? worked up for STDs in the past?
- smoker?
- recent instrumentation like IUD insertion, D and C etc
what elements to look for on physical exam for PID
unstable vitals, may have high fever
abdo tenderness with or without rebound tenderness and peritonitis
Fitzhugh curtis syndrome
increased vaginal discharge with abnormal odour, abnormal bleeding
adnexal tenderness, uterine tenderness
what is Fitzhugh curtis syndrome
inflammation of the liver capsule due to PID leading to adhesions
what tests should you order for PID
CBC
ESR
chlamydia and gonorrhea cervical gram stain
beta hcg
LFTs
kidney function
lactate
blood culture
pelvic U/S
do a diagnostic lap if appy cant be ruled out
how do you manage PID
if stable–outpatient with follow up in 48-72 hours
hospitalize if indicated
when should you hospitalize with IV abx for PID
- unstable vitals, severe V and V, high fever, septic
- if surgical emergency i.e appy cant be excluded
- pregnant
- likely to be non compliant at outpatient
- unresponsive to oral therapy
- known tubo-ovarian abscess
- presence of IUD
- immunodeficient or HIV positive
- peritonitis present in upper quadrants
what is the oral abx tx for PID
ceftriaxone 250 mg IM plus doxycycline 100 mg PO BID for 14 days with or without metronidazole 500 mg PO BID for 14 days
what is the IV tx for PID
cefoxitin 2g IV q6h plus doxycycline 100 mg IV/PO q 12h
continue IV tx until clinical improvement for 24 hours–> then step down to oral doxycycline
if allergic to cephalosporins, use IV clinda and genta
how do you treat tubo-ovarian abscess
ampicillin to cover gram positive plus gentamicin to cover gram neg plus metronidazole to cover anaerobes
what does ampicillin cover
gram positive
what does gentamycin cover
gram negative
what does metronidazole cover
anaerobes
what are the most common organisms causing PID
chlamydia is more common that gonorrhea
what are the possible sequelae of PID
infertility
ectopic pregnancy
chronic pelvic pain
dyspareunia
pelvic adhesions
what are the things to think about for post partum care with regard to:
brain
baby blues
PP depression
PP headache
contraception
what are the things to think about for post partum care with regard to:
breasts
skin to skin
breastfeeding
engorgement
mastitis
what are the things to think about for post partum care with regard to:
bowel
constipation
what are the things to think about for post partum care with regard to:
bladder
diuresis
incontinence
UTI
what are the things to think about for post partum care with regard to:
belly
uterine involution
endometritis
incision site
after pain
skin
what are the things to think about for post partum care with regard to:
bleeding
PPH
lochia
what are the things to think about for post partum care with regard to:
bottom
hemorrhoids
perineum
what is a way to remember all the things to cover in post partum care
7 Bs
brain, breasts, bowel, bladder, belly, bleeding, bottom
non obsgyn ddx for ectopic
appendicitis
diverticulitis
cystitis/stone
obstetric ddx for ectopic
ovarian torsion
hemorrhagic cyst rupture
PID
gyne ddx for ectopic
threatened abortion
what should you ask on history for ectopic
previous hx of ectopic
hx of PID/pelvic infection or STI/pelvic surgeries or endometriosis
IVF
means of birth control–IUD?
congenital abnormalities of the tube?
what should you look for in physical for ectopic
general well being and vitals
peritoneal signs–rupture?
tender adnexa, uterus small for GA
what labs should you get for ectopic?
CBC
type and screen
crossmatch
quantitative b hCG
transvaginal U/S
LFTs and renal function
what should you do in the case of a suspected ectopic, hCG less than 2000, cant see IUP
monitor 48 hours (must increase by 66%)
what should you do in the case of a suspected ectopic, nCG above 2000 and cant see IUP
likely ectopic
what three signs suggest a ruptured ectopic
positive pregnancy test
hemodynamic instability
peritoneal signs
how do you manage a ruptured, unstable ectopic
ABCs
large bore IVs with NS/blood product and pressors ready
exploratory laparotomy to stop bleeding and remove ectopic
*if ruptured but stable, can do exploratory laparoscopy to evacuate hemoperitoneum, coagulate bleeding and salpingotomy/ salpingectomy
what are the options for an unruptured, stable ectopic
surgery or methotrexate
what are the criteria for using methotrexate for an ectopic
less than 3.5 cm
no FH motion seen
hCG below 5000
hemodynamically stable and no signs of rupture
what is the dosing of methotrexate for ectopic
50 mg/m2 IM
track serial HCG
contraindications to methotrexate therapy for ectopic
hemodynamically unstable
impending/ongoing ectopic mass rupture
immunodeficient, active pulm disease, peptic ulcer disease
coexistent viable intrauterine pregnancy
breastfeeding
non compliant with follow up
baseline hematologic/RENAL/ hepatic lab values that are abnormal
what are the surgical options for treatment of ectopic
laparoscopy for salpingotomy or salpingectomy
–> follow HCG weekly until less than 5
laparotomy if unstable
ovulatory ddx for infertility
advanced maternal age
hypo hypo
PRL
hypothyroid
POF
ovarian tumour
PCOS
obesity
androgen excess (i.e CAH)
cushings
structural ddx for female infertility
blocked tubes–> PID, tubal ligation, endometriosis, previous ectopic, pelvic adhesions
uterine fibroids
congenital malformation of the uterus
uterine septum
uterine polyps
asherman’s syndrome
cervical stenosis from procedures or infection
cervicitis
ddx of male causes of infertility
abnormal sperm
testicular failure from mumps/trauma
varicocele
chromosome abnormalities (Klinefelter)
impotence
hypo hypo
labs to order to work up infertility
semen analysis
confirmation of ovulation
TSH
PRL
day 21 progesterone
FSH
LH
pap smear
STD cultures
how to work up possible ovulatory causes of infertility
menstrual history
mid luteal progesterone
LH urinary kit
basal body temp
FSH, LH, PRL, TSH
testosterone, DHEAS, 17-OHP, 24 hour cortisol
overnight dex suppression test
day 3 FSH
clomiphene challenge test
antral follicle count
AMH
work up of structural causes of female inferility
HSG
hysteroscopy
pelvic U/S
laparoscopy
workup of male infertility
semen analysis
TSH, FSH, PRL, testosterone
karyotype
testicular U/S
management of ovulatory causes of infertility
correct endocrine problems
clomiphene
gonadotropin injection
management of structural causes of female infertility
surgical correction if possible
endometriosis corrected by lap/IVF
tubal disease–> lap or IVF
surrogate
management of male infertility
improvement in coital practices
varicocele repair
low semen volume or poor semen managed by washing sperm for ICSI and IUI
what do you do if infertility remains unexplained
IVF and ICSI or donor sperm and egg
menopause symptoms related to menstruation
change in flow
irregular
menopause symptoms related to urogenital
incontinence, UTIs
vaginal atrophy, dyspareunia
vaginal dryness/itching
shrinking length and diameter
reduced sensitivity and libido
increased trauma
pelvic prolapse
menopause symptoms related to vasomotor
hot flashes
night sweats
insomnia
menopause symptoms related to psych
worsening PMS
depression
irritability
mood swings
loss of concentration
poor memory
anxiety
menopause symptoms related to other
weight gain
skin changes
dental changes
what physical exams should be done when a woman is presenting in menopause
full physical from head to toe
include breast, pelvic (sensitive because atrophy) and pap smear
what labs should be ordered in menopause
FSH to confirm
cholesterol level, DM screening, mammography if warranted, pap, UA, DEXA if high risk for OP, TSH
lifestyle mods for menopause
weight bearing exercise and eat healthy
stop smoking
reduce caffeine and alcohol
what meds can be used to manage menopause
HRT for 6-12 mo if still has uterus
vitamin D and calcium/ bisphosphonate for OP
vaginal estrogen cream or lubricant for vaginal atrophy
SSRI/SNRI/Clonidine for vasomotor symptoms
contraindications to HRT for menopause
chronic liver impairment
pregnancy
known estrogen dependent neoplasm (breast, ovary, uterus)
hx of clots
undiagnosed vag bleeding
benefits of HRT for menopause
improves sx
decreases bone loss
decreases colon ca
reduces CV risk if begun early in menopause
risks of HRT for menopause
increased risk of breast ca
cholecystitis
CV risk if started after menopause
ddx for vaginal discharge
BV
trichomonas
yeast infection
chlamydia and gonorrhea
normal discharge of ovulation
bartholin’s duct abscess
non gyne discharge
rule out: PID, TSS, endometritis
what should you rule out with pelvic disharge
PID
TSS
endometritis
what are the 4 cardinal questions of obstetrics
- are you bleeding
- has your water broken
- are you having contractions
- is the baby moving
1-3–> is she in labour?
4–> baby’s health
GO OVER ANTEPARTUM HEMORRHAGE CARDS
DO IT–for bleeding in third trimester
what is the mechanism of the combined OCP
suppresses ovulation
thickens cervical mucus
prevents tube peristalsis
decidualizes endometrium
97% effective in typical use
pros of the combined OCP
improved cycle regulation
less dysmenorrhea, menorrhagia, PMS sx
increased bone mineral density
decreases PID, endometriosis, ectopic pregnancy
decreased endometrial and ovarian ca
decreased fibroid risk, functional cysts, benign breast disease
less colon ca
decreased perimenopausal sx
less acne or hirsutism
cons of the combined OCP
spotting/breakthrough bleeding
breast tenderenss
nausea, vomiting
mood changes
fluid retention and weight gain
headache
mild increase in clotting
post pill amenorrhea up to6 mo
gall bladder disease–cholelithiasis, cholecystitis
benign liver adenoma (rare)
cervical adenoca (rare)
retinal thrombosis (rare)
absolute contraindications to the combined OCP
pregnancy
less than 6 weeks post partum and lactating
history of DVT, PE, VTE
hereditary thrombophilia
smoker over age 35 with more than 15 cigs per day
ischemic heart disease
CVA
uncontrolled HTN (sBP above 160 or dBP above 100)
complicated valvular disease (pulm HTN, a fib, subacute bacterial endocarditis)
migraine headache with aura or focal neuro sx
DM with neuropathy/retinopathy/ nephropathy
severely high cholesterol
BREAST/ENDOMETRIAL CA
LIVER DISEASE
UNEXPLAINED VAG BLEEDING
relative contraindications to combined OCP
controlled HTN
fibroids
lactating
migraines in women over 35
high cholesterols
mild liver disease
symptomatic gall bladder disease
history of cholelithiasis on OCP
lupus
seizure disorder
use of meds that interfere with OCP metabolism
drugs that reduce the efficacy of the OCP
barbituates
carbamazepine
phenytoin (dilantin)
rifampin
st johns wort
topiramate
medications whose efficacies are changed by the OCP
diazepam (valium)
hypoglycemics
methyldopa
phenothiazines
theophylline
TCA
what advice should be given to a woman just starting the OCP
start immediately
take pill for 21/28 days then for the 7 days take placebo or no pill
may get withdrawal bleeding within 3-5 days of completion of 21 days or hormones
for first week–> USE BACK UP CONDOM
take at same time every day
what do you do if you miss a dose of the OCP in the first week
missed 1 pill–> take the 1 missed pill and continue rest of packet at normal
if missed more than 1 pill–> take 1 pill, then take 1 pill a day until the end of the packet; use barrier method for 7 days, and use emergency contraception if had unprotected sex within last 5 days
what do you do if you miss a dose of the OCP in the 2nd or 3rd week
missed less than 3 pills–> take 1 pill and 1 pill a day until end of packet–> skip hormone free interval cycle
missed 3 or more pills–> take 1 pill and 1 pill a day until end of packer; use barrier method for 7 days and use emergency contraception if you had unprotected intercourse within the last 5 days; skip hormone free interval period
how does the level of estrogen in the combined hormonal patch compare to the OCP
higher in patch
how do you use the combined hormonal patch for contraception
change patch weekly for 3 weeks–no patch for 1 week, get withdrawal bleeding
what do you do if you miss a combined hormonal patch in the first week
if delayed patch change for less than 1 day–> change patch ASAP and reapply new patch at same time next week
if delayed patch change for more than or equal to 1 day–> change patch ASAP and reapply new patch at same time next week… barrier method for 7 days and emerg contraception of unprotected sex for last 5 days
what do you do if you miss a combined hormonal patch in the 2nd or 3rd week
if delayed patch change for less than 3 days–> change patch ASAP, reapply new patch at same time next week…finish current cycle and start new cycle without hormone free interval
if delayed patch change for more than or equal to 3 days–> change patch ASAP, reapply new patch at same time next week… finish current cycle and start new cycle right away without hormone free interval–> barrier method for 7 days and emerg contraception if unprotected sex within last 5 days
how does the nuva ring work
continuous low steady hormones
total hormone exposure is lower
left in place for 3 weeks then removed for 7 days with withdrawal bleeding
what do you do if you miss a nuva ring in the first week
ring absent for less than or equal to 3 hours–> insert ring ASAP and keep scheduled ring cycle
ring absent for more than 3 hours–> insert ring ASAP and keep scheduled ring cycle with addition of barrier for 7 days and emerg contraception if unprotected in last 5 days
what do you do if you miss a nuva ring in the second or third week
ring absent for less than 3 days–> insert ring ASAP and keep scheduled ring cycle… no hormone free interval before next cycle
ring absent for more than or equal to 3 days–> insert ring ASAP and keep scheduled ring cycle… no hormone free interval before next cycle… ass barrier for 7 days, emerg contraception if unprotected in last 5 days
absolute contraindications to DMPA
pregnancy
breast ca
unexplained vag bleeding
what happens if you are taking the progestin only pill, and you delay your pill by more than 3 hours or miss more than or equal to 1 pill
if you had unprotected intercourse in last 5 days–> emerg contraception–> continue taking one pill daily at same hour–> back up contraception for 48 hours
if no recent unprotected sex–> take 1 pill asap, continue daily at same hour… back up contraception for 48 hours
what meds have drug interections with Yuzpe or Plan B
anticonvulsants
rifampin
st johns wort
contraindications to emerg contraception
pregnancy
no contraindications for hormonal meds
contraindications for copper IUD
uterine anomaly
undiagnosed vag bleeding
stenosed cervix
wilsons disease
copper allergy
PID/STI
cervical or endometrial ca
inability to place/retain device
what should you counsel the patient on when they take emerg contraception
need to take as soon as possible
side effects
some spotting/period like bleeding can happen after taking pills
next period will be off by 2-3 days
followup with GP–> if no period within 3 weeks–> take pregnancy test
get a regular form of birth control and use condoms to prevent STIs
what are common side effect of emerg contraception
nausea
vomiting
fatigue
dizziness
if you vomit within 1 hour of taking pill, may need another dose
definition of primary amenorrhea
no menses by age 14 with no secondary sex characteristics OR no menses by 16 with secondary sex characteristics
definition of secondary amenorrhea
no menses for 3 mo if normal cycle, and 9 mo if previous oligomenorrhea
what is the ddx for primary amenorrhea regarding the hypo/pituitary axis
stress
diet
exercise
congenital GnRH deficiency or tumour suppression
constitutional delay
hyperprolactinemia
hypothyroid
infiltrative disease
what is the ddx for primary amenorrhea regarding the ovary
congenital dysgenesis (i.e turners, XY, XX)
gonadal dysgenesis –> XY–sawyers syndrome
PCOS
what is the ddx for primary amenorrhea regarding the congenital outflow tract
imperforate hymen
transverse vaginal septum
mullerian agenesis
what is the ddx for primary amenorrhea regarding receptor/enzyme problems
complete androgen insensitivity (46 XY)
5 alpha reductase deficiency
17 alpha reductase deficiency
what should you rule out first in the setting of secondary amenorrhea
PREGNANCY
what can cause hypo hypo secondary amenorrhea
stress
diet
exercise
PRL
hypothyroid
infiltrative disease
inflammatory/iatrogenic causes
meds
ANYthing that damages the hypothalamus or pituitary
sheehans
what can cause hyper hypo secondary amenorrhea
premature ovarian failure
perimenopausal
turners
what can cause eugonadotropic hypogonadism leading to secondary amenorrhea
PCOS
outflow tract abnormality (ashermans, cervical stenosis)
what can cause secondary amenorrhea that has not yet been covered
non classical CAH
steroid secreting tumours of the ovary
adrenal tumour
chronic disease
what should you ask on history for amenorrhea
endocrine sx–> galactorrhea, weight loss, diet, thyroid sx, hirsutism, virilization
what should you focus on on physical for amenorrhea
syndromal features?
neuro exam
signs of androgen excess or insulin resistance
galactorrhea, breast devel
signs of cushings
estrogenization in pelvic exam
what tests should you order to work up amenorrhea
beta HCG
TSH
PRL
FSH
progestin challenge– > if bleeding, either PCOS or outflow tract abnormality//if not bleeding, do estrogen plus progestin challenge–> if bleeding, indicates low endogenous estrogen so measure FSH, LH–> if high FSH/LH–> karyotype (POF vs chromosome problem)//if low FSH/LH, do MRI (look for brain mass, infiltrations vs functional disease)
when is SIPS offered
before 13+6 weeks
when is QUAD offered
after 13+6 weeks
what are the 5 parts of SIPS
at 10-13+6 weeks–> PAPP-A
at 15-20+6–> AFP, hCG, inhibin A, uE3
85% detection rate (vs 77% for QUAD)
4% false detection rate
what trisomy is characterized by low MSAFP, low estriol, high beta hCG and low PAPP-A
trisomy 21
what trisomy is characterized by low MSAFP, low estriol, low beta hcg and low PAPP-A
trisomy 18
what trisomy is characterized by variable MSAFP, estriol, beta hcg
trisomy 13
what is IPS
SIPS plus NT
when is IPS offered
if mom is 35 or older at EDD
twins
IVF and ICSI
hx of child/pregnancy with trisomies
HIV positive
what do you do if the nuchal translucency is above 3.5mm
NT above 3.5mm–> increased risk of fetal heart defect–> offer echo at 18-20
what are the diagnostic prenatal tests
CVS and amnio
when do you do a CVS or amnio
positive screening tests
mom above 40 at EDD
greater risk for chromosomal abnormality
multiple gestation AND above 35 at EDD
when do you do CVS
between 10-12+6 weeks
what is the CVS loss rate
1-2%
what are the side effects of CVS
cramping, bleeding, infection
what are the risks of CVS
fetal limb deformation if done early
when is amnio done
after 15 weeks
what is the amnio loss rate
0.5%
what are the risks of amnio
bleeding
fluid leakage
infection
cramping
what are the maternal risks of multiple gestation
preterm labour and PPROM
placenta previa
cord prolapse
PPH
cervical incompetence
GDM
preeclampsia
