Obstetrics and Gynecology Flashcards
When would you offer an external cephalic version
If there is transerse lie or breech presentation at 37 weeks and vaginal delivery is not contraindicated
Diagnosis and treatment of gonorrhea and chlamydia
Dx: nucleic acid amplification test (gold standard) on urine or cervical swab
Empiric: ceftriaxone and azithromycin
Confirmed chlamydia only: azithromycin or doxycycline
Confirmed gonorrhea only: ceftriaxone and azythromycin
Hospitalization and IV cefoxitin or cefotetan plus oral doxycycline if pregnancy, failed outpatient treatment, inability to tolerate oral medications, noncompliant with therapy, severe presentation (e.g. high fever, vomiting), complications (e.g. tubo-ovarian abscess, perihepatitis)
Boggy, tender, globular uterus
Adenomyosis
Gestational diabetes blood glucose targets and treatment
Fasting ? 95, 1-hr postprandial ? 140, 2-hr postprandial ? 120
Tx: dietary modifications (first line), insulin, metformin, glyburide (second line)
Management of shoulder dystocia
BECALM Breath, do not push, lower head of the bed Elevate legs (McRoberts position) Call for help Apply suprapubic pressure Enlarge vaginal opening with episiotomy Maneuvers
Treatment for spontaneous abortion
Expectant management
Medical induction (misoprostol)
Suction curettage if infection or hemodynamically unstable
Indications for cerclage
History of second trimester delivery
Short cervical length (< 2.5 cm) via TVUS
Evaluation for primary amenorrhea
Pelvic exam or ultrasound
If uterus, check serum FSH
If FSH increased –> karyotype
If FSH decreased –> cranial MRI
If no uterus, check testosterone and do karyotype
If 46XX and normal female testosterone, Mullerian agenesis
If 46XY and normal male testosterone, androgen insensitivity syndrome
Diagnosis and management of pre-eclampsia
Risk factors: nulliparity, maternal age < 18
Dx: new-onset HTN > 20 weeks plus proteinuria and/or end-organ damage
Severe features: SBP > 160 or DBP > 110 (2 times > 4 hours apart), thrombocytopenia (< 100,000), increased creatinine (> 1.1), increased transaminases, pulmonary edema, visual or cerebral symptoms
Management: delivery > 37 (> 34 weeks if severe), magnesium sulfate (seizure prophylaxis), antihypertensives (IV labetalol, IV hydralazine, PO nifedipine)
Complications: fetal growth restriction/low birth weight, placental abruption, DIC, eclampsia
Treatment for ectopic pregnancy
Stable: methotrexate
Unstable: surgery
HELLP syndrome
Hemolysis, elevated liver enzymes, low platelets
Systemic inflammation and activation of complement and coagulation systems –> platelets rapidly consumed, microangiopathic hemolytic anemia causes hepatocellular necrosis and thrombi in the portal system causes elevated liver enzymes, liver swelling, and liver distension of hepatic capsule
Types of fetal growth restriction
Definition: ultrasound-estimated fetal weight < 10th percentile
Symmetric: global growth lag caused by chromosomal abnormalities or congenital infection in the first trimester
Asymmetric: “head-sparing” growth lag caused by uteroplacental insufficiency or maternal malnutrition in the 2nd/3rd trimester
Management and complications of intrauterine fetal demise
Management: dilation and evacuation or vagnial delivery is 20-23 weeks, vaginal delivery if ? 24 weeks
Complication: coagulopathy after several weeks of fetal retention
Diagnosis and management of placenta previa
Dx: transabdominal followed by transvaginal ultrasound, placenta within 2 cm of internal cervical os
Tx: pelvic rest (no intercourse, digital exams), scheduled cesarian at 36-37 weeks
Risk factors for cerebral palsy
PREMATURITY Intrauterine growth restriction Intrauterine infection Antepartum hemorrhage Placental pathology Multiple gestation Maternal alcohol consumption Maternal tobacco use Tx: physical, occupational, and speech therapies, baclofen and botulinum toxin for spasticity
Vaccines contraindicated during pregnancy
HPV
MMR
Live attenuated influenza
Varicella
When to administer Rhogam?
For Rh- mothers, administer at 28 weeks or if spontaneous abortion or trauma
If baby Rh+, administer within 72 hours after delivery
Clinical features and treatment of magnesium toxicity
Magnesium sulfate is given to prevent eclamptic seizures and for fetal neuroprotection; renal insufficiency can cause hypermagnesemia
S&S: loss of deep tendon reflexes, somnolence, respiratory depression
Tx: IV calcium gluconate bolus
Treatment for lactation suppression
Comfortable, supporting bra
Avoidance of nipple stimulation and manipulation
Application of ice packs to the breasts
NSAIDs to reduce inflammation and pain
Management of hypothyroidism during pregnancy
Increase levothyroxine dose 30% at the time pregnancy is detected; adjust every 4 weeks based on TSH and total T4 using pregnancy-specific norms
The increasing need for thyroid hormone replacement is due to increased estrogen which induces increased levels of thyroxine-binding globulin decreasing the available T4/T3.
Management of Erb-Duchenne palsy
Damage to C5, C6, C7; a/w shoulder dystocia
Tx: gentle massage and physical therapy to prevent contractures
Prognosis depends on whether damage resulted from mild nerve stretching or compression as opposed to severe rupture or avulsion
80% of patients have spontaneous recovery within 3 months; surgical intervention can be considered if no improvement by age 3-6 months
Bartholin gland cysts
Soft, mobile, nontender masses located at the base of the labia majora (4 and 8 ‘oclock positions)
Tx: observation (if asymptomatic), I&D followed by Word catheter placement
Management of preterm labor
Preterm labor = regular contractions that cause cervical change < 37 weeks
Management: betamethasone, penicillin if GBS+ or unknown, tocolytics if < 34 weeks, magnesium sulfate if < 32 weeks
Types and causes of decelerations of fetal heart monitor
Early decelerations –> fetal head compression
Variable decelerations –> umbilical cord compression/prolapse, oligohydramnios
Late decerlations –> uteroplacental insufficiency
Treatment of condyloma acuminata
Caused by HPV 6, 11
Chemical: podophyllin resin, trichloroacetic acid
Immunologic: imiquimod
Surgical: cryotherapy, laser therapy, excision
Types of antepartum fetal surveillance
Nonstress test (reactive = > 2 accelerations)
Biophysical profile (normal = 8-10)
Contraction stress test (normal = no late or recurrent variable decelerations)
Doppler sonography of the umbilical artery to assess growth restriction (normal = high-velocity diastolic flow)
Parts of the biophysical profile
Each of the following are graded as normal (2 points) or abnormal (0 points) for a total of 10 points
- Nonstress test (normal = > 2 accelerations)
- amniotic fluid volume (normal = single pocket > 2x1 cm or amniotic fluid index > 5)
- Fetal movements (normal = > 3 general body movements)
- fetal tone (normal > 1 episode of flexion/extension of fetal limbs or spine)
- fetal breathing movements (normal = > 1 breathing episode for > 30 seconds)
Side effect of epidural anesthesia
Hypotension
Anesthesia blocks sympathetic fibers –> decreased vascular tone –> vasodilation and venous pooling –> decreased venous return –> decreased cardiac output
Managment: prevention with IV fluids, positioning patient on left side to increase venous return, IV fluid bolus, vasopressors
Management of Kumpke palsy
damage to C8 and T1; a/w shoulder dystocia; may manifest as ipsilateral Horner syndrome
Tx: gentle massage and physical therapy to prevent contractures
In most cases function returns within a few months; surgical intervention if no improvement by age 3-9 months
