Obstetrics and Gynecology Flashcards
List the risk factors for gestational diabetes
- History of gestational diabetes or macrosomic infant
- History of impaired glucose tolerance or impaired fasting glucose
- Family history of diabetes mellitus
- Current fetal macrosomia or polyhydramnios
- Age >=35
- Aboriginal, Hispanic, South Asian, Asian, African
- BMI >=30
- Low HDL or high triglyceride
- PCOS, acanthosis nigricans, metabolic syndrome
- Essential hypertension or pregnancy related hypertension
- Corticosteroid use
- Multiple gestations
- Glycosuria
Discuss screening for gestational diabetes
All Women between 24-28 weeks with 50g glucose challenge test
- <7.8 then normal
- 7.8-11.0 require 75mg OGTT measuring fasting, 1h and 2h
- FPG >5.3 or 1h>10.6 or 2h>9 then gestational diabetes - > 11.1 then gestational diabetes
Discuss the management of gestational diabetes
Management
- referral to high-risk pregnancy
- First line is through diet and exercise
- initiate insulin if after 2 weeks still not on target
- FPG <5.3
- 1h PG <7.8
- 2h PG <6.7
Follow up
- Stop insulin and diet postpartum
- Follow up with 75g OGTT between 6 week to 6 month postpartum
Discuss the eligibility, population and screening method for average and high risk breast cancer
- average risk Eligibility - no acute breast symptoms - no personal history of breast cancer - no current breast implants - no screening mammogram within last 11 months Population - Women 50-74 Method - Mammogram every 2 years
- high risk Eligibility - No acute breast symptoms - high risk criteria Population - Women 30-69 Method - Mammogram and breast MRI every 2 years - ultrasound if cannot do MRI
Discuss the High Risk Criteria for breast cancer screening
- Known carriers of deleterious gene mutation BRCA1/BRCA2)
- First degree relative of mutation carrier and decline genetic testing
- determined to be at >=25% lifetime risk by IBIS or BOADICEA risk assessment tool
- Received chest radiation before age 30 and at least 8 years previously
Discuss cervical cancer screening
- begin at age 21 if sexually active otherwise postpone until initiation of sexual activity
- q3 years unless results are concerning
- stop at age 70 if last 3 paps in last 10 years have been normal
Discuss the components, mechanism and use of oral contraceptive pill
Component
- low dose estrogen and progestin
Mechanism
- inhibit ovulation
- change cervical mucus
- cause pseudodecidualization of endometrium to inhibit implantatation
- inhibit tubal peristalsis to prevent fertilization
Use
- start at either 1st Sunday after menses, day 1 of month or immediately
- takes 7 days before it can work
- 21/7 method where hormone free days allow for menstruation
List the contraindications to OCP
smoker and over age of 35
- <6 weeks post partum if breastfeeding
- history of VTE
- current breast cancer
- uncontrolled hypertension
- ischemic heart disease
- complicated valvular disease
- history of stroke
- migraine headache with aura or over 35 with migraine
- severe diabetes or cirrhosis
- SLE and APLA
- thrombophilia
List the benefits of OCP
Short Term
- regulation of menstrual cycle and decreased bleeding
- decreased dysmenorrhea, acne or premenstrual syndrome
Long Term
- decrease risk of endometrial, ovarian, and colorectal cancer
- decrease risk of benign breast disease
Other
- decrease risk of PID and ectopic pregnancy
- decrease risk of ovarian cyst
- improve endometriosis
Discuss the contraceptive patch and vaginal ring
- same as oral contraceptive where use for 3 weeks with 1 free week
Discuss the benefits of the progestin only pill
Mechanism - need to take pill everyday at same time and it increases cervical mucous - still have regular menstruation Indication - breastfeeding women or those with previous VTE Adverse Effects - irregular bleeding - worsening mood
Discuss the benefits of injectable progestin DMPA
Mechanism - inhibit ovulation - thicken cervical mucous - pseudodecidualization Use - injection every 3 months where have 2 week interval at mark where still effective Contraindication - known or suspected pregnancy - unexplained vaginal bleeding - current breast cancer Adverse Effect - 50% develop amenorrhea after 1 year and 75% after 2 years - weight gain due to increase appetite - decreased bone densit - delay to fertility: require 9 months after to return Benefit - treat menorrhagia, dysmenorrhea and endometriosis - treat menses related symptoms - decrease risk of endometrial and cervical cancer - decrease seizure
List the contraindications to an intra-uterine device
Contraindications - known pregnancy - puerperal sepsis - immediate post septic abortion - current PID or STI - cervical or endometrial cancer - current breast cancer - unexplained vaginal bleeding - distorted uterine cavity - malignant trophoblastic disease Adverse Effects - unscheduled vaginal bleeding - pain or dysmenorrhea - uterine perforation - infection - expulsion - failure where have increased risk of ectopic
Discuss the benefit of copper IUD
Mechanism
- foreign body reaction that lead to endometrial change that adversely affect sperm transport and inhibit sperm motility directly
- best used for emergency contraception 7 days post
Discuss the benefit of a mirena (LNG-IUS) IUD
- contain progesterone
- last up to 5 years
Mechanism - thicken cervical mucous
- suppress endometrial estrogen and progestin receptor
- inhibit ovulation
- inhibit implantation
- induce endometrial changes
Discuss the use of Plan B/Norvelo
- progesterone only Mechanism - inhibit ovulation - change endometrium to prevent implantation - disrupt luteal phase - effect on tubal transport - does not disrupt established pregnancy
Discuss the frequency of antenatal visits
- 1st visit between 8-10 weeks gestation
- Every 4 weeks for first 28 weeks
- Every 2-3 weeks from week 28-36
- Weekly after 36 until delivery
Discuss Screening on initial antenal visit
Complete Ontario Perinatal Records 1 and 2 Initiate antenal bloodwork - CBC - Type and Scren - VDRL - Hepatitis B - Rubella - HIV - PAP (if none in previous 3 years) - Chlamydia/Gonorrhea - Urine Culture and Dip Initiate prenatal vitamines
Discuss Screening tests between 11-14 weeks gestation
Enhanced First Trimester Screen done 11-13+6 weeks
- ultrasound to measure nuchal translucency
- pregnancy associated plasma protein
- free bHCG
- AFP
Non-Invasive Prenatal Testing
- blood test for cell free DNA at 9-10 weeks gestation and onward
- screen for trisomy 13, 18, 21 and triploidy
Chorionic Villous Sampling
- 10-12 weeks
Fetal Heat Rate
- 12 weeks
Discuss screening tests between 15-22 weeks gestation
Maternal Serum Screen - 15-20 weeks Amniocentesis - 15-22 weeks Ultrasound for Fetal Morphology - 18-20 weeks Symphysial Fundal Height - 20+ weeks
Discuss screening tests done between 22-28 weeks Gestation
Gestational Diabetes
- 24-28 Weeks
WinRho Injection for Rh- Patients
- 28 weeks
Discuss screening and management done between 28-Delivery
Ultrasound for Fetal Growth - 32-34 weeks Group B Strep - 35-37 Weeks Fetal Lie by Palpation - 35-37 weeks Ultrasound for Fetal Growth and BPP - 40+ weeks
Discuss the follow up screening for cervical cancer
ASCUS - Women <30 or no HPV Testing - Repeat cytology in 6 month - negative repeat cytology in 6 month - if ever positive for ASCUS or worse then Colposcopy ASC-H - Colposcopy AGUS/Atypical endocervical/endometrial cells - Colposcopy - possible endometrial sampling LSIL - colposcopy or - repeat cytology in 6 month (same as women <30) HSIL Or Squamous Cell Carcinoma - colposcopy
