Obstetrics and gynecology Flashcards
How do you assess contraction strength clinically? What is appropriate contractions for active labour
A strong contraction will feel like your forehead (tightness of the abdominal wall). 60-90s duration and q2-3 minutes
What are the 4Ps of labour assessment
Power
Passage
Passenger
Psyche
When do you not want to do oxytocin
If the labour is already strong, you do not want to run the contractions into each other for the fetus to have room for each other
What areas of the pelvis can restrict the birth canal?
Pubic symphysis, ishial spines, curvature of the sacrum
What issues with the passenger can
Impede labour?
Baby with a posterior presentation or LGA
How is oxytocin administered in labour. Post parturition?
IV with a pump. Very small quantities titrated to contractions. Reassess in 3-4hrs. Afterwards it’s a larger dose to prevent PPH
How would you assess adequate cervical dilation
0.5cm/hr
What is the concern with a vaginal delivery of a breech baby
Baby can get stuck with the head in the uterus and the cord is getting compressed in the vagina, as well the arm can get stuck behind the neck
What percent of babies are breech at term? What are your options for delivery?
3%. Wait and see if it turns, external cephalic version, screen for any factors concerning for vaginal birth (not frank presentation, no concern about LGA, pelvis etc).
What complications are associated with vaginal breech birth?
Higher risk of seizure post birth 24hrs. Sometimes the head doesn’t deliver and the baby dies. Sometimes the OB on call isn’t comfortable with vaginal breech birth and will direct to c section
If you have had a previous C section, what is the feasibility of vaginal birth for next pregnancy!
About 2 years after previous c section. If you have c section for failure to progress, then there’s a 60-70% chance for successful svd.
When can you not do a c section
If they’re already fully dilated, with head +2 it’s unsafe
What is a late deceleration. What is the physiology?
Starts after the onset of the contraction and takes more than 30s to reach the nadir, which occurs after the peak of the contraction.
Associated with fetal hypoxia
What is an early decel? What physiology?
Early means <30s to reach the nadir, which coincides with the peak of the contraction.
Physiology associated with vagal tone from the head getting squeezed.
What are the steps you need to induce labour
- Mechanically dilate the cervix (foley or cervedil tampon, monitor NST.
- Have pt return 12-24hrs later and reassess, AROM and then
- start oxytocin (if needed)
When does GBS prophylaxis need to happen? What agent do you use?
Penicillin G q4hrs start 5mil units 2-3hrs before arom or if SROM start as soon as rupture occurs
What are some causes of sudden fetal bradycardia which does not recover
Placental abruption, cord compression or prolapse, epidural side-effect, uterine hypertonia, uterine rupture
What maneuvers can you do to resolve shoulder dystocia
McRoberts maneuver (flex knees and hips back as far as possible), suprapubic pressure, Episiotomy, rotate the baby to make the anterior shoulder the posterior shoulder, reach in and grab the posterior arm and swing it over and across the chest and out), all 4s position. Do NOT pull on the head, apply fundal pressure or panic.
What can you do when there’s a profound fetal bradycardia
Reposition, check maternal vitals, discontinue oxytocin, examine the patient (check prolapse, scalp stimulation, fetal scalp electrode), nitro spray if long contraction, call for help
What are variable decels
Quick descent, U/W pattern - appearance not consistent
What is fetal tachycardia concerning for
Potential infection
What are goals of preconception counselling?
Identify & optimize risk factors. Familiarize with menstrual cycle (stop with contraceptive pill, 3 months pre conception + folic acid).
Why do we ask women trying to conceive to take folic acid? How much?
400 mcg / day, reduces neural tube defects
1mg if family history of neural tube defect or malabsorption, DM, teratogenic meds
4-5 mg if partner or mom or previous child has neural tube defect.
reduces neural tube defects by 70%
How long do you get people to TTC before infertility workup?
1yr if <35, 6 months if >35
What is the antenatal visit schedule?
1st visit 8-12w, q4w until 28, q2w until 36w, weekly after that until delivery
What should you also ask when doing OBHx esp initial visit?
Ask about postpartum complications!
What are some important points to screen for in the initial visit?
Intimate partner violence, eating disorders (due to expected weight gain), anxiety & depression (esp post partum period).
What are some key landmarks for symphisis fundal height?
T20 at umbilicus, T10 at the symphisis,
What are the key screening and diagnostic tests for the first trimester?
CBC, ABO and antibody screen (Rh, and others) Infectious diseases (HbSAg and HIV, and others urine chlamydia and gonorrhea, varicella and parvo (if working with kids), Genetic screening: options are none, enhanced first trimester screen (blood draw + U/S), NIPT ($500)
What are the second trimester screening tests?
Anatomy U/S
GCT (between 24-28 wks)
Tdap vaccine
What are the third trimester tests
Rhogam
GBS swab
Post dates investigation: BPPs (fetal breathing, heart rate, movements, amniotic fluid). Induction recommended by 41+3 (most will be sooner)
What are some important antenatal counselling points?
Weight gain in pregnancy. Exercise 30minx5, Diet (esp if high risk for GDM), medications nothing except tylenol, flu shot,
Birth plan
Someone there to support you, options for pain control…everything else
What timing do you give Celestone? Why do we give it. What is the dose?
Up to 34+6, lung maturation / reduces NEC, 12mg q24hrs 2 doses.
When is it gestational HTN vs chronic
If htn is present before 20 wks then chronic
Describe the classification of perineal tears
1st degree. Skin and mucosa
2nd degree perineal muscles and fascia torn but not sphincter
3rd is sphincter torn
4th is rectal mucosa
What is the definition of postmenopausal bleeding?
Unexpected bleeding 12mos after LMP
What are the causes of postmenopausal bleeding?
Atrophy Estrogen replacement therapy Endo cancer (15-20) Endometrial hyperplasia (5-10) Endometrial Polyp Cervical ectropion (more common in pregnancy, less common in postmenopause)
What are the risk factors for endo cancer?
Individual factors (obesity, high-fat diet, DM/HTN)
Reproductive factors (nulliparity, PCOS, early menarche / late menopause)
Unopposed estrogen replacement (HRT)
Endometrial polyps or hyperplasia
Tamoxifen
Lynch syndrome
Functional ovarian tumors (that make estrogen)
What factors are protective for endometrial cancer?
OCP >5yrs
Mirena IUD
Full-term pregnancy (ie not early term losses)
How does endometrial cancer typically present?
Vaginal bleeding 90% of the time
Pelvic pressure/pain
Purulent discharge (e.g. secondary to cervical stenosis)
Weight loss / back pain
What do you need to do to workup postmenopausal bleeding?
Spec exam / pelvic exam, endometrial biopsy (can do with IUD too), U/S, Pap.
Who needs to get a pap? When do we do them?
age 21-70 q3y
What is abnormal postmenopausal endometrial thickening? What are other concerning findings on U/S
> 5mm abnormal
>11mm, fluid collections, increased doppler flow/vascularity is very concerning
How do you differentiate between the two types of endo cancer?
Type 1 - more common, estrogen dependent, can start from hyperplasia w or w/o atypia, (endometrioid). 75-85% of cancer
Type 2 - less common, typically older age of onset, papillary serous/clear cell, less good prognosis 15-25% of cancer
What other cancers of the uterus are there (other than endometrial carcinoma)
Sarcomas - MMMT / leiomyosarcomas etc.
What is a sonohysterogram?
Uterus filled with fluid transcervically to get better visualization
When do you want to do a D&C+hysteroscopy when working up a pt for endometrial cancer?
If biopsy comes back, but pt is high risk or U/S is very suspicious.
How do you treat endo cancer?
Surgical staging - Hysterectomy and bilateral salpingoophorectomy; must come out in one piece (so as not to spread the cancer). If high stage or high grade, explore abdo/pelvis, biopsy any lesions, lymphadenectomy (pelvic & para-aortic), radical hysterectomy if cervical extension.
What is the staging for endometrial cancer?
Stage 1 uterus/endocervical glands
Stage 2 is cervix
Stage 3 is pelvic extension
Stage 4 is distant spread
How is HTN in pregnancy classified?
Chronic HTN (pre-existing, may have comorbid conditions, may get preeclampsia) Gestational HTN (after 20 wks, with co-morbidities and/or pre-eclampsia)
Preeclampsia: gestational HTN + new proteinuria or 1+ adverse conditions
What are the steps you need to induce labour
- Mechanically dilate the cervix (foley or cervedil tampon, monitor NST. 2. Have pt return 12-24hrs later and reassess, AROM and then start oxytocin.
When does GBS prophylaxis need to happen? What agent do you use?
Penicillin G q4hrs start 5mil U 2-3hrs before arom or if SROM start as soon as rupture occurs
What are some causes of sudden fetal bradycardia which does not recover
Placental abruption, cord compression or prolapse, epidural side-effect, uterine hypertonia, uterine rupture
What maneuvers can you do to resolve shoulder dystocia
Mcroberts maneuver (flex knees and hips back as far as possible), suprapubic pressure, Episiotomy, rotate the baby to make the anterior shoulder the posterior shoulder, reach in and grab the posterior arm and swing it over and across the chest and out), all 4s position. Do NOT pull on the head, apply fundal pressure or panic.
What can you do when there’s a profound fetal Brady
Reposition, check maternal vitals, discontinue oxytocin, examine the patient (check prolapse, scalp stimulation, fetal scalp electrode), nitro spray if long contraction, call for help
What are variable decels
Quick descent, U/W pattern - appearance not consistent
What is the first step to manage antepartum hemorrhage
Stabilize get cross-type and screen, start large-bore IV NS or RL
Once stabilized what do you need to do to find a diagnosis?
Consider meds, past ObHx, how much bleeding, trauma or IPV
Why is the anatomy scan before 20 weeks?
If not compatible with life, then can offer option of abortion
What is the prevalence of low-lying placenta at 20wks? At term?
30%; 1/200
How far from the cervix is the placenta when it is low-lying
2
What advice for placenta previa
Limit physical activity and intercourse, give copy of u/s, FU at 32-34 weeks with u/s with 2 week follow up. Steroids for lung maturation
What is the key contraindication for the vag exam
If you don’t know where the placenta is, don’t do it
What is placenta accreta
Placenta grows into myometrium
Why is placenta previa associated with postpartum hemorrhage?
Because there aren’t as many muscle fibres lower in the uterus to squeeze the placenta
Why is concealed abruption more concerning
Concealed delayed diagnosis with earlier DIC onset
How do you diagnose abruption?
Clinically, fetal hr not reassuring, reduced fetal movements, most commonly bleeding PV
How do you manage abruption
Deliver quickly, AROM (releases pressure), don’t forget Rhogam
Why do you want to rupture membranes in general?
Accelerate labour, monitor status of fluid eg meconium, attach a scalp electrode
What is vasa previa
Associated with vellamentous placenta (umbilical vessels not protected), rare. Presents with bleeding (fetal blood in the vagina), not reassuring fetal tracing
What is concerning about a sinusoïdal FHT
Severe fetal hypoxia
What is the definition of PPH?
Decline by more than 10% in hct or clinical symptoms; more than 500cc vag or 1L c/s
What are the acute and delayed causes of PPH
Acute: most commonly atony of uterus (large, distended, tired), retained placenta, tear, inversion or coag defect.
Delayed also retained products of contraception, coag defect,
What are the 3 Ts of postpartum hemorrhage?
3Ts: tone, trauma/tear, or tissue (placenta or succentriate lobe); r/o coagulopathy (IVF also risk factor for retained product)
When do you give oxytocin during delivery? How do you give it?
After delivering anterior shoulder (but risk of placental entrapment), or after the placenta. IV - 5 units or IM 10, or 20 in a L
How do you manage persistent PPH
Ask for help and stabilization. Recheck 3Ts and massage the uterus. Can give oxytocin, misoprostol PR 400-800mcg (N/V fever), ergot 0.25IM (not if HTN or on antiretrovirals), hemabate 0.25mg IM or intramyometrial (PGF2) (prostaglandin-not for asthma)
TXA
What is minimum acceptable urine output?
30mL/hr
How do you manage a persistent PPH that does not respond to medical management?
Bakri Baloon, interventional radiology, check for uterine rupture (risks include scars in the uterus, trauma, hyper stimulation, grand multi parity) surgical mgmt (D&C, Cho or BLynch stitch or hysterectomy).
Uterine inversion; what are the causes?
Placenta accreta or iatrogenic. Check abdomen? Do you feel the uterus?
How do you manage uterine inversion
First replace the uterus with the placenta intact, then deliver; may need to relax uterus with nitroglycerin
how do you manage prolonged PPH?
Up to 6 weeks pp; check coagulopathy, u/s for delayed or retained products of conception
What is normal menstruation?
Q24-28days, <8 days, <80mL, no clots
What is oligomenorrhea/amenorrhea
Infrequent or no menstruation
What is menorrhagia
Too much bleeding
What is metrorrhagia
Bleeding outside of normal cycle
What must you rule out when people present with abnormal uterine bleeding?
Coagulopathy or early pregnancy
What is the differential for abnormal uterine bleeding
PALM (structural: polyp, adenomyoma, leiomyoma, malignancy), COEIN (non-structural: coagulopathy , ovulatory, endometrial, iatrogenic, not classified)
What are the causes of ovulatory bleeding?
Ovulatory: mid cycle spotting no treatment reqd, corpus lutéal defect (typically >40, also no treatment), menorrhagia (need to treat)
How do you manage menorrhagia?
Progesterone (not ideal), OCP, visanne (progestins), NSAIDs, Tranxemic acid, GnRH agonist
What do you give for emergent heavy bleeding g
IV Premarin (estrogen) + progesterone or OCP, iUD
What are the effects of estrogen and progesterone on the endometrium?
Estrogen is like fertilizer, progesterone is the lawnmower
What are the surgical management of menorrhagia
D&C, endometrial ablation, hysterectomy
What are causes of anovulatory bleeding
Thyroid, prolactin, malignancy, PCOS (do they want to get pregnant
How do you work up anovulatory bleeding
Endometrial biopsy if >40 + risk factors by for hyperplasia, PCOS
What is the postpartum period? What are the major physiologic changes?
6 weeks after delivery, the uterus shrinks in size (at umbilicus after delivery, 1 week midway and 2 weeks unpalpable) and epithelium remodels; The blood vessels shrink etc.
What is abnormal lochia
Gushes of blood, excessive bleeding or bleeding beyond 8 wks
How do you work up abnormal postpartum bleeding?
Beta hCG; u/s
What is delayed PPH
> 24hr to 6 wks post delivery; can be caused by retained products or abnormal placenta involution
What is management of delayed PPH
Misoprostol; surgery if medically refractory
What is the cause of incomplete voiding after pregnancy
Typically due to overfull bladder; treat with intermittent catheterization (or indwelling catheter if needed
Incontinence postpartum. Is it common, when does it typically resolve?
Common up to 3 months.
What is pelvic floor physio? When do you start? What is it used for?
Start 8 weeks post delivery. 3/4 laceration or incontinence. If can’t pay, vagina bible
What are the changes to the abdominal wall after pregnancy?
Diastasis recti, wait 6 weeks post c/s no heavy lifting; If several cm apart at 6 wks recommend avoiding heavy lifting for 6 weeks. Pigmented changes: striae and linea nigra
Who should get VTE prophylaxis?
Previous event or known thrombophilia; anticoagulate throughout pregnancy, previous event then anticoagulant 6 wks ppt. If FH consult hematology
Describe normal postpartum care
Regular diet, analgesia around the clock, rhogam or MMRV, empty bladder within 6-8hrs. skin to skin and breastfeeding (contraception at 6wk visit). Baby blues
How do you manage pain post-partum
Ice pack, sits baths (void in the bathtub), ketorolac iv if 3/4, hemorrhoid care - no suppositories, stimulant laxatives (do not use docusate)
What are red flags for pain
Severe uncontrolled pain, r/I hematoma. If pain initially ok then getting worse check stitches and infection; do not reapproximate/restitch it will come back together.
What is the ddx for fever
Wind, water (UTI), walking (DVT), wound, womb (endometritis) and breast (mastitis)
What counselling would you do around sexual activity?
Wait 4-6 weeks post delivery, can offer IUD or depo provera in hospital. If they have dyspareunia more than 3 months after delivery then work up
when can ovulation occur after giving birth. What is recommended contraception
4-6weeks. Best option is barrier method LNG-IUS. Officially the pill is not supposed to, but anecdotally patients note decreased breast milk supply
How do you diagnose endometritis
Uterus tender on exam, risk factors are prolonged rom, internal fetal monitoring, intrapartum chorio, C/S.
What is the prevalence of mood disorders post-partum
15% of women within 6 MPs of delivery
What is the baby blues?
Normal self-limited 3-4 days onset pp and peaks on day 5, lasts 10 days.
What is postpartum hair loss? When do you get concerned?
Normal, temporary and starts 3months pp lasting 3-9 months. Not related to breastfeeding. R/o hypothyroidism and iron deficiency if >12mos
What is the trigger for milk production pp
Decline in progesterone pp leads to milk production. Estrogen is inhibitory; prolactin needed to keep supply
What is mastitis
Infection of mammary gland
What is galactocele
Blockage of the duct, self-limiting
What is typical bm supply, what do you need to supplement with
600cc day, low iron, need to add Vit D
What are contraindications to bf
Drugs or excessive alcohol, galactosemia, untreated tb or HIV, certain meds, breast cancer treatment
How to judge supply? How can you address it?
Weight gain & wet diapers.
What are the 3 presentations of postpartum thyroiditis
7-8 % of général pop; higher risk if hypothyroid, DM. Screen high risk
What increases risk of ovarian cancer
BRCA1/2 mutations, nulliparity, post-menopausal (age), FH, lynch syndrome, endometriosis (clear cell ovarian cancer)
What decreases risk of ovarian cancer
OCP, tubal ligation, salpingectomy , pregnancy, hysterectomy (due to decrease in tube surface area)
What symptoms of pelvic mass increase suspicion for cancer
bloating, increased abdo diameter, intermittent pelvic pain
Where are most ovarian tumours located?
Posterior to the uterus
What other exams would you perform in addition to the bimanual when you suspect an ovarian malignancy
Abdo exam, chest exam (r/o pleural effusion), breast and rectal exams (more common primaries than ovarian). U/S
What investigations do you order with ovarian mass
U/S abdo and pelvis, tumor markers (beta hCG, CA125 (epithelial), AFP, LDH, CA19.9 (breast), CEA (colon).
What are the characteristics of benign vs malignant masses?
Malignancy: bilateral (due to trans peritoneal spread), cystic and solid areas, ascites, Doppler flow, inclusions / papillae
What can cause a false positive CA125?
Pregnancy, menstruation, endometriosis, cysts, ectopic, fibroid, tubo-ovarian abcess
What is the RMI II
Pre (1) or post menopausal (4) x characteristics of malignancy on u/s: LAMBS (loculations, ascites, metastasis, bilateral, solid components: 0, 1, 2+ = 4) x CA125; if >200 send to gyne onc
What are the different types of ovarian cancer?
Stromal (granulosa tumor, elevated estradiol), Germ cell (other markers), epithelial (CA125 except muncinous)
How does the differential for adnexal mass change with age?
<9 80% malignant, 11-18 50% dermoid, 20-50 90% benign, 50+ 20-30% malignant
Do benign cysts progress to cancer?
no
Why is screening not recommended for ovarian cancer?
No evidence that U/S or CA125 detects cancer early and increases risk of unnecessary surgery
How do you manage a simple / physiologic cyst?
expectant management, unless very large, torting or other reason
What are the components of a staging surgery for ovarian cancer
Lymph node dissection, check peritoneum and abdo organs for mets.
What percentage of ovarian cancers are hereditary?
10%
At what beta hCG would you be able to see an inter uterine pregnancy
1500
At what beta hCG can you confidently say that if you can’t see a viable IU pregnancy, then it’s an ectopic
3000 (TVUS)
What rate of increase of beta hCG is expected in viable pregnancy
Doubling every 72 hrs
What are the key characteristics you look for to determine a pregnancy
A gestational sac and a yolk sac
What are the criteria for using methotrexate to terminate pregnancy
Beta < 5000, Size < 3.5mm, No FHR, stable, no other contraindication to methotrexate (must be reliable, not breastfeeding, blood dyscrasias, PUD, renal/hepatic disease, immunodeficiency, pulmonary dx, etc.). Requires baseline CBC/ lytes, creatinine, liver enzymes and beta (can do 0,4, 7 or weekly until beta down to zero. Must give rhogam if mom is Rh negaaztive.
What are the criteria for PID? What is it?
Pelvic pain + cervical motion tenderness or uterine tenderness or adnexal tenderness. Inflammation of upper female genital tract? Often polymicrobial (bc once bacteria ascend, they disrupt cervical mucus. Not always sexually transmitted GC/Chlamydia.
What is Fitz-Hugh-Curtis
Utero-hepatic adhesions, pathognomonic for PID / chlamydia
<p>What is expectant management for ectopic pregnancy?</p>
<p>If you have a beta <300 and falling then you can follow esp if there is evidence of spontaneous abortion?</p>
What changes occur in preeclampsia?
headache, vision change, CP dyspnea, elevated serum creatinine / uric acid, elevated WBC, INR or aPTT, low platelets, nausea, vomiting RUQ or epigastric pain, elevated AST/ALT/LDH or bilirubin, low albumin, abnormal FHR / IUGR, oligohydramnios, reversed end-diastolic flow.
How much protein is the cutoff for preeclampsia?
300mg / 24hrs (but really, it’s urine albumin:creatinine ratio).
What are the effects of preeclampsia on baby? Why?
IUGR (due to poor placental implantation, leading to vasoactive factor secretion or potentially immunological given incr. risk of preeclampsia for first pregnancy / new partner).
When should you do umbilical artery doppler?
IUGR, if you suspect placental insufficiency
What can cause a false positive EFTS?
poor placentation (low pap-A, high AFP).
What chronic conditions can masquerade as preeclampsia?
SLE (flare) and chronic kidney disease.
What physical exam is relevant for preeclampsia?
Head to toe (super comprehensive for OSCE): vitals - BP (not supine!), FHR, fundoscopy, chest exam, SFH, leopolds, reflexes, clonus.
What’s the normal value for uric acid in pregnancy?
10x gestational age
What investigations should be done for gestational HTN.
CBC + blood smear, AST/ALT, uric acid, creatinine, INR/PT and aPTT, urine ACR. If concerned, can US for IUGR or placental issues.
How do you manage pre-eclampsia?
Weigh harms to mom vs harms to baby. Between 34-36+6, there can be a mild benefit to baby if not severe maternal complications. At 37+wks just deliver (vaginally!), there isn’t a benefit to continuing. Give MgSO4 (prevent eclamptic seizure).
How do you monitor when giving MgSO4
Have calcium gluconate available, make sure she’s peeing, monitor reflexes, breathing.
What are the physiologic changes in pregnancy?
Endocrine (progesterone, estrogen, and relaxin)
Reproductive: Uterus increases in size, cervix (mucus plug), vagina increases in elasticity and changes colour to purple
MSK: center of gravity changes forward, exaggeration of lordosis, pelvic joint loosening.
CV: increased CO, HR, reduced systemic vascular resistance, increase in blood volume (+40-50%)
Respiratory changes: increasing edema in upper resp tract, diaphragm elevates in later pregnancy,
Kidney: sodium retention, increased urination, incontinence, hydronephros
Weight gain, nutrition. GI changes (N/V), reduced lower esophageal tone.
Immunosuppression (RA, MS -> improve in pregnancy).
What are the questions that you need to answer when managing pre-existing conditions in pregnancy”?
What is the effect of the pregnancy on the disorder?
What is the effect of the disorder on the pregnancy, by trimester? On labour? On postpartum?
What are some important things to manage around pre-existing diabetes and pregnancy?
Poor glycemic control = heart defects and neural tube defects (don’t stop meds!). Target A1C ~6. Pre-conception folate.
Need to adjust meds to account for increased insulin resistance.
Macrosomia / poly with poor later glycemic control.
Increased risk of stillbirth (induce earlier). Can give low-dose ASA early.
Hold meds at delivery (because insulin resistance goes down).
What can you give for pre-eclampsia prevention?
daily low-dose aspirin (81mg/day) beginning in the late first trimester for women with a history of early-onset preeclampsia and preterm delivery at less than 34 0/7 weeks of gestation, or for women with more than one prior pregnancy complicated by preeclampsia.
What is adenomyosis?
Invasion of the endometrium into the myometrium.
What are common causes of pelvic pain?
Endometriosis, adenomyosis, chronic pelvic infection, adhesions, degenerating fibroids
What is endometriosis?
Endometrium growing outside uterus, undergoes cyclical bleeding.
What are symptoms of endometriosis?
Pelvic pain often more severe during menses/ovulation, dysmenorrhea, dyspareunia, dyschezia, dysuria, AUB-O infertility.
O/E you may get cervical motion tenderness or uterosacral tenderness.
What is medical therapy for endometriosis?
1st line
OCP -> continuous or cyclic
NSAID -> ibuprofen, advil etc (reduces prostaglandin formation)
2nd line GnRH agonist (Lupron) + low dose estrogen Progenstin (Visanne) Mirena GnRH antagonist (Orlissa)
What are clues to adenomyosis on hx and pe and u/s
Hx of HMB, dysmenorrhea
PE nonspecific findings, bulky or tender nucleus
U/S: inhomogenous myometrium
How do you treat adenomyosis?
Mirena (1st line) NSAIDS OCPs Lupron with addback Hysterectomy
How does the prevalence of endometriosis vs adenomyosis with age
Endometriosis - young women first dx (teens to 30s)
Adenomyosis - 40s.
Dyspareunia - what are the key questions?
Where is the pain? Labia / vulvar (lichen sclerosus or atrophy), vaginal, cervical, “deep” pain? (ovary / uterus)
How do you treat vaginal atrophy?
Vaginal estrogen cream
How do you treat lichen sclerosus?
High-dose local steroid
“Recurrent” UTI could also be caused by what?
Vaginal / vulvar pathology
What issues are there with the formula that predicts gestatioonal size (haddock)
Biometry is based on mostly caucasian babies, so small size may simply be genetic / constitutional.
What is the cutoff on biometry that should prompt further investigation?
< 10th% – want umbilical artery doppler and fetal MCA doppler.
What is the differential for IUGR?
Maternal causes: HTN, pre-gesteational DM, malnutrition, smoking, any chronic condition, CF, HF, lung disease, clotting / coagulopathy, renal
Fetal: Chromosome abnormalities, TORCH infections, any other congenital abnormality, multiple gestation
Placenta: insufficiency, eccentric cord insertion, placenta previa, placenta accreta, infarction.
What investigations can performed if there is concern for IUGR?
TORCH screen
uterine artery doppler 19-23 wks (one shot deal)
Amniocentesis (karyotype)
NIPT
What happens to the spiral arteries in pregnancy?
The media of spiral arteries is replaced by trophoblast cells which reduces resistance and increases blood flow.
What can we do to manage IUGR?
For this pregnancy, consider delivery based on fetal well-being (BPP, dopplers,
Prevention.
Start ASA at 12-16 wks, watch out for preeclampsia
Regular surveillance with weekly ultrasounds, celestone, paeds consult, ?preterm delivery
What are indications for use of ASA low dose in pregnancy?
pre-gestational HTN, obesity, maternal age >40, history of ART, pre-gestational DM, previously complicated surgery etc. 2+ risk factors
How do you interpret umbilical artery doppler?
Pulsatile pattern, look for bloodflow in diastole. Concerning features are absent or reverse end-diastolic flow (concerning for high placental resistance)
How do you interpret MCA doppler?
PI >1.5 (low PI is shunting bloodflow to brain).
What is the cerebro-placental ratio?
CPR = MCA PI / UA PI, if low, it’s an early sign of fetal problems (vs losing points to BPP).
What do we counsel for future pregnancy with IUGR?
Early US with dating, use of EFTS to screen, start ASA at 12-16wks.
What is the order of deterioration of the fetal dopplers?
UA, then MCA, DV, then UV.
What is the most important thing to rule out with FSH/LH?
Ovarian failure. (high FSH/LH).
What is the workup for amenorrhea?
Get diet history / activity (athlete's triad) Contraception / OCP TSH - r/o thyroid Prolactinoma PCOS
What investigations do need to do in the context of PPROM? What risks are there?
U/S for position, UCx, GBS swab, vaginitis screen (gonorrhea/chlamidia); Abruption, chorio, PTL, breech, IUFD, cord/limb prolapse
What do you do for management of PPROM?
Admit for observation, give celestone < 35wks, MagSO4 4g for neuroprotection, 1g/hr until delivery < 34wks.
Can do PenG 5million then 2.5 q4h. Or erythromycin 250mg QID x 10 days.
Do not use tocolytics due to risk of chorio proceeding to
What is the definition of preterm labour? What do you give?
Contractions < 37wks causing cervical change.
Celestone (within 24 hrs - 1wk after 2nd dose). Tocolytics to get transfer of NICU and completion of steroids. Consider abruption / infection as cause?
When is cervical length useful as a predictor of preterm labour?
<27wks US.
What is the difference between IUGR and SGA?
Both <10%ile for gestational age but IUGR due to underlying pathology vs SGA which is constitutional?
What dopplers would you order for surveillance of IUGR?
UA doppler; PI measures resistance, high = bad.
MCA doppler, low resistance = bad (fetus is shunting blood to brain)
What do you get points for in BPP?
Breathing, activity / movement, fluid, tone.
What are the criteria for active labour?
> 5cm, regular contractions
What progression would you expect for cervical dilation in a multip vs primip?
dilation at 1cm/hr for multip or 0.5cm for primip.
What is the differential for first trimester bleeding?
Ectopic pregnancy (until proven otherwise)
Abortuses: threatened, missed, complete, incomplete, inevitable, septic.
Pregnancy of unknown location
Molar pregnancy
What is the management for missed or incomplete AB
expectant, medical (miso) or Surgical (D&C).
What is the chromosomal makeup of a complete or incomplete molar pregnancy?
Complete: is 46 XX or XY
What is the workup for AUB?
CBC, ferritin TSH and swabs
Pelvic U/S +/- sonohysterogram
consider coagulopathy in young woman with heavy menses,
Endo Bx if >40 or <40 and incr. risk of malignancy.
What is the management of AUB?
Expectant management
-iron
Medical
non-hormonal TXA +NSAIDS
Hormonal (depo, mirena IUS, micronor, nexplanon)
Visanne (Dienogest)
Surgical
hysteroscopy +- ablation (in perimenopause)
myomectomy (only to preserve fertility, tends to be morbid) or hysterectomy
UFE uterine artery embolization; don’t use it if want pregnancy, endometrial cancer etc.
What are contraindications to estrogen birth control
Smoking >35, migraine with aura, liver dysfunction, history of DVT/PE (heart valve disease, or known thrombophilia), personal history of breast cancer or CVA, undiagnosed bleeding PV, pregnancy, uncontrolled HTN, end-organ diabetic disease.
What is the difference between stress urinary incontinence, urge incontinence, and overactive bladder?
Stress = leaking with cough, laugh, sneeze, jumping UI = when you need to go, you leak. OAB = urgency + frequency +/- incontinence
What do you want to ask on history for urinary incontinence?
Characterize incontinence (how often, how much, pads) Fluid intake, triggers (alcohol/caffiene), impact on QOL Don't forget neurological symptoms! Cauda equina?
What is the workup for incontinence?
Spec exam, atrophy, prolapse
Cough stress test (not really necessary)
Investigations: urine CX, post-void residual, UA, uroflow or urodynamic study.
What is the management of incontinence
Expectant
-Lifestyle (BMI, fluid intake, trigger avoidance, pelvic physio)
Medical
-Pessary or anticholinergic or mirabegron (if OAB)
-vaginal estrogen (if atrophy)
Surgical
Vag hysterectomy +/- repair
Mesh or laser
What is the differential for pelvic mass?
GI/GU (appendix, diverticulum, malignancy, pelvic kidney, peritoneal cyst)
Ovary
Benign cyst, thecal luteal cyst, Endometrioma, cystadenoma
Malignant: epithelial (CA125!), germ cell in young children (AFP/betaHCG/LDH), Sex cord or stromal (virilizing).
Uterine (fibroid, pregnancy or malignancy)
Tubal (ectopic, TOA, malignancy, hydrosalpinx)
Invasive cervical cancer
What is the workup for pelvic mass
Use TVUS, send for CA-125, MRI if needed.
What are contraindications for SVD?
Placenta or vasa previa, active HSV or untreated HIV, breech or transverse lie. Previous classical or mutiple CS, full thickness myomectomy.
How do you manage a decel?
If early, can be ok.
If late, try bolus fluid, reposition, turn off pit, VE tor rule out cord prolapse
If continues, then deliver
What are the 3 types of fibroids and their associated symptoms
Submucosal -> bleeding.
Intramural (pressure/bulk/hydronephrosis)
Subserosal +/- pedunculated (mass effect, hydronephrosis)
What are the gyne causes of acute pelvic pain
Adnexal torsion, Miscarriage, fibroid degeneration, OHSS, ectopic pregnancy, ruptured / hemorrhagic cyst, PID
What are some non-gyne causes of pelvic pain?
GI: appendicitis (on R), diverticulitis (on L), IBD
GU: UTI, renal colic
What are other criteria which help diagnose PID?
Leukocytosis, inflammatory markers, purulent discharge, WBCs on the wet mount, swab +ve for gonorrhea or chlamydia, fever >38.3
What is definitive diagnostic criteria for PID?
Pyosalpinx or TOA, endometrial biopsy showing endometritis, laparoscopy with purulent exudate & salpingitis.
What do you want to do on exam for PID?
General appearance, vitals, abdo exam (peritonitis), pelvic exam (spec, bimanual + swab).
What is the workup for acute pelvic pain?
betaHCG, Rh (group & screen), CBC, urinalysis, swabs or urine GC/chlamydia, pelvic US / MRI / CT, laparoscopy.
What are the short-term complications of PID?
TOA (pain, protracted illness)
What are the long-term complications of PID
Recurrent PID (20%), increased risk of ectopic pregnancy (+20-50%) and infertility (x5), chronic pelvic pain (30%).
What are the criteria to treat PID as an outpatient?
Stable, no acute abdomen, severe disease, able to tolerate oral meds, reliable, no TOA, not pregnant, no other surgical emergency (need to r/o torsion or appy), not immunocompromised.
How do you treat PID as an outpatient?
Outpatient ceftriaxone 250 IM X1 + doxycycline 100mg PO BID 14 days, +/- metronidazole 500mg PO BID 14 days (if PID due to procedure), F/U in 72 hours.
How do you treat chlamydia cervicitis as an outpatient?
1g azithromycin +doxycycline 100mg PO BID x14 days
How do you treat PID as an inpatient
Ceftriaxone 2g IV Q24hr (d/c 24 hrs of afebrile) plus doxycycline 100mg BID 14 days.
How do you treat TOA?
Start antibiotics, try IR drainage, if not drainable, do laporotomy.
what is the difference between a missed abortion and a complete abortion?
Missed = nonviable fetus, no products passed yet. Complete = no products visible, cervix closed.
What is the management for heavy menstrual bleeding?
Non-hormonal (NSAID / TXA) Hormonal - CHC, Progesterone only depo or oral provera - Lupron UAE Surgery Ablation or hysterectomy
What are the benign ovarian masses
Functional cyst: Follicular cyst, corpus leteal cyst, theca lutein cyst (pregnancy)
Neoplasm: Epithelial (serous or mucinous cystadenoma, endometrioid, brenner), sex chord stromal (fibroma or thecoma), germ cell (teratoma, struma ovarii, carcinoid)
What is the definition of recurrent pregnancy loss? What are the causes?
2+ failed clinical pregnancy. Genetics (balanced translocation or aneuploidy), antiphospholipid antibody or immunologic issue, uterine abnormality eg septum, thyroid disease, coagulopathy
What are the causes of vulvar itching?
Candida vulvovaginitis, lichen sclerosus, dermatitis (contact, atopy)
What are the risks of GDM?
Maternal gest HTN, preeclampsia, macrosomia, premature birth
Increased risk of stillbirth, increased risk of C section
RDS, jaundice, hypoglycemia
4 signs/symptoms of uterine rupture
Pain out of proportion Increased bleeding Shock Shoulder tip pain Cessation of contractions Hematuria
Abnormal FHT, loss of station, palpable abdominal fetal parts.
What are the risk factors for preeclampsia?
Past history (HTN, diabetes, renal disease, past history of preeclampsia or FH, new partner, increased age, obesity, multiples
What risk factors determine GBS prophylaxis when GBS status is unknown?
Premature, PROM, previous history of GBS,
What are the Complications of PPROM?
Preterm labour, fetal neonatal maternal infection, cord prolapse, placental abruption, increased risk of C/S, risk of pulmonary hypoplasia and limb contractures / deformities.
How do you manage a cord prolapse?
Don’t touch the cord
OBS alert - call for help
Reduce pressure on the cord, trendenlenberg or backfill bladder, give tocolytics to buy time.
Emergent C-section
What types of twins are monozygotic, when does the split determine what presentation?
Dichorionic diamniotic split before day 3
Monochorionic diamniotic between days 4-8
Monochorionic monoamniotic from 9-12
Conjoined day 13+
Which antibodies are the most common cause of alloimmunization?
Rhesus (RhD) and Kell (many others are rarer)
Under what situations can women become alloimmunized?
Blood transfusion; feto maternal hemorrhage (e.g. delivery, placental abruption
What are the risks to the fetus if the mom is alloimunized?
Fetal anemia, hydrops (accumulation of fluid in multiple body cavidies), IUFD, jaundice
When do you give RHOgam or RhIG; what is the dose?
within 72hrs of alloimmunization and at 28wks; 300 microgram IM dose = 25 mL fetal-maternal bleed. Only if mom is not alloimmunized.
What is the betke kleihauer test?
Measures fetal HbF in maternal blood.
After an Rh-ve mom delivers do you have to give Rhogam?
Only if the newborn is Rh+ve on coombs test.
How do you evaluate risk for fetal issues from alloimmunization?
Type the father, type the baby via NIPT (and check bilirubin). Monitor through U/S; usually now U/S is mostly what we do (Dopplers, BPP).
How do you calculate an amniotic fluid index
Find AP diameter deepest pocket in each quandrant and add them up, but should be between 5-25 cm. Each pocket should be 2-8cm.
What are the key characteristics of bacterial vaginosis?
Not sexually transmitted, white or grey thin copious discharge, pH >4.5, whiff test, PMN & clue cells. Treat with metronidazole
What are the key characteristics of candidiasis?
Not sexually transmitted, white clumpy discharge with erythema / edema of vagina / vulva. pH <4.5, budding yeast with pseudohyphae on wet mount. Treat with antifungals.
What are the key characteristics of trichomoniasis?
Sexually transmitted - treat partners. Yellow frothy discharge + strawbery cervix. pH >4.5, flagellated protozoa. Treat with metronidazole.
How do you manage erythroblastosis fetalis?
Increased monitoring, serial titres. FBS/Intrauterine transfusion. Time the delivery in an appropriate location with NICU; warn paeds at time of delivery.
What are the physiologic changes in multiples?
Further increase in blood volume, more nutritional demands (Fe/Folate). Increased risk of anemia, Increased uterine size: uropathy, SOB.
What are the common maternal complications in multiples?
Increased risk of GDM, gest HTN, HELLP, preterm labour, and PPROM, increased risk of preeclampsia
Causes for discordant growth? Diagnosis?
IUGR / discordant growth is more than 20% difference. Twin-twin transfusion; constitutional, anomaly, infection, unequal placental
How do you treat TTTS?
laser ablation of the placental anastomoses.
What are the increased fetal risks for twins?
IUGR /discordant growth, monochorionic-diamniotic TTTSor TAPS; monochorionic/monoamniotic: conjoinment or cord entanglement. Co-twin demise, placenta previa, malpresentation & cord prolapse, preterm delivery (57% twins, triplet births >90%). Risk of CP and increased risk of death by 1 yr.
What is genetic screening for twins?
Can do eFTS and NIPT, higher order multiples will be NT and maternal age only.
What is management for twins?
Weekly visits in T3, increase surveilance, serial u/s. No restrictions or cerclage, bed-rest off work etc. Consider early delivery / induction esp. if complications <37wks twins, < 35 wks for triplets.
How do you deliver twins?
If vertex-vertex with no complications or vertex-breech with no major size discordance. Otherwise C/S if twin A is non-cephalic.
Need appropriate level NICU, 2 lg bore IV, continuous EFM, early epidural strongly recommended. U/S available for fetal position. Sufficient and experienced personnel, delivery in OR with double-set up if C/S needed. Very active management of PPH.
What are the risk factors for cervical neoplasia?
HPV infection !!!
Things that make it more likely: early sexual activity, multiple partners, not using barrier contraception, history of STI, lack of immunization or immunocompromise, lack of access to screening.
What are the different things that can come back on PAP
Satisfactory or unsatisfactory cytologic sample
Epithelial abnormality or no abnormality
If the former, then either ASC-H or HSIL
any visible abnormality or malignancy
LSIL or ASCUS conservative followup
What are the management options for cervical dysplasia
Ablation /LEEP if no concern about spread
Trachalectomy or radical hysterectomy for 1B, any spread and there should be chemoradiation
