Stuff to memorize/enumerate

Question 1

In Breech delivery, what are the 3 types of vaginal delivery? expound.

What are the maneuvers for delivery of breech?

What is external cephalic version?

What is internal podalic version?

3 types of CS incisions?

indications for CS?

Answer 1

1. Spontaneous breech delivery - dont hold anything
2. Partial breech extraction - upto umbilicus
   - episiotomy is done, mediolateral is preferred.
   - posterior hip, anterior hip then external rotation to sacrum anterior
   - do the maneuvers
3. complete breech extraction - all the body is assisted
   - hand introduced through vagina and both fetal feet are grasped
   - ankles are held with the middle finger inbetween
   - feet are brought through the introitus, continue maneuvers for baby dedlivery
4. Pinards maneuver -> to deliver the legs, finger parallel to femur, abduct thigh, pressure popliteal fossa and grasp feet to deliver leg
   - grab ASIS and sacrum then gentle downward traction to deliver body
   - rotate body to bring shoulder to view
5. Loveset maneuver -> arm fingers are allinged to humerus, continue traction, then rotate body 180 degrees into position for delivery,
   - sweep arm so posterior shoulder slides , by depressing body, anterior shoulder emoerges along with arm
6. Mauriceu smellie veit maneuver -> index and middle finger on maxilla to flex head
   - > two other fingers are hooked over fetal neck and grasp the shoulders
   - > downward traction with gentle suprapubic pressure
7. external podallic version is the attempt to rotate baby back in women greater than 37 weeks AOG
8. Internal podalic version is when the baby is on transverse or oblique lie to deliver the baby via breech extraction
9. Classical - vertical, from below umbilicus to slightly above lower uterine segment?
10. Lower segment CS (Kronig incision) -> vertical cut through lower uterine segment
11. Kerr incision -> transverse cut through pubic area through lower uterine segment
12. fetopelvic disproportion, footling breech, non reassuring fetal heart rate, unstable, failure to progress through labormother

Question 2

NSD + CTG

Determine the fetal lie and positions via Leopold’s maneuver

Describe what your will find for the baby (saan best heard ung FHT?)

How do you confirm rupture of membranes?

When fully dilated what stage of labor?

What is the purpose of episiotomy?

What are the three decelerations and what causes them, what is the management

Answer 2

1. you know this
2. baby best heard on fetal back on upper shoulder
3. alkaline test, ferning, pooling on posterior fornix, feeling hair of baby
4. 10cm dilated, stage ++
5. widen diameter of introitus
6. early late variable, early is physiological, late is due to uteroplacental insufficiency, variable due to nuchal cord
   - treatment of early is just NSD, treatment of uteroplacental insufficiency may be administration of oxygen, lie down left lateral knee to chest to relieve inferior vena cava by uterus

Question 3

AVD

For forceps (enumeration)

1. Indication (10)
2. Prerequisites (6 or 7)
3. 1 types of forceps delivery (3) and explain
4. (Complications (2 maternal 2 fetal)
5. Anesthesia

additional - when to never use forceps? (3)

Answer 3

for additional: unengaged head, head position is not known, never apply forceps unless cervix is fully dilated

Fetal indications
1. nonreassuring fetal heart rate
2.premature placental separation
2.1 frfagile fetal head
Maternal
3. maternal heart disease
4. pulmonary injury or compromise
5. intrapartum infection
6. neurological conditions
7. exhaustion
8. prolonged stage of labor
9. Station should be low or outlet station

Types of forceps delivery

1. mid, low, outlet
   - mid is 0-+2, low is >2+ but not at the pelvic floor, head rotated 45 degrees, outlet is scalp visible at introitus and fetal skull reached pelvic floor, rotation does not exceed 45 degrees

Prerequisites

1. experienced operator
2. engaged head
3. ruptured membranes
4. vertex presentation
5. completely dilated cervix
6. precisely assessed fetal head position
7. cephalopelvic disproportion not suspected
8. fetal coagulopathy or bone mineralization disorder
9. fetus at least 34 weeks AOG
10. empty bladder

Maternal complication
1, Laceration
2. Pelvic floor disorder-urinary incontinence, pelvic floor prolapse
Fetal complications
1. Acute perinatal injuries -> cephalohematoma, subgaleal hematoma, retinal hemorrhage
2. facial nerve injury

Anesthesia -> epidural anesthesia or pudendal block

Question 4

GDM

1. Diagnosis and basis (6)
2. Maternal and fetal effects
3. Diagnostic tests and values (answered in the first one)
4. Antepartum and postpartum management
5. CS/Vaginal delivery? (write why)

Answer 4

1. Historical and pregnancy risk factors - obesity, history type 2 DM, history of GDM
2. Urinalysis -> check for glucosuria
3. FBS/RBS/HbA1c - FBS >=92
4. 50/100/75 OGTT
   - 50 -> no need fasting, measured after 1 hour, if result is 130-140 proceed to 100
   - 100 -> fasting 8-14 hours -> take blood sample 1 hour and 2 hour - 1 hour >=190, 2 hour >= 165
   - for 75 -> 1 hour is 180, 2 hour is 140, fasting is 92

Maternal complications:

1. preeclampsia,
2. coronary heart disease
3. difficult delivery due to macro fetus
4. diabetic ketoacidosis
5. infection
6. diabetic neuropathy, nephropathy, retinopathy

Fetal complications

1. Macrosomia
2. Abortion
3. preterm
4. polyhydramnios
5. congenital malformations

Antepartum management

1. Nutritional therapy
2. Blood glucose monitoring
3. Pharmacological management (first line is insulin -> NPH)
4. fetal movement counting

Intrapartum

1. Individualized depending on glucose control
2. Induction of labor at 39 weeks in patients requiring insulin (0.7 units/kg/.day)
3. if well controlled, no more than 40 weeks of expectant management
4. if with maternal or fetal indications deliver before 39 weeks

GDM itself is not an indication of CS, only do so if you find a basis

Question 5

Vacuum

Question 6

Gonorrhea + chlamydia

1. Basis, risk factors
2. Diagnostics
3. management
4. Prevent recurrence
5. maternal effects
6. fetal effects

Answer 6

1. based on case
2. naat, GS, Culture, KOH, etc, DFA, EIA
3. Ceftriaxone 250mg IM SD, or Azithromycin 1g SD for NG
4. 1 for Chlamydia, Azithromycin 1g PO single dose OR Doxy 100mg 7 days BID
5. Partners should both be treated. refer all sexuial partners for last 60 days, avoid sexual intercourse until resolution of symptoms. If unsure of treatment, antibiotic is an option
6. Maternal effects -> preterm and chorioamnionitis
7. Fetal effefcts -> conjunctivitis, low birth weight, small for gestational age

Question 7

Endometriosis and Adenomyosis

1. diagnosis and basis
2. Differentials
3. Management (medical or surgical)

Answer 7

1. endometriosis and adenomyosis
   basis (based on case)
2. for endometriosis, anything that causes pelvic pain and bleeding and dysmenorrhea. Diagnose via MRI, ultrasound, or (definitive) laparoscopic visualization
3. for adenomyosis, can be leiomyoma or ovarian new growths. most significant risk factor is multiparity. corpus enlarged to 14 weeks, symmetrically enlarged uterus, HMB. Diagnose through TVS and MRI
4. For endometriosis, first look at goals, so relief of pain -> nsaids, promotion of fertility -> gnrh, long term goal is prevention of recurrence
   - Danazol, GnRH agonists, OCPs, NSAIDS for pain. PROGESTIN for olderwoman who has completed childbearing
   - For surgical, do laparoscopic surgery -> TAHBSO for advanced diseases or normal resection for symptom relief
5. For adenomyosis there is no suitable medical management and the only definitive treatment is hysterectomy

Question 8

HPV

1. Diagnosis
2. Differential diagnosis
3. Workups
4. Management
5. Route of delivery if genital warts are present

Answer 8

1. Pap smear, clinical presentation, HPV DNA test
2. condyloma acuminata, squamous papolloma
3. check for cancer, VILI, VIA, etc
4. immunological (vaccine) surgical, chemical, cautery
5. vaginal

Question 9

PCOS

1. Diagnosis and basis
2. Rotterdam criteria
3. Other causes of hyperandrogenism
4. Goals of management
5. Management

Answer 9

1. Based on the case (in short, hirsutism, amenorrhea, obesity, enlarged polycystic ovaries)
   - Anovulation
   - Irregularities of mentruation
   - Hyperandrogenism
   - NO OTHER ENZYMATIC DISORDERS (cushings, tumors)
2. Rotterdam criteria 2 out of 3
   - Hyperandrogenism T >70, androstindione > 245, acne, hirsutism, AN
   - Mentrual irregularity (anovulation or oligoovulation)
   - Polycistic ovaries (>12 follicles in each ovary)
3. Nonspecific - iatrogenic, exogenous
4. Pregnancy - androgen excess in pregnancy
5. Periphery - idiopathic
6. Ovary - PCOS, ovarian tumors
7. Adrenals - Adrenal tumors, cushing syndrome, adrenal hyperplasia
8. Goals of management -> induce ovulation, reduce body weight, reduce androgen levels
9. For ovulation induction: clomiphine citrate as mainstay with or without metformin
10. For androgen control -> anti androgens like spironolactone, finasteride. OCPs alone as first line treatment IF woman does not desire pregnancy
11. Diet and excercise for weight loss

Question 10

Cervical CA

1. Diagnosis
2. Risk factors
3. Most common type
4. Screening test
5. Will you do papsmear?
6. Treatment

Answer 10

1. Diagnosis and basis should be based on case, but here are possible manifestations
   - Vaginal bleeding postcoital
   - intermenstrual bleeding
   - Dyspareunia
   - pelvic pain

MEMORIZE risk factors

1. immunocompromised state
2. Genetics
3. Iatrogenic
4. Early coitarche
5. Multiple partners (6)
6. HPV
7. History of STI
8. History of vulvovaginal dysplasia
9. OCP use
10. Smoking
11. Squamous cell is most common

Screening test

1. Pap smear
2. Colposcopy guided biopsy
3. Lugols iodine (VILI)
4. Visualization thru acetic acid (VIA)
5. HPV DNA testing or co testing or reflex testing
6. no need to papsmear cause its already evident

Treatment

1. concurrent chemoradioation with CISPLATIN
2. can do radiotherapy alone if cannot tolerate chemo (internal or external beam radiation)
3. Surgical via cone biopsy or radical trachelectomy
4. follow up every week during chemo, 2 weeks after chemo, 3 months for 1st 2 years, 6 months 3rd to 5th year, annually thereafter

Question 11

Ovarian new growth Dermoid cyst

1. Diagnosis and basis
2. Causes of on and off right lower quadrant pain
3. Diagnostics
4. Interpret UTZ finding
5. Management
6. Interpret laparoscopic finding (possible other ovarian growths) give management (2)

Sali mo na ung mga ibang ovarian lesions

Sex cord stromal tumors:

Answer 11

1. ddx: serous cystadenoma, adenofibroma, cystadenofibroma, mucinous cystadenoma, benign cystic teratoma.
   - basis could be because there is associated throtoxicosis, carcinoid syndrome, and autoimmune hemolytic anemia
2. Ovarian torsion, ectopic pregnancy, ovarian neoplasms, appendicitis
3. UTZ, exploratory laparoscopy, MRI, palpation -> Kustner’s sign
4. depends on case
5. Laparotomy or laparoscopy
6. Fibroma -> meigs syndrome ovarian fibroma, ascites, hydrothorax, abdominal enlargement -> TAHBSO

Question 12

Antepartum and intrapartum management notes

Question 13

Ovarian cancers

Symptoms?
Risk factors?
Diagnostics?
Treatment?
Indications for surgery

Answer 13

1. initially asymptomatic
2. low abdominal discomfort
3. abdominal pain
4. Dyspareunia
5. Abdominal enlargement
6. Frequent urination
7. Constipation
8. Obesity
9. OCP use
10. Old age
11. TVZ
12. CA-125

Treatment
1. chemotherapy