ObsGyn OSCE Notes

Obstetrics Gynecology OSCE Pack

Nick Graham Nic Todd Vania Lim Zak Peters Jill Coolen

Table of Contents

Standard History and Physical Template

Gestational Hypertension Abnormal Uterine Bleeding

First Trimester Bleeding and Abortions Antepartum Bleeding

Infertility Prenatal Care

High Risk Pregnancy Ectopic Malpresentation Shoulder Dystocia Fetal Monitoring Diagnosis of Labour Pelvic Examination Violence Against Women Urinary Incontinence Menopause

Small for Dates Large for Dates Prematurity Birth Control

Abnormal Pap Smear Post Partum Complications Amenorrhea

Pelvic Mass Pelvic Pain STIs

Vaginal Discharge

Standard ObsGyn History and Physical

History:

• ID: age, GTPAL, gest age, CC • HPI:

• 4 cardinal questions: CTX, PVB, LOF, FM • current pregnancy: • EDC, LMP • bloodtype • GBS/HepB/HIV • GDM/HTN/infs/fevers/rashes • prenatal care • fetal U/S • PGyneHx:

• menses: LNMP, freq/duration/flow, pain, intermenstrual bleeds, postcoital bleeds, menarche

• sexual: # partners, M/F, types, contraception, STIs • paps: frequency, last date, abnormal results

• procedures: cone biopsy, gyne surgeries • PObsHx:

• births: year, delivery type, gest age, sex, BW, hours in labour • abortions: year, abortion type, gest age, procedures

• PMHx:

• PSHx: C/S, gyne surgeries • All:

• Meds: drugs, PNV, OCP • FHx:

• SHx: smoking, EtOH, drugs, occupation, partner relations

Physical: • appearance: • vitals: HR, BP, RR, Sats, T • FHR: • CVS: • resp:

• GI: BS, tendernes, Leopold, SFH, contractions, scars, # fetuses

• GU: Presentation, Position, Place (station), Pelvis (size), Puncture (ROM), cervical placement/texture/dilation

• MSK: rashes

Gestational Hypertension

Background:

• Definition:

• diastolic HTN which develops after 20 weeks gestation • Etiology:

• imbalance of vasoconstrictors and vasodilators(+ arteriolar constriction, capillary damage, protein extravasation and hemorrhage)

• Risk Factors:

• maternal: primagravida, new partner, PMHx, FHx, DM, HTN, renal insuff, thrombophilias, extremes of age (<18 or >35), vascular/connective tissue disease, African

• fetal: IUGR, oligohydramnios, GTN, multiple gest, fetal hydrops • Classification:

• essential • secondary

• B. Gestational Hypertension

• 1. Without proteinuria(24hr urine protein < 0.3g/d)

• Without adverse conditions • With adverse conditions

• 2. With proteinuria(24hr urine protein > 0.3g/d)

• Without adverse conditions

• With adverse conditions (24hr urine protein > 3.0g/d)

• C. Pre-existing hypertension and superimposed gestational hypertension with proteinuria

• D. Unclassifiable antenatally

• Adverse Conditions: SBP>160, DBP>110, proteinuria >5g/24hr, HELLP, oliguria (<500ml/24hr), CNS Sx, pulmonary edema, epigastric pain/tenderness, fetal growth restriction

• Complications:

• meternal: hemorrhagic stroke, seizure, DIC, HELLP, left ventricular failure, liver dysfunction, renal dysfunction, abruption

• fetal: placental insufficiency(fetal loss, IUGR, prematurity, abruptio placentae)

History:

• ID: • HPI:

• onset of BP (>20wks), baseline BP

• S/S: HA, visual changes, epigastric/RUQ pain, SOB, CP, decreased urine output, wt gain, edema, N/V

• 4 cardinal questions(placental insufficiency)

• pregnancy complications • U/S findings

• PGyneHx: STIs, abN paps

• PObsHx: previous pregnancies (most common in first)

• PMHx: HTN, renal disease • PSHx: • All: • Meds: • FHx: • SHx: Physical: • appearance:

• vitals: BP 140/90 -> do bloodwork, 160/105 -> worrisome • FHR:

• H+N: fundoscopy(papilledema)

• CVS: decreased heart sounds, S4 (pericardial edema)

• resp: crackles(pulmonary edema)

• GI: epigastric/RUQ pain, SFH (IUGR)

• GU: • MSK:

Investigations:

• bloodwork

• CBC (thrombocytopenia of HELLP)

• Cr, urea, urate(renal insufficiency)

• AST, ALT (elevated in HELLP)

• LD, peripheral smear(hemolysis of HELLP)

• PT, PTT, d-dimer, fibrinogen(DIC)

• type and screen • urine

• U/A(proteinuria)

• 24hr collection(proteinuria = >0.3g/d)

• fetal monitoring

• BPP w cord dopplers & EFW

Management:

• Gestational hypertension without adverse conditions: • bedrest

• monitor

• fetal surveillance

• Gestational hypertension with adverse conditions: • stabilize and deliver

• maternal monitoring: neurovitals q1h, U/O q1h, U/A q12h • fetal monitoring: continuous

• anticonvulsant therapy:

• MgSO4 4g IV bolus over 20 min, then IV 2g/hr • Antidote: Calcium gluconate

• antihypertensive therapy:

• acute: Adalat, Labetalol, Hydralazine (maintain BP at 140/90) • chronic: Methyldopa, Labetalol, Adalat

Orders:

• Admit to Obstetrics under Dr Nick • Diet: NPO

• Activity: bedrest • Neurovitals q1h

• continuous external fetal monitoring • IV NS @ 150cc/hr

• insert foley catheter; foley to urometer • ins/outs q1h

• urinalysis q12h • NST qd

• BPP w cord dopplers and EFW tomorrow • CBC, lytes, BUN, Cr

• AST, ALT, LDH

• PT, PTT, d-dimer, fibrinogen • type and screen

• MgSO4 4g IV push then 2g IV q1H

• Hydralazine 5mg IV push over 5 minutes q15min until BP <140/90; repeat 6 hrs later if BP > 140/90

Abnormal Uterine Bleeding

Background:

• Etiology: peri- and post-menopausal bleeding • Gyne causes:

• endometrial ca(until proven otherwise)

• anovulatory bleeding • atrophic vaginitis • lichen sclerosis

• ovarian, cervical, vaginal or vulvar neoplasm • fibroid, adenomyosis

• endometrial hypertrophy or atrophy

• infection (PID, vaginitis, cervicitis, endometritis) • trauma

• Non-gyne causes: • thyroid

• chronic liver disease • coagulation disorders • leukemia

• hypersplenism • renal disease

• adrenal insufficiency or excess • rectal or urethral bleeding • drugs

• metastatic cancer • Etiology: reproductive age bleeding

• Gyne causes: • normal menses • pregnancy • contraceptive complications • infection • PCOS • fibroid, adenomyosis

• endometrial hypertrophy or atrophy

• cerivcal, vaginal, vulvar, endometrial, or ovarian neoplasm • trauma

• Non-gyne causes: • thyroid

• chronic liver disease • obesity

• coagulation disorders • leukemia

• hypersplenism • renal disease

• adrenal insufficiency or excess • rectal or urethral bleeding • drugs

• metastatic cancer

• ID: age, GTPAL

• HPI (current GyneHx): • menorrhagia

• menses (freq, duration, flow)

• intermenstrual or postcoital bleeding • dysmenorrhea • pelvic pain • PGyneHx: • menses • STIs • AbN paps

• PObsHx: past pregnancies • PMHx: • PSHx: • All: • Meds: • FHx: • SHx: Physical: • appearance: • vitals: • FHR: • H+N: • CVS: • resp: • GI: • GU:

• speculum exam for cytology, swabs • bimanual

• MSK: • Neuro:

Management:

• Stabilize: ABCs; give crystalloids; ins/outs; insert foley; type and crossmatch if severe

• Investigations: • bloodwork

• CBC ± ferritin

• +/- type and crossmatch • BhCG

• TSH

• hormones (FSH, progesterone, PRL, androgens) • coagulation profile

• liver panel

• assessment of endometrium

• indications: age>40 or RFs for endometrial ca (nulliparity, obesity, PCOS, FHx, tamoxifen)

• office endometrial biopsy; hysteroscopic sampling; D&C • assessment of Cervix

• cervical cultures; pap smear • pelvic U/S

• Treatment: • Medical • NSAIDs • antifibrinolytics • danazol • progestins • combined OCP

• progestin intrauterine system (Mirena) • GnRH agonists

• Surigcal • D&C

• endometrial ablation • hysterectomy

• uterine artery embolization

First Trimester Bleeding and Abortions

Background:

• DDx of First Trimester Bleeding:

• Abortion - threatened, inevitable, complete, incomplete, missed • Abnormal pregnancy - ectopic, molar

• Post-coital trauma

• Genital lesion - cerical polyp, neoplasm

• Physiologic bleeding due to placental development(most common)

• Etiology of First Trimester Spontaneous Abortions • Vascular

• Infection - UTI, hepatitis, pneumonia, malaria • Trauma

• Anatomic - bicornuate uterus, leiomyoma, synechiae from D&C, cervical incompetence

• Metabolic - inadequate progesterone secretion by corpus luteum • Inflammatory/Immune - antiphospholipid Ab

• Neoplasm

• Congenital - chromosomal

• Other - drugs (teratogens, anesthetics, other drugs), systemic disease • Types of abortions:

Type Description

Treatened bleeding +/- cramping Cx closed no tissue passed U/S; void physical activity/_{intercourse if no FHR: allow to spont. pass vs D&C} Inevitable bleeding + cramping Cx open no tissue passed D&C +/- oxytocin

Incomplete bleeding + cramping Cx open tissue passed D&C +/- oxytocin

Complete no more bleeding Cx closed uterine cavity empty U/S D&C if retained_fragments Missed baby retained but dead Cx closed U/S D&C monitor for DIC if >12wks Septic resuscitate patient amp+gent or clinda D&C +/- oxytocin

Recurrent three or more consecutive losses investigations: karyotype, assess_{structural abnormalities, assess autoantibodies} Therapeutic complications: uterine perforation, hemorrhage,cervical laceration, infection, risk of sterility,

Asherman's syndrome

History:

• ID: • HPI:

• describe bleed: onset, amount, pain/cramping, color, passage of tissue • 4 cardinal questions • Hx of current pregnancy: • EDC • prior bleeds • U/S results • PGyneHx:

• currently sexually active? • PObsHx: • PMHx: • PSHx: • All: • Meds: • FHx: • SHx: Physical: • appearance: pallor

• vitals: hypotensive, tachycardic • FHR: • H+N: • CVS: • resp: • GI: • GU: • external genitalia

• speculum: cytology, cultures, assess Cx dilation • bimanual: uterine tenderness, adnexal tenderness • rectovaginal exam

• rectal exam • MSK:

• Neuro:

Management:

• Stabilize: ABCs, IVFs, ins/outs, foley, type and screen, Rh status • Investigations:

• CBC/d • BhCG

• pelvic U/S

• Treatment: +/- D&C +/- oxytocin

Antepartum Bleeding

Background:

• Definition:

• vaginal bleeding @ >20wks GA

• NO PELVIC/RECTAL until previa ruled out • ABC's first • DDx: • Vasa previa • Placenta previa • Abruptio placenta • Uterine rupture • Bloody show

• Cervical (cervicitis, polyp, cancer) • Vaginal (post-coital)

• Non-gyne (hematuria, BRBPR) • Abruptio Placenta

• classification: concealed vs apparent

• presentation: pain with bleeding, pain is sudden/constant, localized to back and uterus

• RFs:

• HTN

• previous abruption

• large uterus (macrosomia, polyhydramnios, multiple gest) • EtOH, smoking, cocaine

• uterine anomaly • trauma

• multiparity • management:

• maternal stabilization

• if mild and term: expectant delivery

• if mild and prem: observe mom and fetus; deliver • if moderate/severe: vaginal delivery or C/S • Placenta previa

• classification: partial vs complete vs marginal vs low-lying placenta • presentation: painless bleeding

• RFs: • multiple gest • uterine anomalies • multip • accreta • management: • maternal stabilization

• admit and observe if: minimal bleeding, <36wks, fetus stable, no contractions

• C/S if: previa unstable, fetal distress, >36wks • Vasa previa

• presentation: painless bleeding, tachycardia, bradycardia, severe variables • RFs:

• velamentous insertion of cord on low lying cervix • diagnosis: • Apt test • palpable cord • management: • immediate C/S • Uterine rupture

• presentation: painful bleeding, during labour: suprapubic pain, contractions stop, vaginal bleeding, hemoperitoneum

• RFs:

• prior uterine surgery • trauma

• uterine distension (macrosomia, polyhydramnios, multiple gest) • uterine anomolies

• choriocarcinoma, difficult labor (forceps, vag breech, shoulder dystocia)

• diagnosis: clinical • management: TAH

• Complications of Antepartum Hemorrhage • Maternal • shock • DIC • anemia • C-section • uterine atony --> PPH • hysterectomy • death • • Fetal • HR abnormalities • hypoxia > HIL > LTND -> CP • prematurity • death History: • ID: GTPAL, #wks • HPI:

• quantify bleeding: onset, amount, color, pain • trauma

• 4 cardinal questions

• current pregnancy complications

• U/S findings: ?previa, ?polyhydramnios, ?macrosomia, ?uterine anomaly • bloodtype • HTN • PGyneHx: • PObsHx: • PMHx: • PSHx: • All: • Meds:

• FHx:

• SHx: smoking, cocaine

Physical:

• appearance: pallor

• vitals: hypotensive, tachycardic • FHR: • H+N: • CVS: • resp: • GI: • SFH, leopolds • GU:

• do U/S first to R/O previa • MSK:

• Neuro:

Management:

• bloodwork:

• CBC/d, type and crossmatch

• coags: PT, PTT, fibrinogen, FDP, D-dimer

• hemolysis: peripheral smear, haptoglobin, t.bili, LDH • AST, ALT • urine: • urinalysis • treatment: • as per cause

Infertility

Background:

• Definition: failure to conceive after 12 months of unprotected intercourse

• Classification: primary vs secondary (i.e. no children ever, or children and then no children); infertility vs sterility

• Factors:

• male: production (35-40% of infertility), delivery

• female: ovulatory (20% of infertility), cervical, uterine-tubal, peritoneal • multiple (40% of infertility)

• idiopathic (20% of infertility) • Semen Analysis:

• WHO criteria for normal semen: • volume 2.5mL (1-5mL) • concentration >20 million/mL • total count >40 million

• motility >50% • normal forms >30% • azoospermia:

• absence of sperm • confirm with 2 samples

• assess for fructose

• etiology: genetic (Kleinfelter's), congenital absence of the vas, post radiation/chemo

History:

• ID:

• F: age, GTPAL (clarify if previous pregnancies with current partner) • M: age

• HPI:

• primary vs secondary infertility (i.e. any children previously) • duration of unprotected intercourse

• coital frequency

• fertility W/U and Tx to date • PGyneHx:

• menses: • LNMP

• Menstrual Hx: menarche, regular/irregular, frequency, duration, flow • Moliminal Sx: bloating, cramping, breast tenderness, mood changes • Midcycle Sx: Mittlesmirtz, cervical mucus

• Dysmenorrhea: primary vs secondary • Dyspareunia

• sexual: STIs/PID; contraceptive history • paps: last, frequency, abN

• other: hyperandrogenism (hirsuitism, alopecia, acne), wt change • PObsHx:

• PMHx: pituitary, thyroid, Cushings, endometriosis, PCOS, PID, uterine abnormalities • PSHx: laparotomy, laparoscopic, D&C, bowel Sx

• All:

• Meds: folic acid • FHx: infertility • SHx:

• Male Partner: • ID: age

• PMHx: pregnancies with other partners

• PSHx: torsion, inguinal repair, TURP, radiation • All:

• Meds: chemotherapeutics • FHx: infertility

• SHx: occupational exposure to heavy metals, hot showers • GU Hx:

• heat/toxin exposure • testicular trauma

• infections: STIs, mumps, TB • underwear - tightie whities • erections/ejaculations/libido

Physical (Female):

• appearance: body habitus, hair distribution • vitals:

• H+N: acanthosis nigricans • CVS:

• resp:

• GI: scars, masses, tenderness • GU:

• speculum: +/- pap and swabs • bimanual

• MSK:

• hyperandrogenism (hirsuitism, acne, alopecia)

• insulin resistance (acanthosis nigricans, acrocordons) • Neuro:

Physical (Male):

• appearance: body habitus, hair distribution • vitals: • H+N: • CVS: • resp: • GI: DRE • GU:

• hernias, varicoceles, penis, scrotum, testicular volume • MSK:

• Neuro:

Investigations (Female):

• ovarian:

• bloodwork

• hormones: Day 3 FSH(check ovarian reserve),LH, estradiol, PRL, TSH, day 21 prog (check ovulatory status)

• PCOS: DHEAS, testosterone, 17-hydroxyprogesterone, fasting insulin, fasting glucose, lipid profile, sex hormone binding globulin • endometrial Bx • transvaginal U/S • cervical: • mucous analysis • post-coital test • uterine/tubes: • HSG (day 5-10) • laparoscopy • peritoneal: • laparoscopy Investigations (Male): • Semen analysis Management: • Azoospermia:

• therapeutic donor insemination (TDI)

• anonymous frozen sperm, IUI, 50% success rate at 6mos • Oligospermia:

• attempt IUI, ICSI with IVF • Ovulatory problems:

• Tubal problems:

• nothing if at least one tube is patent • ?tubal surgery

• IVF if tubes grossly damaged • Uterine factors: • ?surgery • Unknown: • unknown

Prenatal Care

Background: History:

• ID: age, GTPAL, ethnicity, occupation, partner information • HPI:

• establish gest age (LNMP, menstrual cycle length, contraception, early U/S, IVF embryo transfer)

• concerns thus far (PVB, N/V) • PGyneHx:

• PObsHx:

• PMHx: chicken pox • PSHx: anesthetic history • All:

• Meds: folic acid, teratogens

• FHx: DM, HTN, mult gest, stillbirths, chromosomal/congenital abnormalities • SHx: smoking, drugs, EtOH, domestic violence, financial or enviornmental

Physical:

• appearance:

• vitals: baseline BP, vitals, weight • H+N: • CVS: • resp: • GI: • GU: • MSK: • Neuro: Investigations: • bloodwork • CBC • blood type • antibody screen • Rubella titre • varicella

• RPR • HsbAg • +/- HIV • urinanalysis • R&M, C&S • PV

• pap (if none within 6 mos)

• swabs (GC, chlamydia, vaginal vault)

Management: • subsequent visits • qmonthly until 28wks • q2wks from 28-36wks • q1wk from 36wks to delivery • 6wks postpartum

• gestational dependent management • 10-12wks: CVS

• 12wks: early pregnancy review (ex: nuchal translucency) • 15-16wks: genetic amniocentesis

• 15-20wks: maternal serum screen (MSS)

• 18-20wks: routine detailed anatomic ultrasound • 24-28wks: gestational diabetes screen (50g OGCT)

• 28wks: repeat CBC & antibody screen, administer WinRho if Rh neg • 36wks: GBS swab

• prenatal screening vs prenatal diagnosis

• Screening - risk assessment (ex: nuchal translucency, MSS, ultrasonography)

• Diagnosis - karyotype obtained (ex: CVS, amniocentesis)

High Risk Pregnancy

Background:

• Maternal mortality

• 0-4/10,000 deliveries

• eclampsia, amniotic fluid embolism, MVA • Perinatal mortality

• neonatal death (within 1 wk): 3/1000 • stillborn: 4/1000

Examples of High Risk:

• Diabetes • Hypertension

• preeclampsia, essential, chronic • keep wt down 15-20lbs

• aberuption, placenta previa • Premature labour

• Premature ROM • Rh disease • Small for dates

Ectopic Pregnancy

• def'n - embryo implants outside of endometrial cavity • incidence - 2%

• 9% of maternal deaths • Etiology

• PID/salpingitis --> 50% secondary to damaged fallopian tube cilia from PID • adhesions - tubal ligation reversal

• long tubes/anatomic abN --> fibroids, ovarian mass • Kartagener's syndrome --> lack of motile cilia • intrinsic abN of fertilized ovum

• conception late in cycle

• transmigration of fertilized ovum to contralateral tube • Risk Factors (< 50% women have any fisk factors)

• demographics --> older, black, minority women • smoking

• endometriosis

• gyne --> IUD use, Hx of PID, salpingitis, infertility, clomiphene citrate • prev procedures --> ANY surgery on fallopian tube (prev ectopic, TL, etc),

abdo surgery, IVF pregnancies

• structural --> uterine leiomyomas, adhesions, abN uterine anatomy • prior ectopic (10 - 20% subsequent ectopic after first occurrence) • Signs/Symptoms

• ectopic triad --> pain, bleeding, adnexal tenderness (+ cervical motion tenderness)

• shoulder tip pain (referred from diaphragm) • adnexal mass

• peritoneal signs --> tendernss (90%) +/- rebound (45%) • temp > 38degC (20%)

• doughy abdo from clots • Grey Turner's/Cullen's

• signs of pregnancy --> Chackwick's sign, Hegar's sign • Dx

• U/S --> only definite if fetal cardiac activity detected in tube/uterus • tubal ring --> specific finding on endovaginal U/S

• serial absolute hCG levels --> should double q48h w/ intra-uterine pregnancy

• rise < 20% is 100% predictive of non-viable pregnancy

• prolonged doubling time, plateau, decreasing levels prior to 8 wks --> non-viable gestation, provides NO info on implantation

• 1000 - 1200 w/o +ve U/S • laparoscopy for definitive Dx

• may pass entire decidua at once and look like a SA

• ID --> age, GTPAL, GA (LNMP, cycle length, pregnancy tests, contraception) • HPI

• pain --> OPQRST

• PVB --> amt, quality, quantity, ?tissue

• hemodynamic stability --> lightheadedness, SOB, shoulder tip pain • r/o other etiologies

• ?dysuria, ?hematuria, ?fever

• change in appetite/bowel habit, BRBPR • N/V • NPO time • PObsHx, PGyneHx • Hx of prev ectopics? • prev surgeries • STDs/PID, infertility • abN anatomy, abN paps • dysmenorrhea, dyspareunia • PMHx, PSHx, FHx

• Meds/Allergies --> induction of ovulation? • P/E --> ABCs!!, ht, wt, pallor

• full physical focusing on abdo/pelvis

• pelvic --> may defer if known or highly suspicious for ectopic -->AVOID RUPTURE

• if etiology of pain under investigation • inspection of female genitalia

• speculum exam --> pap, swabs, ?signs of pregnancy

• bimanual --> ?CMT, ?unilateral adnexal tenderness, mass, ?uterine enlargement

• Investigation

• bloodwork --> CBC, hCG, progesterone • urine R&M, C&S --> r/o UTI/pyelo

• US --> transvaginal (hCG > 1500), transabdo (hCG > 4500) • Management

• surgical

• indications --> hCG > 10,000 or hemoperitoneum

• linear salpingostomy if tube salvageable, otherwise salpingectomy, inspect contralateral tube

• monitor hCG weekly until non-detectable --> 15% risk persistent trophoblast

• give RhoGAM if pt Rhneg (applies to surgical and medical management)

• medical

• MTX (std of care) --> suppresses growth, decreases risk rupture • 50 mg/m2 IV or IM

• approx 84% success rate after single dose • tubal patency after MTX up to 80%

• S/E --> increased liver enzymes, diarrhea, gastritis, dermatitis

• follow hCG weekly until undetectable --> plateau/rising levels implies persisting trophoblastic tissue --> REQUIRES further medica/surgical Rx

• criteria for increased success of medical Rx • pt clinically stable, NO Sx of rupture

• U/S --> empty uterine cavity, < 3.5 cm unruptured ectopic pregnancy, NO fetal heart activity

• hCG 1000 - 10,000 mIU/mL

• NO contraindications fo MTX --> breastfeeding, hepatic/ renal/hematologic disease, PUD, active pulm disease • compliance + good f/u!!

• baseline labs --> CBC, BUN/Cr, liver enzymes, T&S

• f/u --> quantitative hCG q3d until 15% fall, then q weekly until < 15 • 2nd dose in 1 wk if 30% fall NOT observed

• rpt TV U/S in 3 wks • HSG in 3 mo

• NO EtOH, folic acid, or sex until full resolution

Malpresentation:

Presentation Types: • Cephalic (97/100)

• vertex->vaginal : most common=occiput anterior; followed by left/right occiput transverse and occuput posterior

• face (1/500) : mentoanterior (60%) --> vaginal delivery

• brow(1/1400) : unstable b/t vertex and face. Vaginal delivery if converts, but most likely C/S

• Breech (3/100)

• frank (65% or 2/100) : external version with vaginal or C/S • complete (10%) : external version or C/S

• incomplete (1-2 footling)(25%) : external version or C/S

• Compound (1/700) : limb prolapses with presenting part. Deliver vaginally unless converts to shoulder

• Shoulder (3/1000) : associated with transverse or oblique lie. C/S these babies! Risk Factors:

Maternal: big uterus (linked with multiparity), uterine or pelvic abnormalities (contracted pelvis)

Maternal-fetal: poly/oligohydraminos, previa

Fetal: small baby (premature/IUGR), multiple gestation, congenital abnormalities (6% associated with malpresentation -- 2x normal rate or congenital abnormalities)

Diagnosis: • Leopolds • Vaginal exam

• Always confirm with ultrasound Management:

Procedure Criterion Risks Contraindication

External

version-->tocolysis, analgesia, U/S guided +/- Rhogam >37 weeks GA, unengaged, singleton, reactive NST. (lots of fluid) (multiparity) (small baby) Abruption Cord compression Uterine rupture Maternal: previous classical C/S or myomectomy Maternal-Fetal: Oligohydraminos, previa, PROM, prev T3 bleed Fetal: IUGR, congenital abnormality Vaginal Delivery Maternal: Adequate pelvis Fetal: >36 GA, 2200-3800 grams, continuous FHM, flexed head Cord compression, birth trauma, asphyxia Congenital abnormality

Shoulder Dystocia

• Etiology = cephalopelvic dysproportion:

• small al pelvis (stteply inclined symphysis, narrow diameter)

• fetal macrosomia (>4000g or >90th %ile; genetic, post-term, gestational diabetes)

• rapid descent (inadequate time for moulding of shoulder to birth canal) • Risk Factors:

• gestational diabetes, DM • post-term

• fetal macrosomia

• arrest, protractions, need to perform mid forceps delivery • Predictability:

• only a small portion can be predicted or prevented with U/S • Management:

1. gentle downward traction on head => "turtle sign" = fetal chin pulled back after delivery of head

2. call for help 3. cut an episiotomy

4. McRobert's Maneuver: flex maternal thighs against abdomen 5. Suprapubic pressure

6. Shoulders rotated to an oblique diameter

7. Woods' Corkscrew Maneuver: place hand behind posterior shoulder and rotate forwards 180 degrees

8. delivery of posterior arm

9. Rubin's Maneuver: abduction of the shoulders 10. deliberate fracture of the clavicle

Fetal Monitoring

Antepartum:

SFH – 20cm at 20wks GA, should grow 1cm/wk

FHM – done at pre-natal checks, NO impact on survival

Wt gain – avg gain = 20 – 25 lbs (wt should change to 20 – 25lbs above IDEAL body wt)

-

commonly lose wt w/in 3 mo post-partum

FM – first noticed by 18 – 20 wks (primigravidas), 14 – 16 wks (multigravidas)

-

Normal = min 6 FM over 2 hrs w/ mom at rest

-

normally felt less in last mo b/c of decreased space

-

MOST helpful in HIGH RISK pregnancy

NST – suggests uteroplacental insufficiency OR suspected fetal distress

-

reactive = 2 accels > 15bpm from baseline lasting >15 sec over 20 min

-

non-reactive = < 2 accels > 15 bpm from baseline lasting 15s over 40 min

o

perform BPP if NST non-reactive

-

only 50% normal babies reactive if ≤ 26wk GA

BPP – NST + 30 min U/S assessment of fetus

Normal (2pts)

abN (0 pts)

AFV – 2 cm fluid pocket in 2 axes

Oligo

NST reactive

Nonreactive

Breathing ≥ 1 episode of 30 sec

< 30 sec

3 distinct limb movements

< 3 movements

1 episode of limb extension-flexion

sequence (tone)

No episodes

N = 8 – 10

6 – repeat in 24 hrs

0 – 4 deliver ASAP

AVF = marker of CHRONIC hypoxemia

All other parmeters indicate ACUTE hypoxia

Hypoxemia à conserve oxygenated blood for brain, heart, adrenals à renal aa constriction à

pre-renal failure à oligo

-

indications for BPP

o

non-reassuring NST

o

post-term pregnancy

o

decreased fetal movmement

o

any other suggestion of fetal distress or uteroplacental insufficiency

PUBS – periumbilical blood sample (mortality 1%) à Hb, pH, blood gases

Intrapartum:

FHM

-

120 – 160 = baseline

o

tachy hypoxia (early) à hemorrhage (vasa previa, Rh, G6P), infection

(hep, parvo), fever (ex from epidural), drugs (anticholinergics, ephedrine for

post-epidural hypotension, salbutamol (tocolytic), TCA, cocaine, LSD,

etc…)

-

variability ≥ 3 cycles of 5 bpm/45sec

o

sign of CNS fxn + homeostasis as hypoxic/acidotic brain loses

variability

-

periodicity à accels (15 bpm for 15sec) w/ contractions is NORMAL

o

often no accels in active phase of labour

-

decels

Early decels

Late decels

variable decels

U shaped

U shaped

var in shape, onset, duration

mirror image of contraction

(onset early in contraction,

return to baseline by end of

contraction), gradual decel

onset late in contraction,

lowest depth AFTER peak

of contraction, return to

baseline after end of

contraction

most common type of

periodicity seen during

labour

due to vagal response to

head compression

due to fetal hypoxia +

acidemia, maternal

hypotension, uterine

hypertonus

due to cord compression or

forceful pushing w/

contractions

often repetitive, NO effect

on baseline FHR or

variability

may cause decreased

variability + change in

baseline FHR

may/may not be repetitive,

often w/ abrupt drop in

FHR, usually no effect on

baseline FHR or variability

BENIGN – usually seen w/

Cx dilation of 4 – 7 cm

MUST see 3 in a row, all

w/ same shape to define a

late decel

BENIGN unless repetitive,

w/ slow recovery, or when

assoc w/ other abN of FHR

OMINOUS – usually sign

of uteroplacental

insufficiency

rule of 60s (for severe var

decels) à decel to < 60 bpm

>60 bpm below baseline

>60sec in duration w/ slow

return to baseline

*Pathophys of variable decels à Veins compressed before arteries à decreased venous return à

decreased BP à stim baroreceptors à HR increases à further contraction compresses arteries à

increased PVR à increased BP à stim baroreceptors à HR decreases à contraction ends à opens

vessels à decreases PVR à BP drops à stim baroreceptors à HR accels + overcompensates at first

Diagnosis of Labour

-

def’n of labour

o

assoc w/ progressive DILATATION and EFFACEMENT of cervix and DESCENT of

presenting part (STATION) à cervical changes

-

preterm à > 20, < 37 wks GA

-

term à 37 – 42 wks GA

-

post-term à > 42 wks GA

-

Braxton-Hicks contractions à “false labour”

o

Irreg, occur throughout pregnancy

o

NOT assoc w/ any dilation, effacement or descent

Four Stages of Labour

1

st

stage

2

nd

stage

3

rd

stage

4

th

stage

latent phase à

contractions infreq/

irreg, slow Cx

dilation* (to 3 – 4 cm)

and effacement

from full dilation to

delivery of baby

separation + expulsion

of placenta

time for uterus to

return to baseline state

(may last wks)

active phase à rapid

Cx dilation to 10 cm

(nullip >1.2 cm/hr,

multip >1.5 cm/hr)

progress measured by

descent

lasts up to 30 min

before intervention

indicated

aka puerperium

active à max slope on

Friedman curve

avg duration à multip

20 min

nullip 50 min

oxytocin IV drip or 10

U IM after delivery of

anterior shoulder

active à painful,

regular contractions

q2min, lasting 60 – 90

sec

*3cm for multip, 4 cm for nullip

- prolonged latent phase à nullip > 20 hrs, multip > 14 hrs

-

dysfxn’l labor à power, passage, passenger

o

only Dx once in active labour

o

Signs of Placental Separation

1.) gush of blood

2.) lengthening of cord

3.) uterus becomes globular

4.) fundus rises

Cardinal Movements of Fetus during Delivery

1.) descent

3.) flexion à allows smaller diameter to present through mid-pelvis

4.) internal rotation (to OA ideally)

5.) extension à delivery of head

6.) external rotation (restitution) à head rotates in line w/ shoulders

7.) expulsion à delivery of shoulders + body

Pelvic Examination:

• Wash, Permission (chaperoned by nurse), Drape

• Tell the patient what you are about to do before you do it • Inspection:

• External genitalia - edema, lesions, female genital mutilation • Hymen - annular, septate, cribriform, parous introitus

• Glands - Bartholin, Skene • Reassure

• Speculum Exam:

• Warm, lubricate speculum

• Insert speculum at 45 degree angle, directed posteriorly • Locate the cervix

• Os, polyps, friable, erythema

• Obtain specimens for culture and cytology

• Inspect vaginal canal as withdraw speculum - odor, color, consistency, quality

• Reassure • Bimanual Exam:

• Gyne:

• Cervix - size, shape, consistency, CMT

• Uterus - examine by pressing downward with non-dominant hand on abdomen

• size, shape, position (ante/retroverted) • Adenexa - size, shape

• Reassure • Obstetrics:

• Presentation - vertex,

• Position - OA (2 sutures, triangle anterior), OP (3 sutures, diamond anterior)

• Place (station) - relation to ischial spines • Pelvis

• Puncture (ROM) • Reassure

• Rectovaginal:

• Indications: rectovaginal fistula, virginal patient (?) • Reassure

Violence Against Women

• prevalence:

• physical assault: 1/3 to 1/10 women living with a man • sexual assault: 1/8 in USA

• RFs for physical assault: • age 18-24 • pregnancy • disability • FHx of abuse • attempted divorce/breakup History: • ID:

• quiet/secluded area, do not leave pt alone (have nurse/crisis counsellor present), contact assault crisis team

• CC: (often non-specific)

• story doesn't fit injuries • delayed presentation

• recognizable injury patterns/locations

• constant visits with non-specific S/S's (HA, abdo pain, pelvic pain, etc.) • depression

• EtOH/drug abuse

• avoidance of male relationships • changes in sexual behavior • increased anxiety

• decreased self-esteem

• phobic reactions to being alone • new onset nightmares

• HPI:

• careful/accurate documentation! • (approach HPI chronologically)

• date and time of assault and present exam

• physical surroundings and circumstances of assault • nature of assault and associated pain

• weapons or foreign objects used and where used • number of assailants

• other known victims

• acts committed (coitus, fellatio, cunnilingus, sodomy) • if ejaculation occurred and where

• condom use

• if vomiting/LOC occurred

• if patient washed, wiped, bathed, couched, defecated, brushed teeth, changed clothes

• use of drugs, EtOH, meds in proximity to assault • date of last tetanus

• date and time of last consensual intercourse • PGyneHx: • PObsHx: • PMHx: PTSD • PSHx: • All: • Meds: • FHx: • SHx:

Physical:

• vitals:

• screening entire P/E: • collect evidence:

• collect clothes

• inspect clothes, skin, nails • fingernail cleanings

• comb pubic hair; collect head and pubic hair • saliva sample

• GU:

• external inspection • speculum

• vaginal/anal/throat swabs for GC, CT, and sperm • GI:

• DRE

• MSK: signs of trauma

Investigations:

• vaginal/anal/throat swabs for GC, CT, and sperm

• bloodwork for typing, syphilis, B-hCG, EtOH, drug panel, HIV baseline, HepB

Management:

• repair trauma • +/-tetanus toxoid • GC/CT prophylaxis

• offer emergency contraceptive/counselling re: pregnancy • offer HIV prophylaxis (not routinely given)

• counseling/eduction • ?psych • ?police • ?social work • follow-up: • 2 wks: GC, B-hCG • 6 wks: syphilis • 12 wks: HIV

Urinary Incontinence

Background:

• Stress incontinence: loss of urine occuring with increased abdominal pressure (coughing, laughing,lifting) often due to bladder prolapse or weak sphincter • Urge incontinece: loss of urine due to involuntary bladder spasm, urgency,

frequency, nocturnal, multiple triggers • Mixed

• Overflow: urine leaks from overdistended bladder with chronic urinary retention • due to outlet obstruction, bladder underactivity, previous surgery, aging,

• Functional & transient incontinence: geriatrics, due to restricted mobility, UTI, severe constipation, diuretics, antipsychotics, psychological

Etiology • Delirium • Infection • Atrophic vaginitis • Pharmacologic, psychological • Endocrine • Restricted mobility • Stool impaction History: • ID:

• HPI: OPQRST - increased abdominal pressure, fluid intake/voiding, fever, polydipsia, flank pain

• PGyneHx:

• Pee: volume, aware, dysuria, urgency, hematuria, nocturia, hesitancy, double voiding, pads/liners, skin irritation, impact • Prolapse: bulge, mass in vagina, reduce prolapse to void/defecate • Poop: freq/consistency of BM, constipation, blood, bulging into rectum,

flatal/fecal incontinence • PObsHx:

• PMHx: CVA, dementia, cancer, DM, hypercalcemia, nephrolithiasis, depression, chronic cough

• PSHx: • All: • Meds: • FHx:

• SHx: smoking, caffeine, EtOH, mobility

• ROS: sensory/motor changes, constipation, menopause, atrophic vaginitis

Physical: • appearance: • vitals: • H+N: • CVS: • resp: • GI: masses • GU: prolapse • MSK: edema

• Neuro: mobility, look at back and limbs

Investigations:

• U/A for C&S, R&M

• Stress test - examine urethral meatus while pt coughs

• Cotton tip applicator test - insert Q-tip to urethrovesical junction, pt strains, normal angle of change 30 degrees

• Urethrocystoscopy

• Cystometrogram - observe pressure changes in bladder during filling • Uroflometry - record rates of urine flow

• Voiding cystourethrogram - observe bladder filling, mobility of bladder base, anatomic changes while voiding

• U/S

• Methylene blue - observe vesicovaginal fistula • PVR

Management:

• Stress incontinence: lifestyle changes, phsyio (kegels, vaginal cones), pessaries, surgery

• Urge incontinence: lifestyle changes (stop caffeine/EtOH, fluid management, prompted voiding), kegels, bladder training, medications (anticholinergics, TCAs, local estrogen)

• Overflow incontinence: double voiding, pessaries, self-catheterization, avoid irritants

Menopause

Definintion:

• permanent cessation of menses >12mos without any pathologic or physiologic cause

• Mean: 51 years

• Premature: >2sd (approx 40yrs)

History:

• ID:

• HPI: fatigue, hot flushes, night sweats, poor concentration, ?sleep deprivation, insomnia, irritability, anxiety, depression

• PGyneHx: LMP, Menses (Regularity, cycle), Duration, Intermenstrual bleeding, pain with intercourse, Fibroids, Last Pap

• PObsHx:

• PMHx: OA, GB disease, migraine, bleeding disorders, HTN, DM, dyslipidemia, CAD/ CVA/A/TIA

• PSHx: hysterectomy, D&C, endometrial biopsy • All:

• Meds: • FHx: • SHx: • ROS:

• H&N: Headaches, lightheadedness • CVS: palpitations

• GU: UTI, urgency, frequency (trigone estrogen dependent), vaginal dryness, dyspareunia, pruritis, D/C, increased infections, decreased libido

• Skin: dryness, hirsuitism, formication

Physical: • appearance: • vitals: • H+N: • CVS: • resp: • GI:

• GU: • MSK: • Neuro:

Investigations:

• FSH high, LH mod increased, estradiol low

Management:

• Perimenopause:

• Normal FSH - low dose OCP • High FSH - HRT

• HRT: indicated for significant Sx • Systemic versus local

• if patient has a uterus use progestin

• Methods - sequential (daily estrogen, progestin 10-14d, menses), continuous (no menses)

• Risks - VTE, endometrial hyperplasia, breast ca, GB disease, CVD • Benefits - decreased osteoporosis, decreased colon ca

• Alternative - black cohosh, don quai, soy

Small for Dates

def'n - SFH not within 2cm of GA after 20 wks US parameters

1.) BPD (biparietal diameter)

2.) head & abdo circumference + ratio 3.) femur length

4.) estimated fetal weight DDx small for dates:

1.) baby --> IUGR, position (fetal lie) 2.) fluid --> oligohydramnios

3.) other --> wrong dates IUGR

def'n - infant wt < 10th percentile for particular GA (not assoc w/ any constitutional or familial cause)

Etiology/Risk Factors:

• maternal

• lifestyle --> malnutrition, smoking, drug abuse, alcoholism • systemic

• cyanotic heart disease, pulmonary insufficiency • DM type I, SLE

• chronic HTN, chronic renal disease • prev IUGR

• maternal-fetal

• any disease causing placental insufficiency

• PIH, chronic HTN, chronic renal insufficiency, gross placental morphological abN (infarction, hemangiomas)

• fetal

• multiple gestation • congenital anomalies

Clinical Features:

symmetric (type I) - 20% asymmetric (type II) - 80% occurs early in pregnancy occurs late in pregnancy inadequate growth of head and

body brain sparing - head : abdo ratioINCREASED head : abdo ratio may be

NORMAL usually assoc w/ placentalinsufficiency usually assoc w/ congenital

anomalies or TORCH infections more favorable prognosis thantype I

Complications:

• prone to meconium aspiration, asphyxia, polycythemia, • hypoglycemia, temp instability, mental retardation • greater risk perinatal morbidity + mortality

Investigations:

• SFH at every antepartum visit

• if mother at high risk or SFH lags > 2cm behind GA:

• BPP --> US should incl assessment of BPD, head + abdo circumference, femur length, fetal weight, amniotic fluid vol (decreased assoc w/ IUGR) • Doppler analysis of umbilical cord blood flow prn

Management:

• prevention --> risk modificiation prior to pregnancy (ideal)

• modify controllable risk factors --> smoking, EtOH, nutrition, maternal illness • confrim dates + assess parents' size

• bed rest in LLDP

• serial BPP (weekly or biweekly) to monitor fetal growth and det cause of IUGR (if possible)

• delivery when extra-uterine existence less dangerous than continued intra-uterine existence

• delivery if GA > 34 wks w/ significant oligo

• liberal use of C/S since IUGR fetus tolerates labour poorly (b/c of poor placenta) Oligohydramnios

def'n - amniotic fluid index of 5cm (2in) or less (< 5th percentile)

AFI determined by sum of vertical diameter of fluid pockets in 4 quadrants on US sign of CHRONIC placental insufficiency

Etiology:

• early onset oligo (T1/2)

• decreased prod'n --> renal agenesis/dysplasia, urinary obstruction, PUV (males), poor placental perfusion

• increased loss --> prolonged amniotic fluid leak (most often labour ensues) • PHx of early oligo

• late onset oligo (T3)

• amniotic fluid normally decreases after 35 wks • common in post-term pregnancies

• PHx late oligo • PROM

Clinical Features:

• cord compression, mec aspiration • early onset

• fetal anomalies --> 15 - 25%

• amniotic fluid bands (T1) --> Potter's facies, limb deformities, abdo wall defects

• late onset

• pulm hypoplasia

• marker for infants who may not tolerate labour well

Dx:

• US

Investigations:

• ALWAYS warrants admission and investigation

• r/o ROM --> Hx, amniostick, pH, nitrazine paper, ferning on microscopy • fetal monitoring --> NST, CTG, BPP

Management:

• consider delivery if at term *Fetal Lung Maturity*

• measured by amnio

• L/S ratio (lecithin, sphingomyelin) --> determined by thin layer chromatography >=2 or, 1.4 w/ mec

• lecithin increases rapidly > 35 GA • 40% false pos for HMD

• 2% false neg in healthy moms, >2% w/ DM • lung profile --> L/S ratio + phosphatidylglycerol (PG)

• PG is a component of surfactant secreted increasingly in gestation • PG unaffected by vaginal contamination/ROM

• presence of PG is evidence that fetus is w/in 2 - 6 wks of full term • indicator for PROM or DM

• 10% false pos, <1% false neg • 5% false neg based on PG alone

Large for Dates

Macrosomia

def'n - infant weight > 90th percentile for particular GA, or > 4,000 gm

Etiology/Risk Factors:

• maternal obesity, DM/gestational DM • PHx of macrosomic infant

• prolonged gestation, multiparity

Clinical Features:

• increased risk perinatal mortality

• CPD (cephalopelvic disproportion) + birth injuries more common --> shoulder dystocia, fetal bone fracture

• complications of DM in labour --> neonatal hypoglycemia, preterm labour, increased incidence of stillbirth

Investigations:

• serial SFH

• further investigations if mother at high risk, or SFH > 2cm ahead of GA • US predictors:

• polyhydramnios

• 3rd trimester abdo circumference > 1.5cm/wk

• head circumference --> HC/AC ratio < 10th percentile • femur length --> FL/AC ratio < 20th percentile

Management:

• Rx underlying causes --> minimize wt gain in obese, tight glycemic control, induce at 41 - 42 wks GA, consider C/S if risk of CPD

• C/S often safer than vaginal delivery Polyhydramnios

def'n - amniotic fluid vol (AFV) > 2,000mL at any stage in pregnancy (> 95th percentile, </= 20 cm)

US criteria: > 8 x 8cm (3.1 x 3.1 in) pocket of amniotic fluid

Etiology:

• idiopathic (40% - most common) • maternal causes

• DM type I --> causes abnormalities of transchorionic flow • maternal-fetal

• chorioangiomas • multiple gestation

• fetal hydrops --> increased erythroblastosis • fetal causes:

• chromosomal anomaly --> up to 2/3 of fetuses w/ severe polyhydramnios • resp --> cystic adenomatoid malformed lung

• CNS --> anencephaly, hydrocephalus, meningocele

• GI --> TEF, duodenal atresia, facial clefts/neck masses (malformations that interfere w/ swallowing)

Clinical Features:

• pressure symptoms from overdistended uterus --> dyspnea, edema, hydronephrosis, GERD

• uterus large for dates, difficulty palpating fetal parts + hearing fetal heart tones • acute onset assoc w/ multiple gestation

Complications:

• cord prolapse, placental abruption,

• malpresentation, preterm labour, uterine dysfxn, • PPH

• increased perinatal mortality

Management:

• find underlying cause --> screen for maternal disease/infection (DM, Rh), fetal US eval

• mild - mod cases --> no Rx

Prematurity

Background:

• preterm labor = onset of labor between 20-37 wks • incidence = 11.5%

• Risk Factors: • African • low SES

• extremes of age (<20 or >35)

• strenuous and physically demanding occupation • low prepregnancy maternal weight

• past preterm delivery • multiple gestations • chorioamnionitis • uterine anomaly • uterine leiomyomata • sepsis • genital infection • incompetent cervix

• history of second-trimester abortion • placental abruption

• placenta previa • fetal anomalies

• abdominal surgery during pregnancy • smoking • pregnancy complications • Clinical Presentation: • uterine contractions • uterine tightening • menstrual-like cramps • pelvic pressure • back pain • rupture of membranes • watery vaginal discharge • vaginal spotting

• Causes of neonatal morbidity and mortality: • RDS • PDA • IVH • sepsis • NEC • hyperbilirubinemia • hypoglycemia History:

• ID: age, GTPAL, race, GA • HPI:

• gestational age, U/S findings

• SES factors associated with preterm labor • SPROM?

• medical conditions that predispose to preterm labor: sepsis, chorioamnionitis, uterine anomalies, multiple gest

• any testing: cervical length, FFN, salivary estriol • standard case room history

• PGyneHx: uterine anomalies, STIs

• PObsHx: previous preterm deliveries, 2nd TM abortions • PMHx:

• PSHx: abdominal surgies during pregnancy • All: • Meds: • FHx: • SHx: occupation, smoking Physical: • appearance: • vitals: • FHR: • H+N: • CVS: • resp:

• GI: uterine tenderness (chorioamnionitis, placental abruption) • GU:

• external: pooling of fluids (ROM), PVB (abruption, previa, bloody show) • cervix: assess dilation, effacement, presenting part, station

• MSK: • Neuro:

Investigations:

• testing to predict preterm labor:

• cervical length measurements: <25mm via trans vag U/S

• fetal fibronectin enzyme immunoassay (FFN): high negative predictive value for delivery within 2 wks

• criteria for FFN:

• membranes intact

• cervical dilation less than 3cm

• gestational age between 24 and 35 wks • external uterine monitoring

• vaginal/cervical

• serial cervical examination • tests to document ROM

• nitrazine test for pH

• microscope slide test for ferning • +/- cervical cultures

• +/- amniocentesis (fetal lung maturity, detection of chorioamnionitis) • urine

• R&M and C&S • imaging

• U/S abdo (confirm GA, R/O multiple gest, determine fetal presentation)

Management:

• IVF: 500ml D5W IV • tocolytic medications

• beta-adrenergic agonists (Ritodrine or Terbutaline)

• contraindications to the use of tocolytic meds: advanced labor, maternal cardiac disease, severe preeclampsia/eclampsia, severe vaginal bleeding, maternal hyperthyroidism, uncontrolled diabetes mellitus, non-reassuring fetal status, severe intrauterine growht restriction, chorioamnionitis, fetal demise, lethal fetal anomaly • side effects: N/V, HA, restlessness, agitation, fever

• complications: pulmonary edema, hypotension, cardiac failure, cardiac arrhythmia, myocardial ischemia, hyperglycemia, hypokalemia, hypocalcemia

• MgSO4

• side effects: hot flashes, headache, nausea, dizziness, nystagmus, dryness of the mouth, lethargy, urticarial eruptions

• complications: pulmonary edema, hypocalcemia, hypotension, resp depression/arrest, fetal and neonatal depression, cardiac

depression/arrest

• prostaglandin sytnthesis inhibitors (indomethacin, ketorolac, sulindac) • side effects: N/V, heartburn

• complications: PPH, prolonged bleeding time, oligo, premature closure of the ductus

• calcium antagonists (nifedipine)

• side effects: dizziness, flushing, nausea, HA • complicaitons: hypotension, liver toxicity • corticosteroids (betamethasone, dexamethasone)

• antibiotics (if GBS positive or unknown) • maternal transport to appropriate facility

Birth Control

Background:

• absolute contraindications • smoking over 35 • migrane with aura • DVT/PE

• MI

• cancer: ovarian, breast, hepatic • liver disease

• familial hyperlipidemia

• undiagnosied vaginal bleeding • pregnancy – • relative contraindications: • hypertension • fibroids • DM • migrane

• Roman Catholic religion

History:

• ID:

• HPI: reason for starting BC, current method of BC • •PgyneHx: • •menses: LMP, PMP • •sexual: • M/W/both, # of partners • •types • •coitarche • •contraception • •STIs/PID • paps: • •procedures:

• •PObsHx: currently pregnant, past pregnancies • PMHx:

• migranes with aura strokes MI, angina DVT / PE

• •breast/ovarian/hepatic cancer liver disease familal hyperlipidemia • (hypertension) • •PSHx: • •All: • •Meds: • •antibiotics: • rifampicin • •anti-convuslants: • •FHx: • •as per PMHx • •Shx

• •smoking over 35yo

Physical: • • appearance: • • vitals: BP • • H+N: • • CVS: • • resp: • • GI: • • GU: • • MSK: • • Neuro: Investigations: • – vitals • – BhCG

• – liver enzymes: AST, ALT • – lipid panel

• – pap, cervical cultures

Management:

Abnormal Pap Smear

Background: • Risk Factors • HPV 16,18 (high) • HPV 6,11 (low) • early coitarche • multiple partners • unprotected sex • previous STDs • high risk partners • Signs/Symptoms

• early: discharge (clear->brown->red), post coital bleeding

• late: irregular spont bleeding, belvic & back pain, bowel & bladder Sx • signs: red, raised, friable lesion, exophytic, fungating tumor

• Screening

• 1st pap @ 18yo or when 1st sexually active for baseline • if has 3 N paps and no FR -> q3y

• if has 3 N paps and >/= 70 can stop • if hyst for benign reasons can stop • false +vc 5-10%, false -ve 10-40%

• not as sensitive for adenocarcinoma (5%) as for SCC (95%) • work up and Rx for adeno different from below

Interpretation of Results:

• Pap Results • atypia

• generic/infxn: repeat in 4mo • HPV changes: colpo

• ASCUS or LGSIL • repeat in 4mo

• negative: repeat in 4mo and swab • positive: colpo

• ASCH or HGSIL or Invasion • no visible lesion: colpo • visible lesion: Bx • Cancer

• colpo

• endometrial cells present • endometrial Bx • Colposcopy

• if lesion is well visualized and not in endocervical canal: Bx

• if lesion is poorly visuallized or extends into canal: Bx and ECC (endocerv curretage)

• Biopsy Results

• if agrees with colpo/ECC: Rx • if differs with colpo/ECC: cone Bx

• if reports microinvasion or higher: cone Bx • ECC Results

Managment:

• L(G)SIL(previously known as CIN 1, HPV effect, mild dysplasia)

• LEEP • laser

• cryotherapy

• therapeutic cone Bx

• H(G)SIL(previously known as CIN 2 & 3, carcinoma-in-situ, moderate and severe dysplasia)

• as above

• +/- hysterectomy • SCC

• Stage 1A (microinvasive)

• Rx decision depends on pt desire for fertility • therapeutic one Bx

• hyst

• Stage 1B (confined to cervix) • radical hyst

• Stage 2 (beyond cervix, but not to pelvic wall or lower 1/3 of vag) • radiation

• Stage 3 (to pelvic wall or to lower 1/3 or vag) • radiation

• Stage 4 (beyond pelvis +/- mets) • radiation

• Abnormal paps in pregnancy

• pap at initial prenatal and colpo/Bx as indicated • cone Bx should be delayed until T2 to avoid SA • if Stage 1A follow to term and Rx after delivery

• if Stage 1B recommend T1 radiation risking SA, T2 delay Rx until viable fetus and delivery

Post Partum Complications

Postpartum Hemorrhage (PPH)

def'n - loss of >500 mL of blood at time of vaginal delivery OR >1000 mL of blood w/ C/S • early --> w/in fist 24 hrs

• late --> b/w 24 hrs + 6 wks after delivery etiology (4T's)

1.) tone

• uterine atony

• most common cause of PPH, occurs w/in first 24 hrs • avoid by giving oxytocin w/ delivery of anterior shoulder • due to....

• labour --> prolonged, precipitous, induced, augmented • uterus --> infection, over-distention

• placenta --> abruption, previa

• maternal factors --> grand multiparity, PIH • halothane anesthesia

2.) tissue

• retained blood clots in atonic uterus • gestational trophoblastic neoplasia 3.) trauma

• laceration (vagina, cervix, uterus), episiotimy • hematoma --> vaginal, vulvar, retroperitoneal • uterine rupture, uterine inversion

4.) thrombin (coagulopathy

• usually identified before delivery (low plts increases risk)

• includes hemophilia, DIC, aspirin use, TIP, TTP, vWD (mos common) Investigations

• assess degree of blood loss + shock clinically

• explore uterus + lower genital tract for evidence of tone, tissue or trauma Management

• ABCs, cross+type 4 units pRBCs • Rx depends on cause

• CBC, coag profile

• 2 large bore IVs + crystalloids Management of Uterine Atony Local control

• bimanual compression --> elevate uterus + massage through pt's abdomen • uterine packing (mesh w/ Abx)

Medical therapy _{(intractable PPH)}Surgical therapy oxytocin 20 U/L NS

or RL continuous infusion, plus may give 10U

intramyometrial (IMM)after placenta

delivery

D&C --> may cause Asherman's syndrome w/ vigorous scraping Hemabate (carboprost) 0.25mg IM/IMM q15min up to max 2mg synthetic PGF-2 alpha analog, contraindicated in CV, pulm, renal, hepatic dysfxn laparotomy w/ bilateral ligation of uterine artery (may

be effective), internal iliac artery (not proven), ovarian artery, or hypogastric artery ergotamine (methylergonavine maleate) 0.25mg IM/ IMM q5min up to 1.25mg - can give as IV bolus of 0.125mg

hyst (last option) w/ angiographic embolization if post-hyst bleeding

(may exacerbate HTN) Retained Placenta

def'n - placenta undelivered after 30 min post-partum etiology

• placenta separated but not delivered

• abN placenta implantation --> accreta (adherent to myometrium), increta (invasion into myometrium), percreta (invasion through myometrium)

Risk Factors

• placenta previa • prior C/S

• post-pregnancy curettage • prior manual placental removal • uterine infection

Investigations

• explore uterus, assess degree of blood loss Management

• 2 large bore IVs, type + screen

• Brant maneuver --> firm traction on umbilical cord w/ one hand applying suprapubic pressure to hold uterus in place

• oxytocin 10 IU in 20 mL NS into umbilical vein • manual removal (if above fails), D&C if required Uterine Inversion

def'n - uterine prolapse through cervix +/- vaginal introitus Etiology

• iatrogenic --> xs cord traction w/ fundal placenta • xs use of uterine tocolytics

• more common in grand multiparous --> lax uterine ligaments Clinical features

• may cause profound vasovagal response --> vasodilation + hypovolemic shock Management

• URGENT management, call anesthesia • ABCs --> IV crystalloids

• use tocolytic drug (terbutaline) or nitro IV --> relax uterus + aid replacement • replace uterus WITHOUT removing placenta

• remove placenta manually + withdraw slowly • IV oxytocin infusion after uterus replaced • re-explore uterus

• may require GA +/- laparotomy Post-partum Pyrexia

def'n - fever > 38degC on any 2 of first 10 days post-partum Etiology (B-5W)

1.) breast engorgement or mastitis (S. aureus) 2.) wind --> atelectasis, pneumonia

3.) water --> UTI

4.) wound --> C/S incision, episiotomy

5.) walking/veins --> pelvic thrombophlebitis (Dx of exclusion), DVT, IV site cellulitis 6.) womb --> endometritis --> spiking fever in 24 hrs (blood + genital cultures) Investigations

• CBC/diff, lytes • blood cultures • urine for R&M, C&S • CXR (if indicated)

• +/- venous dopplers, V/Q scan, spiral CT Treatment

• empiric Rx for wound infections --> clinda + gent (amp + gent by OSCE pack notes) • prophylaxis against post-C/S endometritis --> begin Abx immed after cord clamping

+ give only 1-3 doses Post-partum Breast Problems

DDx NIPPLE pain

1.) position when breastfeeding

• baby's ear, shoulder, hip in straight line

• baby's head should not be flexed, turned, extended • poor position --> nipple traction --> erosions, tears • change positions if nipples sore

• Rx: modified lanolin for healing of trauma 2.) latch

• areola + nipple must be in child's mouth (not just nipple)

• wait until baby's mouth fully open before putting on breast --> ensures whole areola in mouth

3.) suck

• neurologic impairment or tongue tie --> trouble sucking --> nipple trauma 4.) yeast infection

• burning pain in nipple + shooting breast pain during/after nursing • NOTE - eczema spares nipple, Candida does not

• fine cracks at base of nipple

• RF --> Abx use, vaginal candida, nipple trauma

• Rx: topical nystatin for mom, or oral ketoconazole + analgesia (tylenol, ibuprofen, codeine acceptable for breastfeeding)

• baby should get oral nystatin suspension 5.) bacterial infection --> mastitis

6.) herpes simplex of nipple --> CONTRAINDICATION to breastfeeding, Rx: acyclovir 7.) milk blebs

• white pimple on nipple surface

• heat + nursing usually clears, if not open gently w/ #25 needle 8.) vasospasm

• episodic burning pain during/after nursing (vs yeast which is constant pain) • nipple can blanche w/ feeding, pumping or cold

• Rx: keeping mom warm, massaging areola

DDx BREAST pain

1.) strong letdown

2.) engorgement

• occurs on day 3-4 postpartum

• fullness + pain in hard, enlarged breasts

• Rx: freq breastfeeding, cool compresses, analgesia 3.) plugged ducts

• cigar shaped mass radiates out from nipple

• Rx: massage, heat, open any milk blebs present (may cause clogging) 4.) mastitis

• cellulitis of breast --> often Staph

• Rx: rest, heat, freq breastfeeding, pumping

• milk = good bacterial medium --> don't let sit there

• most mother's got infection from child --> no worries about infecting child • if no improvement in 24 hrs, or systemic symptoms occur --> clox (or

cephalexin, clinda) 5.) breast abscess

• needle aspiration + drainage (often >1 time) • breastfeeding should continue

• may have less milk prod'n on infected side

Amenorrhea

primary amenorrhea - no menses by age 14 in absence of secondary sex char OR no menses by age 16 with secondary sex char

secondary amenorrhea - absense of menses > 6mo after documented menarche

Etiology:

1.) anatomical

• failure of end organs (enzyme defects, Turner syndrome) • absence of end organs (uterine agenesis)

• outflow tract defects (septum, imperforate hymen, cervical stenosis, Asherman's syndrome - intra-uterine adhesions)

2.) ovarian failure

• lack of germ cells (eg. menopause) • inappropriate response to FSH • exposure to radiation/chemo 3.) endo imbalances

• pregnancy

• hyper/hypothyroidism

• failure of hypo-pit-gonadal axis (Kallman's syndrome)

• hyperandrogenism (PCOS, ovarian/adrenal tumor, testosterone injections) • Cushing's

4.) other

• androgen insensitivity synreome (AIS)

• drugs (metoclopramide, neuroleptics, danazol)

DDx primary amenorrhea:

1.) uterus, no breasts

• central failure --> GnRH def, constitutional delay, pituitary def, CNS lesions • gonadal failure

2.) breasts, no uterus

• congenital absence of uterus (RKH) --> normal hormones, karyotype • testicular feminization

3.) breasts + uterus present

• premature ovarian failure, PCO • hyperprolactinemia, hypo-pit abN

Hx:

• ID - age, GTPAL • CC - amenorrhea • HPI

• pubertal milestones

• menstrual Hx - ?age of menarche, cycles, duration, etc....

• if primary --> prolonged intense exercising, xs dieting, social issues, psych issues

• ?sexually active --> r/o pregnancy

• Sx of estrogen def --> hot flushes, night sweats • signs of ovulation --> moliminal Sx

• other Sx

• galactorrhea, recent wt gain, H/A, visual changes • Sx of virilization

• use of contraception • PObsHx/PGyneHx

• paps, STDs

• prev pregnancies --> ?Sheehan's syndrome • PMHx

• prev radiation therapy • prev chemotherapy • FHx • delayed/absent puberty • SHx • meds/allergies Phys exam:

• General: Tanner staging, assess stature, hair distribution (androgen xs/insensitivity) • HEENT:

• palpate thyroid --> enlarged, nodules • CVS/pulm

• abdo:

• palpable masses, inguinal hernias • GU:

• external genitalia, vagina --> atrophy, clitoromegaly, imperforate hymen, vaginal septum, evidence of estrogenization of hymen, absence of vagina • bimanual exam

• neuro:

• visual changes

Investigations:

• beta-hCG, hormones (FSH, LH, androgens + estradiol) • TSH, prolactin, cortisol/ACTH (Cushing's)

• progesterone challenge --> assess estrogen status • Provera 10 mg OD for 10 days

• any uterine bleed w/in 2-7 days after completion --> positive test, withdrawal bleed (adequate estrogen)

• no bleeding --> hypoestrogenism, or xs androgens • karyotype if indicated --> if premature ovarian failure • US --> confirm anatomy, PCOS

Rx:

1.) hypothalamic dysfxn (low/N FSH, LH)

• if FSH/LH low --> consider CT/MRI of head

• stop meds, reduce stress, adequate nutrition, decrease xs exercise • clomiphene citrate if pregnancy desired

• otherwise OCP to induce menstruation (withdrawal bleed) 2.) hyperprolactinemia

• bromocriptine if fertility desired, OCP if not • surgery for macroadenoma (rarely)

• consider CT head --> document presence of pit micro/macroadenoma 3.) premature ovarian failure (high FSH, LH)

• Rx assoc autoimmune disorders --> thyroid, adrenal

• HRT or OCP to prevent manifestations of hypoestrogenic state • karyotype

• removal of gonadal tissue if Y chromosome present (at 18yrs or earlier if dysgenic gonads)

4.) PCOS

• cycle control

• lifestyle modification to decrease peripheral estrone formation --> decrease BMI, exercise

• OCP or cyclic Provera --> prevent endometrial hyperplasia (unopposed estrogen)

• oral hypoglycemia (metformin, rosiglitazone, pioglitazone) • infertility

• ovulation induction --> clomid • bromocriptine if high prolactin • hirsutism • OCP

Pelvic Mass

Differential: • Gyne • Ovary

• functional ovarian cyst, neoplasm (epithelial, germ cell, stromal, metastatic, tubo-ovarian abscess, endometrioma, ovarian pregnancy)

• Fallopian tube

• tubal pregnancy, tubal cyst, abcess, tubal carcinoma • Uterus

• pregnancy, fibroids, uterine ca, polyps, gestational pregnancy, endometrioma, adenomyoma, sarcoma, anomaly

• Cervix

• polyp, fibroid, cancer, hematoma, ectopic • Non-Gyne