Obgyn Study Guide.docx

OBGYN study guide Health maintenance 1.Contraception 2.Abortion 3.Typical health screening guidelines Teens: Tanner staging <24 y/o, chlamydia and gonorrhea, HIV Young adult: breast exam @20, pelvic exam @21, HPV @21 40-64: colonoscopy (50 y/o, q10y), DM test (45y, q3y), Mammogram (40 y/o, q1y), lipids (45 y, q5y) 65+: bond mineral density (65 y/o, q2)

HPV guidelines Start age 21: every 3 years, cytology alone >30: Co-test cytology with HPV every 5 yrs >65: stop if 3 consec neg cytology or 2 consec neg co-test, neg in past 10 yrs; no history of CIN2 or higher. Most recent, within 5y. OB Pregnancy Screening hCG (detect 6d), double x 2 days before 10 w TVUS: hcg>1500, can detect gestational sack Visits- <28w every month, 28-36w every 2-3w, 36-31 every week 1st trimester screen (11-13w): for Down’s mostly; Nuchal translucency, PAPP-A, bHCG; incrs NT, decrs PAPP-A, incrs bHCG Quad screen (15-21w): For down’s, edward’s, NTD. AFP, inhibin A, bHCG, Estriol. FP- confirm GA AFP- high levels: NTD, abdominal wall defect, fetal death, placental abruption, multi gestations, cystic hygroma, sacrococcygeal teratoma, oligo; low levels: trisomy, molar preggo Targeted US Anatomy scan (18-20w), every 4 w for growth

Estriol- low levels w/ 21, 18, 13 CVS (9-12w)- greater risk limb, can’t detect NTD Amniocentesis (15-20w)- fetal anomaly on US, abn quad, FHx congenital abnormalities, lung maturity Cordocentesis (>17w): FISH- sensitive, karyotype- not as sensitive GTT one hour, 50g (26-28w) Recheck AB screen, admin Rhogham (28w) GBS (36w), HIV testing (some states) Fetal movements (10 over 2 hr)-> NST-> 2 accelerations for 15 sec over 20 min, redo 1-2 hr  CST (negative- no decel, pos- late decal >50%, equivocal-intermittent late or variable, unsatisfactory- <3 contractions 10 min). C/I- PROM, preterm labor, prior C/S, placenta previa  BPP: NST, breathing >30 sec, moving x 3, tone (ext + flex), AFI (>5, pocket >2) Oligohydramnios: ROM, IUGR, GU malformation Poly: malformation (anencephaly, GI), DM, multiple gestation, anemia, virus

1.Postpartum hemorrhage DDX: Primary- uterine atony, placenta accrete, uterine inversion, lacs, rupture Secondary- retained products of conception, infection, inherited coags CARPIT- coag, atony, rupture, placenta, implantation, trauma to GU RF: prolonged, augmented, or rapid labor, hx PPH, operative + episiotomy (esp ML), PEC, overdistended uterus, chorioamnionitis Hx: uterine atony- soft & boggy uterus -> lacs Dx: US- normal endometrial stripe (<5mm); CBC, PT, PTT, fibrinogen, T&S Tx: uterine massage, 2 large bore IV, crystalloids, T&S, vials, I&O’s uterotonic agents- oxytocin (s/e hypotension), methergine (c/i-HTN), hemabate/PGF2a (c/I asthma), dinoprostone/ PE2 (suppository, s/e hypotension), misoprostol/PGE1 (rectal) Tamponade- packing, bakri balloon Exploratory lap w/ B-lynch suture (uterine atony) Worst case- UAE, hysterectomy, hypogastric aa ligation, ligation utero-ovarian lg POC- D&C VWFWhat to do? Prevention- oxytocin infusion, fundal massage Stage 1: IV access x 2, fluids, oxytocin, fundal, 1-methergine, 2-hemabate or misopristol, empty bladder, T&S x 2PRBC Stage 2: vaginal-balloon, repair tears, UAE; c-section: B-lynch, balloon 2.Cerclage Hx: 1+ 2nd trimester loss w/ painless cervical dilation w/o labor or abruption placentae; prior cerclage P/E: painless dilation cervix US: short cervical length before 24 weeks Indication: singleton, PROM <34w, short cervix <24w- w/o cervical insufficiency, cerclage recommended. For no history PROM- vaginal progesterone Transvaginal cerclage- 2nd trimester add, remove at 36-37 w Transabdominal- 10-14 w, non-pregnant state 3. HTN in preggo cHTN- prior to 20 weeks; Complications: superimposed preeclampsia- +proteinuria; abruptio placenta, IUGR, preterm Tx- labetalol, a-methyldopa, hydralazine, nifedipine gHTN PEC >140/90 x2 after 20 w or >160/110 short term, + proteinuria sPEC: PEC+/- proteinuria: thrombocytopenia (<100), renal (incrs BUN, Cr, C:P ratio), LFT’s, pulmonary edema, cerebral or visual symptoms HTN crisis>160/110 BP 1st line- IV labetalol, hydralazine, nifedipine; 1st line EC- Mg (<48 hr use, neuroprotection <32, prolong preg for steroids for those delivery w/in 7 d) S/E- labetalol (neonatal brady, avoid in asthma, HD, CHF)

Hydralazine (hypotension), Nifidepine (maternal tachy, overshoot hypotension) 2nd line- labetalol or nicardipine by infusion pump. Nitroprusside last resort (cyanide tox) Note: tocolysis not recommended <24 and >34 w 4.Late-term + Post-term postterm: >42w; late term: 41-42 RF: nulliparity, prior post-term, obesity, carrying M fetus, anencephaly + placental insufficiency C: neonatal convulsions, meconium aspiration, macrosomia, post-maturity syndrome, oligo, -lac, infection, PPH, C/S Tx: BPP 41 w +, can induce 41-42 week, def 42+ Delivery- oligo 41w+ Episiostomy Indication: FHR, shoulder dystocia, operative delivery, potential for large lac (short perineal body, previous lac, LGA. (does not provide peritoneal protetction, helped op delivery, improved neonatal outcome GALMP, 1st sem US- crown rump length, 2nd sem- BPD, FL, AC. If 1st sem> 1 week, or 2nd sem > 2 weeks use 5.IOL Indications: postterm, PROM >12 hr, HTN series, fetal demise, DM, FGR, twins, chorioamnonitis, abruptio placentae, oligo, cholestasis of pregnancy, IUGR, abn fetal testing, prolonged labor. + Bishop score<6, verification >39 w (US’s atleast 39w, 36 w +hcG, FHT >30w)

C/I: high risk C/S, uterine rupture, placenta previa, vasa previa, herpes, transverse lie, invasive cervical cancer, FHT III, <39 w, prior myomectomy SE: uterine hypertonus, tachysystole, rupture. Fetal hypoxia. Prolapsed cord. Precipitous labor. FHR III- discontinue oxytocin, turn side, give O2 and IV fluid. 2- terb Cervical ripening: <6w, mechanical or chemical (misoprostol/PGE1 or PGE2/dipnoprostone) IOL: oxytocin, membrane stripping, AROM, nipple stimulation Note: before 28w, vMisoprostol most effective. Avoid misoprostol for IOL 3rd trimester TOLAC Candidates: one lTCS, no scars, no previous rupture C/I: classical C/S, inability to form emergency CS 6. Placenta accreta (increta-myometrium only, percreta-myometrium + serosa) RF: C-section w/ previa over scar Dx: US- irregular shaped placenta lacunae, turbulent flow, thinning myometrium, loss of clear space Tx: C/S 34w, leave placenta. 2-UAE, hysterectomy 7. Preterm birth (20-37w) Tx: definite history- 17-a hydroxyprogesterone caproate IM 15-36w, singleton birth, TVUS every 2 w, <25mm before 23w, consider cerclage. Maybe history w/ TVUS<20mm, vaginal progesterone 8. Preterm labor Tx: hydration (decrs ADH), BM therapy- repeat steroids if >7d, no abx unless GBS C/I: IUFD, fetal anomaly, nonreassuring FHT, PEC/EC, maternal bleed, chorioamnionitis, PPROM (unless for steroid admin), 9. Shoulder dystocia RF: abn pelvic anatomy, GDM, post-term, short, obese, macrosomia, protracted labor Dx: turtle sign, failure of external rotation, resistance delivery of anterior shoulder Tx: Call for help, 1-Mc robert’s maneuver (incrs AP), suprapubic pressure obliquely, episiostomy 2-delivery of posterior arm, woods corkscrew (posterior shoulder rotate 180), rubin (push shoulder anterior toward fetal chest) 3-fracture of clavicle, zavanelli maneuver, abdominal rescue, symphiosotomy Complications:b rachial plexus injury, fetal humeral/clavicle fx, hypoxia/death 10.C/S indication- labor dystocia, FHR, malpresentation, multiple gestation, macrosomia, HSV Prolonged 1st stage (NP >20, MP>14h), oxytocin >4h Prolonged 2nd stage (NP>3, MP>2h) 11. Thrombophilia Prior DVT- prophylactic dose LMWH or UFH Low risk: heterozygous factor V or prothrombin; protein C or S deficit Surveillance unless prior VTE, LMWH High risk: antithrombin deficit; heterozygous prothrombin and factor V Surveillance or prophylactic- no VTE

Prior VTE or 1st degree relative- prophylactic LMWH/UFH Warfarin, LMWH,hep- ok for breast feeding Testing for inherited b/c recurrent loss, placental abruption, PEC, FGR not recommended. MTHFR screening not recommended- not related to neg preggo outcomes Screen for factor V leiden, PT g20210A, antithrombin, protein C and S deficits 12. Thrombocytopenia DDx: gestational thrombocytopenia (no incrs risk maternal or fetal bleeding), pseudothrombocytopenia, HIV, drug-induced, PIH, HELLP, TTTP, HUS, DIC, SLE, APL, pregnancy induced HTN Neonatal alloimmune thrombocytopenia- tx IVIG ITP C/S not helpful to prevent IC hemorrhage-> tx prednisone, short-platelet transfusion, 2-IVIG, 3-splenectomy. Additionally, insufficient data recommend med therapy for fetal indications Epidural safe >100 ITP avoid NSAIDs, aspirin, trauma; Vax Hflu Mild thrombodytopenia (<70), monthly platelet counts 13. DM Type 1- IUGR, caudal regression, cardiac anomalies, NTD, still births, perinatal death Type II- macrosomia, preterm, neonatal hypoglycemia, hypocalcemia, hyperbili, polycythemia Tx- A1 diet controlled; A2 and all else is insulin Goal: <100 preprandial, <140 and <120 postprandial, HbA1C, folic acid, ECG, optho exam, P:Cr ratio, At 32-34 w for A2: BPP, US every 4 weeks A1: delivery 41-42 2; A2: delivery 39-42w, insulin drip during labor 14. Twins Incrs risk for fetal anomalies Monochorion- TTSS=> serial amniocentesis, laser coagulation IOL at 38w 15. Bleeding during pregnancy + abortions 1TM bleeding- spontaneous abortion, ectopic, hyadtiform mole, CA, trauma Hx- vaginal bleeding +/- abd pain PE- VS, pelvic exam; hCG, CBC, T&S, Rh antibody, US Periviable birth (20-26 w) Ectopic pregnancy Non-ruptured Beta <50% rise in 48 hrs Fetal pole outside uterus, discriminatory level (beta >2000) MTX Ruptured Hx: severe acute pain Labs: CBC (anemia) TVUS: no IUP, free fluid FHR baseline- 2 minutes/10 mins mean, >10 min is new baseline Tachy- hypoxia, infxn, maternal fever, drugs BTBV: decrs- acidemia (maternal and fetal), asphysxia, narcotics, Mg, barbituates, neuro abnormality. Incrs- mild fetal hypoxemia. Accelerations- 30 sec +, greater than 15 sec above baseline Decelerations- 30 sec + Variable decel: <30 sec, greater than 15 bpm; give amnioinfusion Prolonged decal 2-10 min, maternal hypotension, cord compression, cervical exam, uterine hyperactivity Sinusoidal: 3-5 cycles per minute, >20 min

GYN 1.Pelvic organ prolapse (POP) Anterior compartment- hernia of anterior vagina, assoc w/ cystocele Posterior “ -hernia of posterior vagina, assoc w/ rectocele Enterocele- hernia of intestines through vaginal wall Uterine prolapse/vaginal vault prolapse- uterus, cervix, vagina (uterine procidentia is all 3) RF: parity, advancing age, obesity, hysterectomy, race (Latina + white>AA) Hx: “bulge, falling out of vagina,” Stress incontinence, constipation or incomplete emptying Tx: expectant management, conservative- vaginal pessary (obstetric conjugate- ring + donut, cube, gellhorn), pelvic floor muscle training, estrogen, surgery (recurrence 30%), biofeedback, functional electrical stimulation C/I: noncompliant S/E: irritation of vaginal mucosa, ulcers, necrosis, migration 2.Adnexal masses DDx- GYN: CA, ectopic, leiomyoma, TOA, hydrosalpinx, torsion, corpus luteum cyst, theca lutein cyst Non-GYN RF malignancy: age, post menopause, nulliparity, early menarche, late menopause, FHx Hx: constitutional, lymphadenopathy, ascites, mass characteristics- irregular, fixed, nodular, firm DX: 1-TVUS, 2-CBC, bHCG, Ca-125- only PM, AFP, LDH TOA- aspiration C/I for suspected CA

bHCG

AFP

LDH

CA-125

Dysgerminoma

+

-

+

-

Choriocarcinoma

+

-

-

-

Immature teratoma

-

+

+

+

Embryonal carcinoma

+

+

-

-

Probably Benign Patient Characteristics

+pregnant +pre-menopausal

Physical Exam

Imaging

Serum markers

Likely Malignant +age >60s +post-menopausal +constitutional sx (early satiety, weight loss) +lymphadenopathy +ascites Mass characteristics: +irregular, firm, fixed, nodular

+simple appearing +no solid components +no internal blood flow

+cyst size >10cm +papillary/solid +irregularity +ascites ++Doppler flow

*CA-125 may be elevated in certain benign conditions

CA-125 bHCG, AFP, LDH if less common pathology suspected

3.Premenopausal bleeding P/E: (1)myoma- abdominal mass, irregularly enlarged uterus; (2)symmetric enlarged- adenomyosis, endometrial CA (3)visualization of lesions (vulva, vagina, cervix) (4)iatrogenic- IUD, OCPs, DMPA, anticoag, trauma/FB (5)endometritis- listeria, BV, mycoplasma, Neisseria, chlamydia, Staph, GBS, anaerobes, TB (6)Ovulatory disorders- PCOS, perimenopause/premature ovarian failure, stess/exercise (7)Pregnancy- miscarriage, ectopic, hyadtiform mole, physiologic- ectropian, implantation bleeding Dx: sonohysterography, endometrial biopsy, hysteroscopy, D&C 4.Postmenopausal bleeding Etiology: CA (6%), hyperplasia, polyp (37%), fibroid (6%), proliferative/secretory (14%), AVM NonGYN: thyroid, coagulopathy- uremia, liver dysfnx, congenital, , rectal bleed, urologic (1)Atrophy (30%)- spotting, dyspareunia, itch, burn -> POP. Tx- HRT, vaginal estrogen cream (isolated) (2) Polyps (30-40%)- RF age, tamoxifen, obesity, HRT, lynch, cowden Hx-intermenstrual bleeding Dx- TVUS, sonohysterography or hysteroscopy Tx- polypectomy. Give IUD if on tamoxifen (3) Uterine leiomyomas (fibroids- submucosal cause bleed) PE: enlarged, mobile uterus w/ irregular counter DX: pelvic US, saline infusion sonography Tx: OTC, raloxifene, aromatase inhibitors; hysterectomy, myomectomy, endometrial ablation, UAE (4) Adenomyosis Hx: dysmenorrhea, menorrhagia, also PM on hormone therapy PE: symmetrically enlarged uterus Tx: hysterectomy ()Endometrial hyperplasia- hx bleeding. Prolonged or heavy RF: unopposed estrogen- obesity, age, estrogen, tamoxifen, early menarche, late menopause, nulliparity. FHx- lynch, cowden, endometrial, ovary, breast, colon. DM, estrogen secreting tumor. Dx: TVUS, f/u biopsy if >4mm thick, heterogeneous echo, endometrium not visualized Tx: w/o atypia- MPA; w/atypia- progestin, IUD. Definitive tx- hysterectomy ()Endometrial CA RF: type I (estrogen dep, 90%, hypertrophic), type II (estrogen ind, PM, atrophy) Hx: isolated vaginal bleeding (80-90%), enlarged uterus Dx: TVUS, endometrial biopsy or D&C, Ca-125 pre and post Tx: staging, hysterectomy +BSO + para-aortic LN dissection Sarcoma of uterus- hysterectomy for dx Fallopian tube or ovarian Cervical and vaginal CA Vulvar (nor associared w/ bleeding until advanced) Choriocarcinoma (7) Iatrogenic cause- perimenopausal combined HRT, tamoxifen, Post radiation therapy, steroids, anticoags, SSRI, TCA, antispychotics Endomyometritis- TSS Endometritis