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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: history of CC: OPQRST, associated aggrevating/allieviating factors

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: A. Pre-existing Hypertension

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: Neuro: hyperreflexia

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 History:

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 Treatened Inevitable Description bleeding +/- cramping Cx closed no tissue passed U/S; void physical activity/ intercourse if no FHR: allow to spont. pass vs D&C bleeding + cramping Cx open no tissue passed D&C +/- oxytocin no more bleeding Cx closed uterine cavity empty U/S D&C if retained fragments baby retained but dead Cx closed U/S D&C monitor for DIC if >12wks resuscitate patient amp+gent or clinda D&C +/- oxytocin

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

Recurrent Therapeutic

three or more consecutive losses investigations: karyotype, assess structural abnormalities, assess autoantibodies 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 coags: PT, PTT, fibrinogen, D-dimer

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

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: treat cause

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 Antepartum hemorrhage

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 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 LOCATION

Dx

1000 - 1200 w/o +ve U/S laparoscopy for definitive Dx may pass entire decidua at once and look like a SA ID --> HPI age, GTPAL, GA (LNMP, cycle length, pregnancy tests, contraception)

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 Maternal: previous classical C/S or myomectomy Maternal-Fetal: Oligohydraminos, previa, PROM, prev T3 bleed Fetal: IUGR, congenital abnormality

>37 weeks GA, unengaged, External singleton, reactive version-->tocolysis, NST. analgesia, U/S guided (lots of fluid) +/- Rhogam (multiparity) (small baby) Maternal: Adequate pelvis Fetal: >36 GA, 2200-3800 grams, continuous FHM, flexed head

Abruption Cord compression Uterine rupture

Vaginal Delivery

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 11. Zavanelli's Maneuver: cephalic replacement -> emerg C/S

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 No episodes sequence (tone) N = 8 10 6 repeat in 24 hrs 0 4 deliver ASAP AVF = marker of CHRONIC hypoxemia All other parmeters indicate ACUTE hypoxia Hypoxemia conserve oxygenated blood for brain, heart, adrenals renal aa constriction pre-renal failure 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%) Hb, pH, blood gases
Intrapartum:

FHM 120 160 = baseline o brady hypoxia (late) CHD, drugs (b-blockers, etc)

tachy hypoxia (early) 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 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 late in contraction, most common type of (onset early in contraction, lowest depth AFTER peak periodicity seen during return to baseline by end of of contraction, return to labour contraction), gradual decel baseline after end of contraction due to vagal response to due to fetal hypoxia + due to cord compression or head compression acidemia, maternal forceful pushing w/ hypotension, uterine contractions hypertonus often repetitive, NO effect may cause decreased may/may not be repetitive, on baseline FHR or variability + change in often w/ abrupt drop in variability baseline FHR FHR, usually no effect on baseline FHR or variability BENIGN usually seen w/ MUST see 3 in a row, all BENIGN unless repetitive, Cx dilation of 4 7 cm w/ same shape to define a w/ slow recovery, or when late decel assoc w/ other abN of FHR OMINOUS usually sign rule of 60s (for severe var of uteroplacental decels) decel to < 60 bpm insufficiency >60 bpm below baseline >60sec in duration w/ slow return to baseline *Pathophys of variable decels Veins compressed before arteries decreased venous return decreased BP stim baroreceptors HR increases further contraction compresses arteries increased PVR increased BP stim baroreceptors HR decreases contraction ends opens vessels decreases PVR BP drops stim baroreceptors HR accels + overcompensates at first o

Diagnosis of Labour
o defn of labour regular, painful contractions

o assoc w/ progressive DILATATION and EFFACEMENT of cervix and DESCENT of presenting part (STATION) cervical changes preterm > 20, < 37 wks GA term 37 42 wks GA post-term > 42 wks GA Braxton-Hicks contractions false labour o Irreg, occur throughout pregnancy o NOT assoc w/ any dilation, effacement or descent Four Stages of Labour 1st stage 2nd stage 3rd stage 4th stage from full dilation to separation + expulsion time for uterus to latent phase delivery of baby of placenta return to baseline state contractions infreq/ (may last wks) irreg, slow Cx dilation* (to 3 4 cm) and effacement aka puerperium active phase rapid progress measured by lasts up to 30 min descent before intervention Cx dilation to 10 cm indicated (nullip >1.2 cm/hr, multip >1.5 cm/hr) active max slope on avg duration multip oxytocin IV drip or 10 U IM after delivery of Friedman curve 20 min anterior shoulder nullip 50 min active painful, regular contractions q2min, lasting 60 90 sec *3cm for multip, 4 cm for nullip - prolonged latent phase nullip > 20 hrs, multip > 14 hrs dysfxnl labor 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 2.) engagement presenting part at ischial spines, BPD has passed inlet of true pelvis

3.) 4.) 5.) 6.) 7.)

flexion allows smaller diameter to present through mid-pelvis internal rotation (to OA ideally) extension delivery of head external rotation (restitution) head rotates in line w/ shoulders expulsion 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

Background:

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, bad bladder habits, neurologic disorders, anticholindergics

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 TORCH infections

multiple gestation congenital anomalies Clinical Features: symmetric (type I) - 20% occurs early in pregnancy inadequate growth of head and body head : abdo ratio may be NORMAL usually assoc w/ congenital anomalies or TORCH infections asymmetric (type II) - 80% occurs late in pregnancy brain sparing - head : abdo ratio INCREASED usually assoc w/ placental insufficiency more favorable prognosis than type 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 severe cases --> hospitalize, consider therapeutic amniocentesis

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: bed rest

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: (see course pack)

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 ASCUS

generic/infxn: repeat in 4mo HPV changes: colpo 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 if abN: cone Bx

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 placenta

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 oxytocin 20 U/L NS or RL continuous infusion, plus may give 10U intramyometrial (IMM)after placenta delivery

Surgical therapy (intractable PPH) D&C --> may cause Asherman's syndrome w/ vigorous scraping

Hemabate laparotomy w/ (carboprost) 0.25mg bilateral ligation of IM/IMM q15min up to uterine artery (may max 2mg be effective), synthetic PGF-2 internal iliac artery alpha analog, (not proven), ovarian contraindicated in artery, or hypogastric CV, pulm, renal, artery hepatic dysfxn 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.) 2.) 3.) 4.) 5.) 6.)

breast engorgement or mastitis (S. aureus) wind --> atelectasis, pneumonia water --> UTI wound --> C/S incision, episiotomy walking/veins --> pelvic thrombophlebitis (Dx of exclusion), DVT, IV site cellulitis 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 pain in both breasts just after baby starts to suckle, settles in few months

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

GI

appendix: appendicitis, abscess, neoplasm colon: inflammatory bowel disease, diverticulum/abscess, carcinoma, mesenteric cyst, meckel's, other ca, constipation Urologic bladder/urethra: diverticulum, neoplasm, endometriosis, bladder distension kidney: pelvic kidney, neoplasm, anomaly, abscess Other MSK, neuro, endocrine, lymphoma, metastatic ca History: ID: HPI:

OPQRST (esp timing with menses) bowel: diarrhea, constipation, dyschezia, BRBPR, melenia, N/V, anorexia bladder: incontinence, blood per urethra vagina: bleeding, discharge, intermenstrual bleeds, dysparunia, infertility constitutional S/S: fever, wt loss current Gyne Hx: menses: sexual: STDs, PID, contraception paps/procedures: PGyneHx: PObsHx: PMHx: PSHx: All: Meds: FHx: ca (breast, ovarian, colon, endometrial), fibroids SHx:

Physical: appearance: vitals: FHR: H+N: CVS: resp: GI: GU: MSK: Neuro:

Investigations: bloodwork: CBC/d, +/- type and screen B-hCG, AFP, CA-125 urine: urinalysis cervical:

pap swabs imaging: vaginal or pelvic U/S CT, MRI barium enema IVP

Pelvic Pain
Differential: Acute Gyne

PID torsion (ovarian, fibroid) rupture (ectopic, ovarian cyst) vaginismus Non-Gyne piriformis spasm/levator spasm appendicitis kidney stones diverticulitis UTI perforation Chronic Gyne Menses-related Dysmennorhea Mittleschmurtz PMS Endometriosis Adenomyosis Non-menses related Fibroids Neoplastic Benign cysts Non-Gyne adhesions IBD IBS Psychogenic Neoplastic History: ID: HPI:

OPQRST (esp timing with menses) bowel: diarrhea, constipation, dyschezia, BRBPR, melenia, N/V, anorexia bladder: incontinence, blood per urethra vagina: bleeding, discharge, intermenstrual bleeds, dysparunia, infertility

constitutional S/S: fever, wt loss current Gyne Hx: menses: sexual: STDs, PID, contraception paps/procedures: PGyneHx: PObsHx: PMHx: PSHx: All: Meds: FHx: ca (breast, ovarian, colon, endometrial), fibroids SHx:

Physical: appearance: vitals: FHR: H+N: CVS: resp: GI: GU: MSK: Neuro:

Investigations: bloodwork: CBC/d, +/- type and screen B-hCG, AFP, CA-125 urine: urinalysis cervical: pap swabs imaging: vaginal or pelvic U/S CT, MRI barium enema IVP

Sexually Transmitted Infections (STIs)


Chlamydia most common bacterial STI in Canada; often assoc w/ N. gonorrheae screen high risk groups and during pregnancy Risk Factors: 1.) sexually active youth < 25 yrs old 2.) Hx prev STI

3.) 4.) 5.) 6.)

new partner in last 3 mo multiple partners not using barrier contraception contact w/ infected person Features: asymptomatic (70%) muco-purulent endocervical d/c urethral syndrome --> dysuria, freq, pyuria, NO BACTERIA pelvic pain post-coital bleeding or intramenstrual bleeding (esp if on OCP)

Clinical

Complications: actue salpingitis, PID, chronic pelvic pain infertility --> tubal obstruction from low grade salpingitis perinatal infection --> conjunctivitis, pneumonia ectopics Fitz-Hugh-Curtis syndrome (liver capsule infection) Reiter's syndrome --> arthritis, conjunctivitis, urethritis test of cure for chlamydia req in pregnancy --> cure rates lower in pregnant pop'n (retest in 3-4 wks post-initiation of Rx) Gonorrhea symptoms + RF same as w/ Chlamydia Neisseria gonorrheae Condylomata acuminata/Genital warts HPV --> most common viral STI in Canada (>60 subtypes total, >30 genital subtypes) type 16 + 18 --> most oncogenic (assoc w/ HSIL) types 6 + 11 --> assoc w/ genital warts CANNOT be prevented by using condoms Clinical Features: latent infection NO visible lesions --> detected by DNA hybridization tests asymptomatic subclinical infection visible lesion ONLY after 5% acetic acid applied + magnified OR found on pap test clinical infection visible wart-like lesion w/o magnification hyperkeratotic, verrucous or flat, macular lesions vulvar edema lesions tend to get larger during pregnancy --> C/S if birth canal obstruction Herpes Simplex of Vulva HSV type II (90%), type I (oral, 10%) Clinical Features: may be asymptomatic initial Sx present 2 - 21 days after contact prodromal Sx --> tingling, burning, pruritus multiple, painful, shallow ulcerations w/ small vesicles --> INFECTIOUS lesions

appear 7 - 10 days after initial infection inguinal lymphadenipathy, malaise, fever --> often w/ first infection dysuria, urinary retention if urethral mucosa affected Syphilis Treponema pallidum screen high risk groups, and in pregnancy 1/3 experience late complications if untreated Classifications: Primary syphilis --> 3 - 4 wks after exposure PAINLESS chancre on vulva, vagina, cervix painless inguinal lymphadenopathy serological tests usually NEG Secondary syphilis (can resolve spont) --> 2 - 6 months after initial infection nonspecific Sx --> malaise, anorexia, H/A, diffuse lymphadenopathy generalized maculopapular rash --> palms, soles, trunk, limbs conylomata lata --> anogenital, broad-based fleshy grey lesions serological tests usually POS Tertiary syphilis may involve ANY organ system neuro --> tabes dorsalis, general paresis CV --> aortic aneurysm, dilated aortic root gumma of vulva --> rare, nodule that enlarges, ulcerates, becomes necrotic congenital syphilis may cause fetal anomalies, stillbirths, neonatal deaths latent syphilis NO clinical manifestations, detected by serology only History: ID: age, GTPAL HPI: discharge (amt, color, odor, consistency, duration ,freq, relationship to menses, sexual activity, contraception) pain - OPQRST urethral Sx --> dysuria, hematuria, freq bleeding - IMB, PCB, quantify and characterize contraception - type used, use EVERY time? sexual activity - last episode, type of activity, STI protection partner - how long, his/her past sexual Hx + RF ?genital lesions other S/S --> rashes, burning/pruritus, conjunctivitis, arthritis, non-specific Sx LNMP - ?risk/suspicion of ectopic PGyneHx: prev STIs partner - men or women or both age of first sexual activity, new/multiple partners menses - duration, freq, dysmenorrhea, menorrhagia dyspareunia paps - freq, any abN PObsHx: PMHx/PSurgHx:

FHx: SHx: smoking, EtOH, recreational drugs, occupation Allergies: Meds: prev STD Rx, OCP Phys Exam: General appearance: HEENT: throat lesions, conjunctivitis, LN CVS/pulm: ?signs of tertiary syphilis abdo: tenderness, inguinal LN GU: external exam - visible lesions, erythema, edema, obvious d/c or bleeding speculum exam - d/c, bleeding bimanual exam derm: rashes MSK: joint inflamm (Reiter's) Investigations: cervical culture - chlamydia, gonorrhea rectal + throat culture - gonorrhea gram stain - GN intracellular diplococci (gonorrhea) PCR - chlamydia, ?HPV (in U.S.), HSV cytology (pap smear) HPV - koilocytosis (nuclear enlargement + atypia w/ perinuclear halo HSV - multinucleated giant cells, acidophilic intranuclear inclusion bodies Bx of visible + acetowhite lesions at colposcopy - HPV viral culture for HSV if ulcer present syphilis investigations aspirate of ulcer serum or node darkfield microscopy --> most sens + specific for syphilis (spirochetes) VDRL, RPR - non-treponemal screening tests, non-reactive after Rx FTA-ABS - specific anti-treponemal antibody tests Management: chlamydia doxy 100mg po BID x 7days, or azithro 1g po x 1 dose (may use in pregnancy) treat partners!! REPORTABLE disease gonorrhea ceftriaxone 125mg IM x 1 dose, cefixime 400 mg po x 1 dose, or cipro 500 mg po use cephalosporin in pregnant (avoid quinolones), or 2g spectinomycin IM PLUS doxy or azithro --> Rx concomitant chlamydial infection treat partners!! REPORTABLE disease condylomata acuminata (HPV) patient applied podofilox 0.5% sol'n or gel BID x 3days, then 4 days off, then repeat x 4 wks imiquimod (Aldara) 5% cream 3x/wk qhs x 16 wks given by provider cryotherapy w/ liq nitrogen q1-2 wks

HSV

podophyllin resin in tincture of benzoin - weekly (contraindicated in pregnancy) TCA or bichloroacetic acid weekly - safe in pregnancy surgical removal/laser intralesional IFN imiquimod, podophyllin, podfilox --> do NOT use in pregnancy

1st episode --> acyclovir 400mg po TID x 7-10 days, or famciclovir 250mg TID, valacyclovir 1g BID recurrent episode --> acyclovir 400 mg po TID x 5 days, or famciclovir 120mg BID, valacyclovir 500mg BID x 3-5days daily suppressive Rx --> consider if 6-8 attacks/yr acyclovir 400mg po BID, famciclovir 250mg BID, valacyclovir 500mg severe disease --> acyclovir 5-10mg/kg IV q8h x 5-7days eduate re: transmission avoid contact from prodrome until lesions cleared BARRIER contraception syphilis Rx primary, secondary, latent syphilis of <1 yr duration PenG 2.4 mill units IM treat partners!! REPORTABLE disease Rx latent syphilis > 1 yr duration PenG 2.4 mill units IM q week x 3 wks Rx neurosyphilis IV aqueous penicillin

Vaginal Discharge
Hx: 1.) ID - name, age 2.) CC - vaginal d/c 3.) HPI - characterize d/c color, consistency, odor, quantity, duration, freq relationship to menses, sexual activity, contraception 4.) Assoc Sx pain, dysmenorrhea, dyspareunia bleeding --> duration, freq, quantity, #pads/clots, relation to menses/sex pruritus urinary Sx --> dysuria, hematuria, urgency, frequency fever, chills, rigors, fatigue sores, rash, swelling, warts 5.) PObsHx GTPAL, etc.... 6.) PGyneHx LMP, cycle length, cycle regularity BCPs, STDs pap smear - date, result abortions, ectopics surgery douching, foreign body infertility 7.) Sexual Hx

sexually active? age of 1st sexual activity? # of partners in lifetime, M/F/both? oral, vaginal, anal intercourse types of protection used, consistency of protection use PHx of STD + Rx partners w/ STD trauma/pain during sex travel Hx, sexual contacts while travelling pregnant? 8.) PMHx (incl HIV, immunosuppression), PSurgHx, SHx, FHx 9.) Meds/allergies --> BCP, HRT Phys exam 1.) speculum exam --> look for discharge, cervical friability, yeast, cervical lesions, foreign bodies 2.) vulvar inspection --> atrophy, irritation 3.) bimanual exam --> masses Investigations 1.) swab for gonorrhea/chlamydia 2.) swab for vaginosis/trich 3.) wet mount for trich/vaginosis DDx 1.) physiologic neonate period --> greyish sticky d/c w/ possible blood due to maternal estrogens 6 - 12 mo prior menarche --> thin whitis d/c mid-cycle discharge --> high estrogen states --> pregnancy + OCP use 2.) neoplastic --> VAIN, vaginal squamous cell, cervical CA, fallopian CA 3.) infectious cervicitis --> gonorrhea, chlamydia vulvovaginitis --> BV, Candida, Trichomonas, polymicrobial pyosalpinx, salpingitis 4.) local genital tract inflamm (non-infectious) chemical irritants, douches, sprays, foreign body, IUD, trauma, atrophic vaginitis, desquamative inflamm vaginitis, focal vulvitis 5.) systemic etiology TSS, Crohn's, collagen disease, dermatologic 6.) other --> enterovaginal fistula Bacterial Vaginosis 1.) Dx fishy odour grey-white thin, sticky, homogenous d/c POS whiff test clue cells on gram stain, lack of WBC + lactobacilli pH > 5

2.) Rx Flagyl 500 mg po BID X 7 days or 2g single dose Candida 1.) Risk factors Abx diabetes HIV high estrogen states vaginal contraceptives stress 2.) Dx white, cottage cheese d/c pruritus (+ excoriations) vulvar burning w/ intercourse local edema + hyperemia NEG whiff test hyphae + buds on KOH slide pH < 5 3.) Rx miconazole (monostat) X 10 - 14 days OR clotrimazole (canestan) X 1 - 7 days OR fluconazole 150 mg po single dose terconazole for resistant Candida Trichomonas 1.) Dx frothy grey-white to yellow-green copious d/c, pooling of d/c pruritus (occasional), dysuria, dyspareunia local edema + erythema, strawberry cervix or vagina POS whiff test trichomonads on wet mount --> MOTILE pH > 5 2.) Rx flagyl 2gm single dose + Rx sexual partners wait until after 1st trimester if pregnant Chlamydia 1.) Dx mucopurulent d/c hypertrophic cervical inflamm do culture 2.) Rx azithro, doxy Gonorrhea 1.) Dx may be asymptomatic urinary grequency, dysuria 2.) Rx cipro