3. Sexual History
Pleasure – are you satisfied, how long have you been dissatisfied, what is problem – interest, sensation, dryness, orgasm, erection, pain
25. Cervical Cancer Screening
• ASCCP guidelines
• Start screening age 21
• Q3y until 30
• Q5y 30-65 if cotesting with HPV
• Some studies doing HPV first with reflex pap
• HPV vaccines
45. Ectopic pregnancy
• RF: PID, past ectopic, IUD, ligation, tubal surgery
• Triad: amenorrhea, vaginal bleeding, unilateral pelvic pain, fever,
hypotension
• See on TV US by HCG >1500
• BHCG should double every 2 days
• Tx
• Unstable vitals -> may be ruptured -> emergency laparotomy
• Methotrexate
• Qualiftying criteria: <3.5cm, Absence of fetal cardiac activity, HCG <6000
• Day 1 MTX
• Day 4 recheck HCG – no significant increase or decrease
• Day 7 recheck HCG – 15% decrease from Day 4
• Salpingostomy or salpingectomy
• Rhogam if needed
• Continue to follow HCG
54. Preconception
• Discuss with a couple who is planning a pregnancy:
• Start PNV 400 mcg* (prenatal vitamins) now!
• Look over her med list
• Hereditary diseases (Sickle cell, Thalassemia, CF)
• Modifiable risk factors for preterm labor
• Work-related exposure to infectious agents or chemicals
• Modifiable risk factors for contracting infectious diseases
• History of physical, emotional, or sexual abuse
• Alcohol and tobacco use. Substance abuse
• Personal or FHx of GDM
• Rubella & Varicella immune?
56. Initial Prenatal
• Discuss nutrition, morning sickness, PNV, Breastfeeding
• 1st tri dating u/s (most accurate between 10w-13w6d)
• Bloodwork: CBC, Blood Type and Rh status (Type & Screen), RPR, Rubella, Varicella IgG, HBsAg,
HIV, Hep C
• UA and urine culture (treat even if asymptomatic UTI)
• Urine drug screen (depending on population being treated)
• GC/Chlamydia
• Varicella IgG if no h/o Chicken Pox
• In women of African, Southeast Asian, and Mediterranean descent, screen for
hemoglobinopathies
• Pap smear (if not up to date, and pt is >21)
• 1 hour OGTT (If BMI >35, or there is a Hx of GDM)
• TSH (If at risk, strong FHx, prior IUFD, prior Macrosomia)
• 1st trimester screening if desired (NT, B-hCG, PAPP-A)
• FHT’s heard w/ Doppler by week 12 for sure
66. Postpartum visit
• Edinburgh Postnatal Depression Scale
• The 9 B’s of the Post-Partum visit: Baby, Breast or
Bottle feeding, Blues, Bleeding, Bladder, Bowels,
Birth control, Banging
• Look up last PAP smear
• Kegel exercises (3-5 reps of 10 per day)
• Contraception counseling
67. Nausea and vomiting in
pregnancy
• Vit B6 (pyridoxine) 25 mg PO q6-8h
• + doxylamine 12.5 mg PO q6-8h
• + promethazine 12.5-25 mg q4h PO OR
dimenhydrinate 50-100 mg q4-6h PO
• + reglan 5-10 mg PO
• + IVF +/- thiamine, folic acid
• + methylprednisone 16 mg q8h PO OR
Zofran 8mg q12h
68. Hyperemesis
• Severe n/v, dehydration, fatigue, electrolyte
abnormalities
• US – check for only 1 fetus
• check TSH
• place on scheduled IV benadryl, reglan, zofran, and
pepcid
• IV thiamine x3 d
• Clears, IVF @ 125/hr
• daily weights and nutrition consult
72. Asymptomatic bacteuria / UTI
Macrobid
(Nitrofurantoin)
100 mg BID 5-7d NOT for pyelo, 1T, at term
Daily for ppx (2+ utis during pregnancy)
Bactrim (TMP-SMX) 800/160 BID 3d NOT for 1T, term
Keflex (Cephalexin) 500 mg q6h 5-7d
Ampicillin 250-500 mg q6h 3d Enterococci
Levaquin (Levofloxacin) 250 mg qd 3d Only if resistant to others
Cipro (ciprofloxacin) 250 mg BID 3d Only if resistant to others
Cefpodoxime 100mg BID 5-7d
Fosfomycin 3g orally 1x NOT for pyelo
Amox-Clav 875 mg BID 5-7d
73. G HTN• Chronic HTN
• Pressures must be >140/>90, 2x 4 hours apart
• Deliver at 38-39 weeks
• PIH labs qTrimester, baseline EKG
• Gestational HTN
• >20 week onset
• Tx if >160/>110
• Baseline PIH labs
• Acute Severe HTN
• >160/>110 persistent for >15 minutes with repeat check:
• Labetalol 20mg IV—15 min, repeat x4
• Hydralazine 10mg
• Deliver IV meds over 2 minutes*
• Pre E
• Superimposed PreE = >20wk +/- new proteinuria
• Mild: NST 2x/week, growth scan q3wk. No Mg or steroids; deliver at 37 weeks.
• Severe: NST daily, BPP 2x/week, growth scan q2week. Deliver at 34 weeks. Steroids if <34. Mg OK.
• If unstable, Mg and steroids. Deliver ASAP (severe features)
• Stable: daily NST, BPP 2x/week, growth scan q2 weeks
• HELLP: steroids if <34 weeks + deliver ASAP
• *Pre E labs: CBC (Hb, plt), CMP (Cr, LFTs, Alp Phos), Uric Acid (>5), LDH (>250), Pr:Cr >0.2
• Postpartum Pre E
• Tx BP if >150/>100
• Urine protein if symptomatic
• Mg if Pre E
• HA, biggest predictor
78. FHR
• Reactive NST: 2 accels in 20 minutes, no decels, Moderate variability, normal HR
• DR C BRAVADO
• Determine Risk
• Contractions
• Baseline Rate (110-160)
• Variability (<5 minimal, 6-25 moderate, >25 marked)
• Accelerations (>32 weeks 15x15; 28-32 weeks 10x10)
• Decelerations
• Overall
• Category 1: Moderate variability, normal rate, +/- early decels and accels
• Category 2: Everything in between
• Category 3: ABSENT variability, bradycardia, variable lates/late decels recurrent
• General Measures: Maternal vitals, vaginal exam, o2, change position, IV fluids, scalp stim
• Fetal tachy: meds, maternal fever, infection
• Fetal brady: OP, post-dates, congenital anomalies
• If no accels after fetal scalp stim, d/c pit, signs of academia/hypoxia
• Recurrent variables—cord entrapment/prolapse (amnioinfusion)
• Recurrent lates—uteroplacental insufficiency, epidural hypotension, tachysystole (d/c pit)
80. NST
• Not during labor, only before
• Reactive vs nonreactive – 2 accels / 20m
• <32w 10bpm x 10s
• >=32w 15bpm x 15s
• Without any concerning decels
• +/- contractions
81. BPP
• NST – reactive or nonreactive modified BPP = NST + AFI
• Amniotic Fluid Index
• <5 cm: oligohydramnios
• 5-8 cm: borderline
• 9-25 cm: normal
• >25 cm: polyhydramnios
• DVP: <2cm = oligo, >8cm = poly
• Gross body movements 3x/30 min
• Tone ext/flex 1x/30 min
• Breathing >30s/30 min
• Normal: 10/10, 8/8 (no NST), 8/10 if AFI normal
• Equivalent: 6/10 if AFI normal
• Possibly abnormal 6-8/10 with low AFI, consider delivery
• Abnormal: <6 – deliver if >34w, if <32w repeat BPP in 4-6h
85. Preterm Labor
• RF: multiples, previous preterm, CL <25mm at
<24w, bleeding after 1st trimester
• Prevention
• 17a-OH-P IM daily or vaginally daily from 16w-36w
• Cerclage: ppx at 13-15w or emergency at 16-24w
86. Preterm Labor
• <34 weeks – contractions and cervical change
• r/o labor
• GBS prevention – PCN
• Steroid BTMZ 2 doses 24h apart, up to 36w6d
• Magnesium for neuroprotection <32w
• Procardia/indomethacin/terb for tocolysis
88. Antenatal Steroids
• If at risk of delivery within 7d, benefits best at 2-7d
• Betamethasone 12mg q24h x2 / dexamethasone
6mg q12h x 4
• Even one dose beneficial if not able to
• 23w0d – 36w6d
• 23w0d – 23w6d based on personal preferences/hospital
resources
• 24w0d – 33w6d can do second course if >14d (consider
>7d) since first course
94. GBS Risk factors
• <37 w
• ROM >= 18h
• Maternal temp >= 38.0
• History of GBS UTI during pregnancy
• Previous GBS sepsis, pneumonia, or meningitis in
previous infant
• Treatment: ≥ 2 doses of PCN
101. Bishop Score
<3 IOL unlikely to be successful
<=5 labor will not begin without induction
>6 likely to have successful IOL
>9 likely to have spontaneous labor
Office Management of Early Pregnancy Loss LINDA W. PRINE, MD, Beth Israel Residency in Urban Family Medicine at the Institute for Family Health, New York, New York HONOR MACNAUGHTON, MD, Tufts University Family Medicine Residency at Cambridge Health Alliance, Malden, Massachusetts (Am Fam Physician. 2011;84(1):75-82