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High Yield OBGYN
Kelsey Murray, MD MHA
Grant Family Practice
Columbus, OH
GYN History
Sexual History
Pleasure – are you satisfied, how long have you been dissatisfied, what is problem – interest, sensation, dryness, orgasm, erection, pain
Menstrual
cycle
Menstrual irregularities
Dysfunctional Uterine Bleeding
Anatomy
Uterine ligaments
https://www.youtube.com/watch?v=8HFwIpb6
Eg4
Bladder
Perineum
Pelvic floor muscles
Bartholin gland
cyst
Nabothian cysts
Fibroids
Breast abnormalities
GYNECOLOGY
Contraception
• https://www.reproductiveaccess.org/contraception
/
Medical Eligibility Criteria
• https://www.cdc.gov/reproductivehealth/contrace
ption/pdf/summary-chart-us-medical-eligibility-
criteria_508tagged.pdf
OCPs
Side effects
https://journalce.powerpak.com/ce/prescribin
g-oral-contraceptives-a-new
STI/Vaginitis
Name Tx – Pregnant Tx – not Pregnant (if different)
Bacterial vaginosis – if sx Metro 500mg PO BID x7d Or metrogel 1 app pv qd x5d
Chlamydia Azithro 1g 1x OR Amox 500 po TID x7d Or doxy 100 mg po BID x7d
Gonorrhea Ceftriaxone 250 mg IM + azithro 1g 1x
Trichomonas Metro 2g PO x1
Yeast – Candida Topical azole x7d clotrimazole 1%, miconazole 2% Diflucan 150 mg po x1
Herpes Acyclovir 400 mg po TID x-10d
Syphilis PCN 2.4mill U IM 1x
Warts Cryotherapy, topical therapy, sx
Molluscum Resolve, cryotherapy
Granuloma inguinale Doxycycline 100 mg BID x21d
Lymphogranuloma vereneum Doxycycline 100 mg BID x21d
PID / TOA
PCOS
Endometriosis
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
Ovarian cysts
Ovarian cysts
Anovulatory Bleeding
https://www.aafp.org/afp/2012/0101/p35.html
Anovulatory
• irregular or infrequent periods
• amenorrhea (>3 cycles)
• oligomenorrhea (>35 days between
cycles)
• metrorrhagia (menses at irregular
intervals with excessive bleeding or
lasting >7 days)
• dysfunctional uterine bleeding (after
ruling out other etiologies).
Ovulatory Bleeding
Ovulatory
• Menorrhagia
• regular intervals (every 24 to 35 days)
with excessive volume or duration of >7d
Infertility
• No pregnancy after
12 months of
unprotected
intercourse
• (>6 mo if 35+ years)
https://www.aafp.org/afp/2015/0301/p308.html
Menopause
Postmenopausal bleeding
Incontinence
Breast pain
https://www.aafp.org/afp/2019/0415/p505.html
OBSTETRICS
Pregnancy Attitudes
Questionnaire
One Key Question
• "Would you like to become pregnant in the next
year?"
• yes, no, ok either way, and unsure
Pregnancy Options Counseling
Normal developmental timeline
US dating
Multiples
If No
IUP Seen
Early Pregnancy Loss - Ultrasound
Early pregnancy miscarriage
Diagnostic signs
Suspicious signs
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
Miscarriage Management
shared decision making
Therapeutic Abortion
• <13w D&C
• <9w Mifepristone (progesterone antagonist) +
misoprostol (prostaglandin E1)
• >=13w D&E (to age dependent on state laws)
Abortion Regimens
Recurrent Loss/Preterm
• Multiple 1st trimester losses – SLE, ANA, blood
clotting disorder, consider medical workup such as
DM, Thyroid, etc
• Multiple 2nd Trim / preterm – cervical insufficiency
• Cervical length @ 16w
• Progesterone
• Cerclage if <25 mm at less than 24 weeks and prior
preterm birth <34 weeks. Removal after 36 weeks
Vaginal Bleeding during
Pregnancy – <20w
• Spotting in 20% of pregnancies, 50% continue successfully
• AB
• Incomplete AB – open os, -FHT, + POC half expelled
• Inevitable AB – open os, -FHT, - POC expelled
• Complete AB – closed os, -FHT, +POC expelled
• missed AB - closed os, -FHT, -POC expelled
• threatened AB – closed os, +FHT
• septic AB – retained POC, fevers, WBC
• Multiple gestation miscarriage of one (vanishing twin)
• Ectopic - +HGC, -IUP, +ectopic, +/- rupture
• Molar - +HCG, -IUP, “snow storm” on US, >>HCG
• Subchorionic hemorrhage
• Infection – STI, UTI
• Recent intercourse / other vaginal trauma
• Cervical – malignancy, polyps, trauma
• Non-OB: Lesions, Fibroids, STI, UTI. Bleeding disorders, Foreign body, Trauma, Rx – heparin,
warfarin, Other bleeding – rectal, urethral
Vaginal Bleeding in Pregnancy –
Late - >20w
• Placenta previa
• Vasa previa
• IUFD
• Abruption
• Mucus plug – spotting, mucousy
• Recent intercourse / other vaginal
trauma
• Uterine rupture – hx c/s
• Non-OB: Lesions, Fibroids, STI, UTI.
Bleeding disorders, Foreign body,
Trauma, Rx – heparin, warfarin, Other
bleeding – rectal, urethral
Velamentous insertion
Placenta variations
Placental issues
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?
Safe OTC meds
• Heartburn, gas, bloating, upset stomach: Maalox, Mylanta, Rolaids, Tums, Gas-X, Maalox
Anti-gas, Mylanta Gas, Mylicon, Tagamet, Pepcid, Zantac, Simethicone
• Cold/Cough: Mucinex, Robitussin, Robitussin DM, Vicks 44E, Cough Drops, Vicks Vaporub
• NOT safe: containing alcohol or pesudophedrine or phenylephrine
• Pain Relief, fever: Tylenol
• Allergy Relief: Claritin, Benadryl, Zyrtec
• Constipation: Metamucil, Fiber-lax, Citrucel, Colace, Dulcolax, Milk of Magnesia
• Anti-Diarrhea: Imodium, Kaopectate, Maalox anti-diarrheal, Pepto diarrhea control
• Yeast infection: Monistat, vagistat
• Insomnia: Benadryl, unisom
• Itching: Hydrocortisone
• Cuts/Scrapes: polysporin
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
Prenatal Diagnostic Testing
2nd Trimester
• 15-22 weeks: Quad screen if desired (MS-AFP, B-
hCG, Estriol, and Inhibin A)
• 2nd trimester ultrasound (anatomy scan) @18-22
weeks. This evaluates fetal anatomy &
presentation, AFI, cardiac activity, placental
position, fetal biometry, and fetal number.
• 20 weeks: Begin measuring fundal height at each
visit
3rd Trimester
• 28 weeks – start seeing q2w
• 1 hr OGTT, CBC, Repeat Syphilis, GC, and Chlamydia tests
in high risk patients
• Rhogam, if needed (if Rh-)
• Discuss contraception options
• 27-36 weeks:
• TDaP +/- Flu vaccine
• Sign consent for Tubal Ligation & make copies for patient
(consent only good 30d-6 mo)
• 36 weeks: GBS testing (one time only) & begin
weekly Leopold maneuvers, start seeing weekly
Dating
When do people give birth?
61
Leopold
Leopold 2
Pregnancy Weight Gain
Pre-Pregnancy BMI Total Wt. Gain
Recommended
<18.5 28-40 lbs
18.5-24.9 25-35 lbs
25.0-29.9 15-25 lbs
>30 11-20 lbs
Physiological changes of pregnancy
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
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
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
Aspirin
High Risk Maternal Conditions
• Surveillance at 32-34w
• cHTN, gHTN, Pre-E, cDM, GDM on medications, SLE,
renal disease, Hgb-opathies, hyperthyroidism,
severe asthma, antiphospholipid syndrome
• AMA >35y, obesity
• Prolonged pregnancy, decreased FM,
isoimmunization, previous stillbirth, IUGR, oligo,
polyhydramnios, fetal anomalies
• Sickle cell trait - Inc risk of bacteuria/hematuria =
Urine culture q month, Inc risk of Pre-E = ASA 81
TORCH infections
• GBS, intrapartum Penicillin prophylaxis
• Toxoplasmosis – chorioretinitis, intracranial calcifications,
symmetrical IUGR. Tx = pyrimethamine sulfadiazine
• Varicella – zig-zag skin lesions, microphthalmia, extremity
hypoplasia. Tx = acyclovir. C/S
• Rubella – congenital deafness, cataracts, heart disease
• CMV – deafness, neonatal thrombocytopenia and petechiae. C/S
• HSV – C/S if active maternal lesions
• HIV – antiviral prophylaxis, C/S, no breastfeeding
• Syphilis – huchinson teeth, saber shins, saddle nose, mulberry
molars, 8th nerve deafness
• Hep B – avoid scalp electrodes
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
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
PreE
Gest DM
Gest DM
Preexisting DM
• Detailed anatomy scan
• Fetal echo
• Tight glucose control
• A1c q1mo goal 6.0
• Ophtho eval
• Growth scans
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)
OBGYN high yield
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
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
Growth scan
• HC
• AC
• FL
• BPD
• AFI
OB US basics
• https://www.slideshare.net/Doctorsask/basic-
obstetric-ultrasound-32617637
Preterm Birth – PPROM
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
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
Mag Sulfate
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
Preterm labor protocol
PROM
https://onlinelibrary.wiley.com/doi/abs/10.111
1/jmwh.12195
Abruption
• Painful bleeding
• s/p trauma, cocaine
• Hx abruption, smoking
• Labs: PTT, PT/INR, CBC, Fibrinogen, T&S, consider
Kleinhauer-Betke stain
Uterine window
Uterine rupture
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
GBS – updated 2020
GBS
Abx
Chorioamnionitis
• RF: long labor, prolonged ROM, internal monitors
• Polymicrobial: bacteroides, GBS, E Coli, G vaginalis,
GNR
• Dx
• Maternal fever >38 degrees C
• Uterine tenderness
• Maternal tachycardia HR >110
• Fetal tachycardia >160
• Foul odor of amniotic fluid
• WBC >15 (although often elevated in pregnancy)
• Treatment = ampicillin 2g q6h + gentamycin 1.5 mg/kg
q8h. With C/S clinda 900 mg q8h. Stop when afebrile
for 24h postpartum
OBGYN high yield
Dilation/Effacement/Station
Cervical Dilation
• https://www.youtube.com/watch?v=RkT8wUyr2DU
cervical dilation
• https://www.youtube.com/watch?v=URyEZusnjBI
• Balloon + ping pong
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
Braxton-hicks
https://www.youtube.com/watch
?v=w0iDfcAYZWc stages of labor
Stages of Labor
Fetal movements
• Engagement
• Descent
• Flexion
• Internal Rotation
• Extension
• Restitution (External rotation)
• Expulsion
Presentation
Presentation
ECV
Rotation
Manual rotation
Breech
delivery
Induction
Reasons
Reasons
Indications
• Hypertensive disorders
• Diabetes
• Other Medical disorders
• Postterm
• ROM
• Chorio
• Multiple gestations
• IUGR
• Oligo/polyhydramnios
• AMA
Contraindications
• Placenta/vasa previa
• Non-cephalic
• Prior classical c/s
• TOLAC guidelines per
hospital policy
• Active herpes
• Elective <39 weeks,
unclear dating
113
In Pursuit of
Value-based
Maternity Care
Induction methods
c/s Risk IOL
116
Pros and Cons of IOL
117
- Neonatal outcomes
(stillbirth, IUGR, NICU)
- Maternal complications
- pregnancy-related
complications
- Overall costs
- Ease of scheduling
- Increased Interventions
- ? C/S rate and related
maternal complications
- More epidurals
- Longer hospital time, more
resource intense
- Less patient satisfaction
Date
118
Informed refusal / Risk benefit
119
Risk of Stillbirth
120
Neonatal Complications
121
Neonatal Complications
122
Stillbirth Risk
123
Outpatient cervical ripening
124
IOL - Stripping membranes
IOL -Miso
IOL – Cervidil (dinoprostone)
IOL – Cytotec (misoprostol)
IOL – Foley
IOL – Double balloon
IOL – Laminaria
Artificial ROM (vs Spontaneous
ROM)
IOL - Amniotome
IOL – Pitocin
• 1x1 vs 2x2
• IUPC – goal Montevideo units >200/10min
• SE: tachysystole (5 contractions/10m), change in
EFM
Labor management
• Expectant
• Active
• Reactive
Birthing positions
Vacuum
Forceps
Operative delivery indications /
contraindications
Operative
delivery
Ritgen’s Maneuver
Shoulder Dystocia
Lacerations
• Periurethral
• Periclitoral
• Cervical
• Vaginal sulcus
• Perineal
Knots
• https://www.youtube.com/watch?v=fnwdON-OiFY
• One handed surgical knot tying – practice!!
• https://www.youtube.com/watch?v=eNLYpEqz-XA
• Two handed
• And you can always ask to suture, practice
downstairs in sim lab
PPH
> 1000ml blood loss w/in 24h
PPH
options
• Medications
• Banjo
• Bakri
• D&C
• UAE
• Hyst
OBGYN high yield
Primary PPH
Secondary PPH
Vte ppx
Postpartum fever
• Wind- atelectasis
• Water- UTI
• Wound
• Womb
• Walking- DVT
• Wonder Drug
Lochia
Breastfeeding Cues
Dr. Good’s breastfeeding cheat
sheet
• https://www.slideshare.net/secret/1FgMTayljVnJUa
VTE PPX
VTE PPX Orders

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OBGYN high yield

  • 1. High Yield OBGYN Kelsey Murray, MD MHA Grant Family Practice Columbus, OH
  • 3. Sexual History Pleasure – are you satisfied, how long have you been dissatisfied, what is problem – interest, sensation, dryness, orgasm, erection, pain
  • 18. Medical Eligibility Criteria • https://www.cdc.gov/reproductivehealth/contrace ption/pdf/summary-chart-us-medical-eligibility- criteria_508tagged.pdf
  • 19. OCPs
  • 21. STI/Vaginitis Name Tx – Pregnant Tx – not Pregnant (if different) Bacterial vaginosis – if sx Metro 500mg PO BID x7d Or metrogel 1 app pv qd x5d Chlamydia Azithro 1g 1x OR Amox 500 po TID x7d Or doxy 100 mg po BID x7d Gonorrhea Ceftriaxone 250 mg IM + azithro 1g 1x Trichomonas Metro 2g PO x1 Yeast – Candida Topical azole x7d clotrimazole 1%, miconazole 2% Diflucan 150 mg po x1 Herpes Acyclovir 400 mg po TID x-10d Syphilis PCN 2.4mill U IM 1x Warts Cryotherapy, topical therapy, sx Molluscum Resolve, cryotherapy Granuloma inguinale Doxycycline 100 mg BID x21d Lymphogranuloma vereneum Doxycycline 100 mg BID x21d
  • 23. PCOS
  • 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
  • 28. Anovulatory Bleeding https://www.aafp.org/afp/2012/0101/p35.html Anovulatory • irregular or infrequent periods • amenorrhea (>3 cycles) • oligomenorrhea (>35 days between cycles) • metrorrhagia (menses at irregular intervals with excessive bleeding or lasting >7 days) • dysfunctional uterine bleeding (after ruling out other etiologies).
  • 29. Ovulatory Bleeding Ovulatory • Menorrhagia • regular intervals (every 24 to 35 days) with excessive volume or duration of >7d
  • 30. Infertility • No pregnancy after 12 months of unprotected intercourse • (>6 mo if 35+ years) https://www.aafp.org/afp/2015/0301/p308.html
  • 37. One Key Question • "Would you like to become pregnant in the next year?" • yes, no, ok either way, and unsure
  • 43. Early Pregnancy Loss - Ultrasound
  • 44. Early pregnancy miscarriage Diagnostic signs Suspicious signs
  • 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
  • 47. Therapeutic Abortion • <13w D&C • <9w Mifepristone (progesterone antagonist) + misoprostol (prostaglandin E1) • >=13w D&E (to age dependent on state laws)
  • 49. Recurrent Loss/Preterm • Multiple 1st trimester losses – SLE, ANA, blood clotting disorder, consider medical workup such as DM, Thyroid, etc • Multiple 2nd Trim / preterm – cervical insufficiency • Cervical length @ 16w • Progesterone • Cerclage if <25 mm at less than 24 weeks and prior preterm birth <34 weeks. Removal after 36 weeks
  • 50. Vaginal Bleeding during Pregnancy – <20w • Spotting in 20% of pregnancies, 50% continue successfully • AB • Incomplete AB – open os, -FHT, + POC half expelled • Inevitable AB – open os, -FHT, - POC expelled • Complete AB – closed os, -FHT, +POC expelled • missed AB - closed os, -FHT, -POC expelled • threatened AB – closed os, +FHT • septic AB – retained POC, fevers, WBC • Multiple gestation miscarriage of one (vanishing twin) • Ectopic - +HGC, -IUP, +ectopic, +/- rupture • Molar - +HCG, -IUP, “snow storm” on US, >>HCG • Subchorionic hemorrhage • Infection – STI, UTI • Recent intercourse / other vaginal trauma • Cervical – malignancy, polyps, trauma • Non-OB: Lesions, Fibroids, STI, UTI. Bleeding disorders, Foreign body, Trauma, Rx – heparin, warfarin, Other bleeding – rectal, urethral
  • 51. Vaginal Bleeding in Pregnancy – Late - >20w • Placenta previa • Vasa previa • IUFD • Abruption • Mucus plug – spotting, mucousy • Recent intercourse / other vaginal trauma • Uterine rupture – hx c/s • Non-OB: Lesions, Fibroids, STI, UTI. Bleeding disorders, Foreign body, Trauma, Rx – heparin, warfarin, Other bleeding – rectal, urethral Velamentous insertion
  • 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?
  • 55. Safe OTC meds • Heartburn, gas, bloating, upset stomach: Maalox, Mylanta, Rolaids, Tums, Gas-X, Maalox Anti-gas, Mylanta Gas, Mylicon, Tagamet, Pepcid, Zantac, Simethicone • Cold/Cough: Mucinex, Robitussin, Robitussin DM, Vicks 44E, Cough Drops, Vicks Vaporub • NOT safe: containing alcohol or pesudophedrine or phenylephrine • Pain Relief, fever: Tylenol • Allergy Relief: Claritin, Benadryl, Zyrtec • Constipation: Metamucil, Fiber-lax, Citrucel, Colace, Dulcolax, Milk of Magnesia • Anti-Diarrhea: Imodium, Kaopectate, Maalox anti-diarrheal, Pepto diarrhea control • Yeast infection: Monistat, vagistat • Insomnia: Benadryl, unisom • Itching: Hydrocortisone • Cuts/Scrapes: polysporin
  • 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
  • 58. 2nd Trimester • 15-22 weeks: Quad screen if desired (MS-AFP, B- hCG, Estriol, and Inhibin A) • 2nd trimester ultrasound (anatomy scan) @18-22 weeks. This evaluates fetal anatomy & presentation, AFI, cardiac activity, placental position, fetal biometry, and fetal number. • 20 weeks: Begin measuring fundal height at each visit
  • 59. 3rd Trimester • 28 weeks – start seeing q2w • 1 hr OGTT, CBC, Repeat Syphilis, GC, and Chlamydia tests in high risk patients • Rhogam, if needed (if Rh-) • Discuss contraception options • 27-36 weeks: • TDaP +/- Flu vaccine • Sign consent for Tubal Ligation & make copies for patient (consent only good 30d-6 mo) • 36 weeks: GBS testing (one time only) & begin weekly Leopold maneuvers, start seeing weekly
  • 61. When do people give birth? 61
  • 64. Pregnancy Weight Gain Pre-Pregnancy BMI Total Wt. Gain Recommended <18.5 28-40 lbs 18.5-24.9 25-35 lbs 25.0-29.9 15-25 lbs >30 11-20 lbs
  • 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
  • 70. High Risk Maternal Conditions • Surveillance at 32-34w • cHTN, gHTN, Pre-E, cDM, GDM on medications, SLE, renal disease, Hgb-opathies, hyperthyroidism, severe asthma, antiphospholipid syndrome • AMA >35y, obesity • Prolonged pregnancy, decreased FM, isoimmunization, previous stillbirth, IUGR, oligo, polyhydramnios, fetal anomalies • Sickle cell trait - Inc risk of bacteuria/hematuria = Urine culture q month, Inc risk of Pre-E = ASA 81
  • 71. TORCH infections • GBS, intrapartum Penicillin prophylaxis • Toxoplasmosis – chorioretinitis, intracranial calcifications, symmetrical IUGR. Tx = pyrimethamine sulfadiazine • Varicella – zig-zag skin lesions, microphthalmia, extremity hypoplasia. Tx = acyclovir. C/S • Rubella – congenital deafness, cataracts, heart disease • CMV – deafness, neonatal thrombocytopenia and petechiae. C/S • HSV – C/S if active maternal lesions • HIV – antiviral prophylaxis, C/S, no breastfeeding • Syphilis – huchinson teeth, saber shins, saddle nose, mulberry molars, 8th nerve deafness • Hep B – avoid scalp electrodes
  • 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
  • 74. PreE
  • 77. Preexisting DM • Detailed anatomy scan • Fetal echo • Tight glucose control • A1c q1mo goal 6.0 • Ophtho eval • Growth scans
  • 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
  • 82. Growth scan • HC • AC • FL • BPD • AFI
  • 83. OB US basics • https://www.slideshare.net/Doctorsask/basic- obstetric-ultrasound-32617637
  • 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
  • 91. Abruption • Painful bleeding • s/p trauma, cocaine • Hx abruption, smoking • Labs: PTT, PT/INR, CBC, Fibrinogen, T&S, consider Kleinhauer-Betke stain
  • 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
  • 97. Chorioamnionitis • RF: long labor, prolonged ROM, internal monitors • Polymicrobial: bacteroides, GBS, E Coli, G vaginalis, GNR • Dx • Maternal fever >38 degrees C • Uterine tenderness • Maternal tachycardia HR >110 • Fetal tachycardia >160 • Foul odor of amniotic fluid • WBC >15 (although often elevated in pregnancy) • Treatment = ampicillin 2g q6h + gentamycin 1.5 mg/kg q8h. With C/S clinda 900 mg q8h. Stop when afebrile for 24h postpartum
  • 100. Cervical Dilation • https://www.youtube.com/watch?v=RkT8wUyr2DU cervical dilation • https://www.youtube.com/watch?v=URyEZusnjBI • Balloon + ping pong
  • 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
  • 105. Fetal movements • Engagement • Descent • Flexion • Internal Rotation • Extension • Restitution (External rotation) • Expulsion
  • 108. ECV
  • 113. Reasons Indications • Hypertensive disorders • Diabetes • Other Medical disorders • Postterm • ROM • Chorio • Multiple gestations • IUGR • Oligo/polyhydramnios • AMA Contraindications • Placenta/vasa previa • Non-cephalic • Prior classical c/s • TOLAC guidelines per hospital policy • Active herpes • Elective <39 weeks, unclear dating 113
  • 117. Pros and Cons of IOL 117 - Neonatal outcomes (stillbirth, IUGR, NICU) - Maternal complications - pregnancy-related complications - Overall costs - Ease of scheduling - Increased Interventions - ? C/S rate and related maternal complications - More epidurals - Longer hospital time, more resource intense - Less patient satisfaction
  • 119. Informed refusal / Risk benefit 119
  • 125. IOL - Stripping membranes
  • 127. IOL – Cervidil (dinoprostone)
  • 128. IOL – Cytotec (misoprostol)
  • 130. IOL – Double balloon
  • 132. Artificial ROM (vs Spontaneous ROM)
  • 134. IOL – Pitocin • 1x1 vs 2x2 • IUPC – goal Montevideo units >200/10min • SE: tachysystole (5 contractions/10m), change in EFM
  • 135. Labor management • Expectant • Active • Reactive
  • 137. Vacuum
  • 139. Operative delivery indications / contraindications
  • 143. Lacerations • Periurethral • Periclitoral • Cervical • Vaginal sulcus • Perineal
  • 144. Knots • https://www.youtube.com/watch?v=fnwdON-OiFY • One handed surgical knot tying – practice!! • https://www.youtube.com/watch?v=eNLYpEqz-XA • Two handed • And you can always ask to suture, practice downstairs in sim lab
  • 145. PPH > 1000ml blood loss w/in 24h
  • 146. PPH options • Medications • Banjo • Bakri • D&C • UAE • Hyst
  • 151. Postpartum fever • Wind- atelectasis • Water- UTI • Wound • Womb • Walking- DVT • Wonder Drug
  • 152. Lochia
  • 154. Dr. Good’s breastfeeding cheat sheet • https://www.slideshare.net/secret/1FgMTayljVnJUa

Notes de l'éditeur

  1. https://www.twins.org.au/images/general/publications/Umstad_Craig_Mechanisms_of_twinning.pdf
  2. 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
  3. https://pubs.rsna.org/doi/full/10.1148/rg.2015150092
  4. https://www.researchgate.net/publication/235371785_Maternal_and_fetal_risk_factors_for_stillbirth_Population_based_study https://evidencebasedbirth.com/advanced-maternal-age/
  5. https://link.springer.com/article/10.1007/s00404-013-2957-y
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719843/