OBGYN Shelf notes

Fetal macrosomia

4 mg of folic acid is the recommended dose for women with previous pregnancycomplicated by neural tube defects

Women with BMI > 30 should gain 11-20 lbs in pregnancy

Organogenesis occurs in the first 8 weeks

Methyldopa does not have associations with birth defects

Braxton Hicks contraction are short in duration, less intense than true labor and thediscomfort as being in the lower abdomen and groin.

Labor precautions

Contractions every five minutes for one hour

Rupture of membranes

Fetal movement less than 10 per two hours

Vaginal bleeding

Fetal scalp electrode should be placed if the heart rate cannot be confirmed using externalmethods
o
Don't place an epidural unless fetal heart rate can be confirmed

If an intrauterine pressure catheter is placed and a significant amount of vaginal bleeding isnoted, then uterine perforation may have occurred
o
Tx: with the catheter, monitor the fetus and observe signs of fetal compromise

Most common cause of postpartum hemorrhage: uterine atony

PPH defined as 500 cc blood loss

s/s of depression less than 2 weeks after delivery are called postpartum blues
o
self limited

Ambivalence to the newborn helps distinguish postpartum blues from depression

Ectopic pregnancy must be diagnosed by follow up hCG (< 50% increase in 48 hours).Then methotrexate can be used

The discriminatory zone for beta-hCG is 2000 mIU/ml. This is the level when fetuses can be seen by US

Ruptured ectopic pregnancy is evaluted with exploratory laparatomy

o
Acute ruptured ectopic pregnancy is treated by D&C, not methotrexate

> 25 ng/ml progesterone suggests healthy pregnancy

30% of pregnancies have first trimester bleeding

D&C is indicated for a failing or ectopic pregnancy in a non-acute setting

Methotrexate is used for ectopic pregnancy if there is hemodynamic stability, no rupture,ectopic mass < 4cm w/o heart tone or < 3.5 cm w/
heart tone, normal liver enzymes, normalwhite count

S/s of ruptured ectopic pregnancy: hypovolemia, peritoneal signs, and positive pregnancytest

Oligohydramnios is associated with IUGR

Once IUGR is detected, weekly tests of fetal well-being are required

o
BPP and NST

Polyhydramnios does NOT complicate IUGR

Adult complications of IUGR

o
COPD
o
Diabetes
o
Cardiovascular disease

o
Chronic hypertension

In twin-twin transfusion syndrome, twin A (larger) is at risk for polycythemia

Babies born to diabetic mothers are at risk for hypoglycemia, polycythemia,hyperbilirubinemia, hypocalcemia and respiratory distress.

Sniffing is the correct position for application of positive pressure ventilation in a newborninfant. Flex neck is not necessary. Just for adults.

The majority of first trimester spontaneous abortions is due to chromosomal abnormalitiesin the conceptus

Autosomal trisomy is the most common abnormal karyotype encountered in spontaneousabortuses

In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased.

Provided the patient is hemodynamically stable and reliable for follow-up, expectantmanagement is appropriate therapy for missed abortion
in the first trimester

Cervical incompetence is treated with cervical cerclage in the 2nd trimester

first trimester surgical abortion confers no subsequent obstetric disadvantage

The use of angiotensin converting enzyme inhibitors, such as Lisinopril, beyond the firsttrimester of pregnancy has been associated with
oligohydramnios, fetal growth retardationand neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures anddeath.

The most common cause of sepsis in pregnancy is acute pyelonephritis

Asthma generally worsens in pregnancy

There are no proven alternatives to penicillin therapy during pregnancy and Penicillin G isthe therapy of choice to treat syphilis in pregnancy.
o
Tx: Desensitization to pencillin and subsequent penicillin G therapy

Among women with cardiac disease, patients with pulmonary hypertension are among thehighest risk for mortality with pregnancy. These
women have a 25-50% risk for death with pregnancy.

Severe preeclampsia = protein > 500 mg/dL/24 hours

Magnesium sulfate is the mainstay of therapy during labor and for 24 hours postpartum tolower the seizure threshold in preeclampsia

A therapeutic magnesium level is between 4-7 mEq/L

Loss of deep tendon reflexes occurs at a level of 7-10 mEq/L.

Respiratory depression may occur at levels above 12 mEq/L.

Cardiac arrest may occur at a level of 15 mEq/L.

Thrombocytopenia <100,000 is a contraindication to expectant management of severe preeclampsia remote from term (<32
weeks)

Tx: deliver must be induced immediately

tachycardia and sinusoidal heart rate pattern are consistent with abruptio placenta

Depoprovera can cause irregular bleeding in the first 2 to 3 months

Genuine stress incontinence is best treated with urethroplexy

Urethral bulking procedures are best for sphincteric insufficiency

o
Use artificial sphincter as a last resort

Oxybutynin is the best pharmacologic treatment for detrussor instability

Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the
white line
o
Uterine prolapse is treated by vaginal hysterectomy

Stress incontinence is caused by an increase in intra-abdominal pressure (coughing,sneezing) when the patient is in the upright position.

urge incontinence is caused by overactivity of the detrusor muscle resulting in uninhibitedcontractions, which cause an increase in the bladder
pressure over urethral pressureresulting in urine leakage

Colpocleisis is a procedure where the vagina is surgically obliterated and can be performedunder local anesthesia

Pessary fitting is the least invasive intervention for prolapse

OCPs are a first choice tx for symptomatic endometriosis

o
GnRH agonists have more side effects

Laparoscopy is used to confirm endometriosis

Hemorrhagic cysts resolve on their own, usually

The sudden onset of pain and nausea, as well as the presence of a cyst on ultrasoundsuggest ovarian torsion
o
Exploratory surgery is indicated for an ovarian torsion

A patient with a known history of endometriosis who is unable to conceive and has anotherwise negative workup for infertility, benefits from
ovarian stimulation withClomiphene Citrate, with or without intrauterine insemination.

Asians have the highest rate of molar pregnancy

Molar pregnancy is associated with folate deficiency

Suction curettage is the standard management for molar pregnancies

After suction curretage for molar pregnancy, pregnancy should be avoided in the f/u periodand 6 months thereafter

Partial moles are 69 XXY/XXX/XYY triploid and have lower risk of GTD post-molar pregnancy than complete moles

The risk of developing another molar pregnancy is approximately 1-2%

Complete moles usually present with larger uteri, preeclampsia and higher likelihood of developing into post-molar GTD.

Because metastatic choriocarcinoma is quite vascular, suspicious lesions should never be biopsied.

Quantitative beta-hCG is used to diagnosis disseminated choriocarcinoma

The most recent consensus guidelines (2006) state that management of LGSIL (unless thewoman is pregnant, postmenopausal or an
adolescent) is initial colposcopic examination.

Cervical dysplasia is best treated with LEEP

Mammography should be offered at 50 y/o and repeated annually

Excisional or ablative procedures are not indicated for LGSIL

A hysterectomy with bilateral salpingo-oophorectomy is the definitive treatment for a patient with pelvic pain due to endometriosis.

A transvaginal ultrasound would be the best way to begin a workup for an incidentalfinding of an adnexal mass.

Sinusoidal heart tracing = severe fetal anemia


C section greatly increases the risk for endometritis

Treat septic thrombophlebitis w heparin and abx

anaerobes are the most common organism in endometritis

o
Tx - amp/gent

Oral amoxicillin can be used for chlamydia in a pregnant woman

The primary risk factor for preterm rupture of membranes is genital tract infection,especially associated with bacterial vaginosis.

Similar To 102247212-OBgyn-Shelf

OB/Gyn Shelf Exam Study Notes

Candidal vaginitis tx is w/ clotrimazole for the patient only

PPROM requires amniotic fluid sampling to measure fetal lung indices

o
A sterile speculum should be used to avoid infection

If premature labor occurs and the fetus has an anomaly incompatible w/ life, let the fetus be born

All patients w/ primary amenorrhea and high FSH need to have a karyotype determination

GBS screening occurs at 36-37 weeks. Women should be treated with penicillin G duringlabor, even in the absence of frank chorioamnionitis

Semen analysis should be performed early in the evaluation of infertility

Severe preeclampsia = pressure > 160/110

Untreated asymptomatic bacteriuria of pregnancy can lead to pyelonephritis or cystitis.Treat with nitrofurantoin (or ampicillin or 1st gen
cephalosporin) for 7 to 10 days

OCPs are first line therapy for endometriosis in younger women desiring future fertility
o
Laser treatment is appropriate if the patient is actively trying to conceive

Hypertrophic dystrophy of the vulva is seen in postmenopausal women. Treat w/corticosteroid topically. Biopsy is required to distinguish from
vulvar carcinoma

Behcets disease can present like herpes or syphillis w/ recurrent ulcers and uveitis.

Fetal heart decelerations are the most common encountered anomaly. Associated withumbilical cord compression.

HRT can actually increase the risk of coronary heart disease and stroke rather than reduce

Luteal phase defects are treated with progesterone supplements.

o
Luteal phase defect is suggest by short cycle, history of spontaneous abortions,abnormal body temp.
o
Dx made by biopsy showing endometrial lag by 2+ days

CVS can be done at 10-12 weeks

o
Indicated in women over 35 y/o after an abnormal ultrasound

Amniocentesis is done between 16-18 weeks gestation

MSAFP is a second trimester screen

Puerperal fever is an increase in temperature > 38C for more than 2 consecutive days in thefirst 10 days postpartum
o
Most common etiology - endometritis
o
Spiking fevers in the puerperal period that do not respond to fevers are likely due to pelvic thrombophlebitis -> give heparin
o
Most common pathogens causing endometrisis in the puerperal period: anaerobes

Endometriosis presents most frequently with dysmenorrhea, dyspareunia, and dyschezia

The major cause of death in eclampsia is hemorrhagic stroke

Abruptio placenta and placenta previa are the most common causes of antepartumhemorrhage
o
Most common sx is bright red third trimester bleeding
o
DIC is a major complication of abruptio placenta
o
Risk factors for abruptio placenta are

trauma

maternal hypertension

placental aburption in previous pregnancy

short umbilical cord

tobacco use and cocaine abuse

folate deficiency

Abdominal circumference is the most accurate parameter for estimating fetal weight byU/S

Intrauterine growth restriction

o
2 types = symmetrical and asymmetrical
o
Symmetrical = congenital problems prior to 28 weeks

both head and body abnormal

o
Asymmetrical = insult after 28 weeks

Head normal body not normal

Bilateral edema of the extremities is common in pregancy; benign.

o
Cramps and mild leg edema are very common

Mayer-Rokitansky-Kuster-Hauseer syndrome is the result of mullerian agenesis.

o
Normal secondary sex characteristics
o
Amenorrhea
o
Absent/rudimentary uterus
o
46 XX

Steroids are used to enhance fetal lung maturity when premature rupture of membranesoccur less than 34-weeks gestation

Premature ovarian failure refers to failure of estrogen production by the ovaries that occur in women less than 35 years
o
Autoimmune origin
o
Associated with Hashimotos, Addison's type I diabetes
o
Tx = egg donation

Biophysical Profile testing = sonography + fetal heart monitoring

o
NST reactivity
o
Extremity tone
o
Breathing movements
o
Gross body movements
o
Amniotic fluid volume

Scores of 8-10 on BPP are reassuring

o
Repeat BPP once or twice weekly until term for high risk pregnancies

Non-stress test is based on tracing of fetal heart rate

o
Reactive = Rise of > 15 beats/min for > 15 secs. Reassuring of fetal well being
o
Nonreactive = no accelerations seen

Oligohydramnios = AFI < 5

Risk factors for candida vaginitis are DM, OCPs, pregnancy and immunosuppressivetherapy

Early decelerations are due to fetal head compression

Fetal cord compression presents with variable decelerations

Uteroplacental insufficiency presents with late decelerations

The major source of estrogen in a menopausal women is from peripheral conversion

o
Obese women have mild menopause because of peripheral estrogen production

Pseudocyeis is an imaginary pregnancy that occurs in women with a strong desire to become pregnant

o
Needs psych eval

Primary ovarian failure = decreased estrogen and increased FSH

o
FSH, more than LH, is diagnostic of primary ovarian failure

Superpotent corticosteroid cream is the treatment of choice for lichen sclerosis

Itchy spot in a postmenopausal woman needs a biopsy

o
Distinguish vulvar carcinoma from lichen sclerosis w/ biopsy

Intrauterine fetal demise is diagnosed with real time ultrasonogram

o
IUFD is death of the fetus in utero after 20 weeks gestation and before the onset of labor

Complete placenta previa needs C-section

o
If the mother is stable and the fetus is at term, scheduled C-section is appropriate
o
If the pregnancy is not at term and the mother is stable, expectant management isappropriate

Tubo-ovarian abscesses are usually managed with triple antiobiotic therapy

o
Drainage is indicated if no response after 24-48 hours

In any woman of childbearing age with secondary amenorrhea, first rule out pregnancywith beta-hCG

Patients with inevitable or incomplete abortions should be hospitalized and monitored to prevent complications

For all types of abortions, RhoGAM has to be administered in all women without anti-Rhantibodies

C-section is the only option for placenta previa

o
If bleeding occurs pre-term and the mother can be stabilized and the fetus stable,conservative management at home is appropriate.
Bleeding, however, must ceasefor a couple days.

Patients with PCOS have elevated DHEA. ACTH stimulation produces exaggersted DHEAresponse due to increased sensitivity.

Significant granulocytic leukocytosis may be seen in the immediate postpartum period.

Lochia rubra is the first vagina discharge after pregnancy. It is bright red.

In incomplete abortion, the cervix is dilated and there is incomplete evacuation of theconceptus with fragments retained in the uterine cavity

Risk factors for abortion

o
Infection
o
Environmental - tobacco and alcohol
o
Systemic disorders - hypothyroidism, SLE, DM
o
Local maternal factors - cervical incompetence, uterine abnormalities
o
Fetal factors

RhoGaM is indicated in previously unsensitized Rh-negative women at 28 weeks gestationand within 72 hours of any procedure or incident

Single dose azithromycin is used to treat chlamydial infection. But gonococcal infectionsare treated with empiric abx for both gonorrhea and
chlamydia (ceftriaxone + doxycycline).7 days of doxy can also be used for chlamydia.

Vaginal delivery in breech position must meet the following criteria:

o
fetus in frank or complete breech
o
estimated fetal weight between 2500 g and 3800g
o
flexed fetal head