Obs/gyn in a nutshell Flashcards

Terms Definitions
Gravida
A woman who is or has been pregnant irrespective of pregnancy outcome.
Primigravida
the first pregnancy
Multigravida
subsequent pregnancies
Nulligravida
a woman who is not and has never been pregnant
Nullipara
a woman who has never completed a pregnancy to the stage of viability, she may or may not have aborted previously
Primipara
A woman who has been delivered oonce of a fetus or fetuses (multiple gestation) who reached the stage of viability
Multipara
A woman who has completed two or more pregnancies to stage of viability
Grand multipara
A woman who has completed 5 or more pregnancies to stage of viability
GTPAL
Gravity (G) – total # of pregnancies
Term (T) - Total # of deliveries after 37 weeks.
Parity (P)– total # of deliveries
Live (L)
Abortions (SA, LA, ectopic)
Premature delivery
delivery of an infant weighing between 500 and 2500 gm, after 20 weeks and prior to 37 weeks.
Term delivery
between 37 and 42 weeks
Posterm delivery
after 42 weeks
Fetal Death (Stillbirth)
death occurring in utero after 20 wks gestation
Perinatal Death
fetal or infant death occurring after 20 wks gestation and before 29 neonatal days.
Fetal Death Rate
the number of fetal deaths per 1000 births
Secondary Amenorrhea
Lack of menstrual bleeding for 3 or more months in women with past menses.
Primary Amenorrhea
absence of menarche by age 16
Oligomenorrhea
uterine bleeding that occurs at intervals more than 35 days
Polymenorrhea
uterine bleeding that occurs at regular intervals less than 21 days
Hypermenorrhea
excessive menstrual bleeding occurring during a regular menstruation
Hypomenorrhea
decrease in the amount of menstrual flow, often with a decrease in duration
Menorrhagia
Prolongation of menstrual flow, often associated with and increase of flow
Metrorrhagia
Bleeding occurring irregularly between menstrual cycles
Menometrorrhagia
Prolongation of the menstrual flow associated with irregular intermenstrual bleeding
Premenstrual spotting
variant of metrorrhagia occurring frequently and limited to the few days immediately preceding the menstrual flow.
Climacteric
transition from the reproductive phase to menopause
Dysmenorrhea
painful menses
Dysparunia
painful intercourse
Leukorrhea
vaginal discharge
Menarche
age at which menstruation begins
Premature menopause
Menopause before 35
Procidentia
full uterine prolapse
Classification of Abortion
Threatened
Inevitable
Complete
Incomplete
Missed
Septic
Habitual
Threatened Abortion
vaginal bleeding with or without uterine cramps, closed cx
Inevitable
vaginal bleeding with or without uterine cramps; fetoplacental tissue within the dilated cervix
Complete
embryo if present and entire placenta expelled
Incomplete
some products of conception remaining in the uterus: persistence of cramps, bleeding, or dilatation of the cervix
Missed
retention of products of conception before 20th week of pregnancy, failure of uterus to grow under observation or regression in size.
Septic
any abortion complicated by signs of infection
Habitual
three or more successive pregnancies terminating in spontaneous abortion.
Tylenol (acetaminophen) plain
325 mg i-ii tabs po q3-4h prn
Tylenol extra strength
500 mg. tab i-ii tabs po q 3-4h prn
Tylenol #1
325 mg acetaminophen + 8 mg codeine. i-ii tabs po q 3-4h prn
Tylenol #2
325 mg acetaminophen + 15 mg codeine. i-ii tabs po q 3-4h prn
Tylenol #3
325 mg acetaminophen + 30 mg codeine. i-ii tabs po q 3-4h prn
Talwin (pentazosine)
50 mg. tab. po q 3-4h prn.
Percocet
(oxycodone 2.5 mg+ acetaminophen 325 mg)
i-ii tabs po q 3-4h prn.
Percodan
(oxycodone 2.5 mg + ASA 325 mg) i-ii tabs po q3-4 h prn.
5. Demerol (meperidine)
50 mg po q 3-4h prn
6. Toradol (ketorolac) -NSAID
10 mg po q 6h prn
Demerol (meperidine)
10mg/kg IM Q3-4H for post-op/severe pain prn (always add antiemetic)
Morphine
1mg.kg IM Q3-4H prn for post op/severe pain prn (always add antiemetic)
Gravol (dimenhydrinate)
50 mg po/IM/IV/PR Q4H prn (for nausea)
Stemitil (prochlorperazine)
10 mg po/iv/im Q4H prn (for nausea)
Odansetron (Zofran)
0.15 mg/kg iv Q3-4H prn
Ativan (lorazepam)
1-2 mg SL/PO QHS prn
Seconal
100 mg po QHS prn
Bulk forming laxatives
Bran
Psyllium (metamucil 1-2 tbs po bid)
Osmotic Laxatives
lactulose
MgSO4
Citromag
fleet enema (sodium phosphate)
PMS-Phosphates
Glycerin supplements
MOM (milk of magnesia)
Stool Softeners
Docusate (colace - 100mg po BID)
Mineral oil
Non-specific stimulant/irritant laxatives
Castor oil
Senna alkaloids (Senekot)
Cascara ("brown bomb: 5cc cascara + 15cc MOM)
Bisacodyl (dulcolax supp)
Blood vessels of the umbilical cord
2 arteries, 1 vein.
Signs of Placental detachment
Gush of blood
Cord Lengthening
Uterus becomes globular
Fundus rises
Four muscles of the perenium
bulbar cavernosus
Superficial Transverse Perenial
Levator Ani
Sphincter
Active labour
Contractions causing cervical dilation (>3cm) and effacement.
4 types of tears
1st Degree - Vaginal mucosa
2nd Degree - Mucosa + underlying muscle
3rd Degree - Mucosa + muscle + partial anal sphincter
4th degree - complete tear into rectum.
4 T's of postpartum hemorrhage
Tone (enlarged uterus - multiples, polyhydramnious, macrosomia; infection; distended bladder; prolonged PIT; prolonged induction)
Tissue )Retained products, clots, fibroids)
Trauma (Rupture, inversion, operative vaginal delivery, tears)
Thrombin (VWD, LMWH, DIC)
BPP
Breathing movements - 1 of <20s w/in 30 mins
Body movements - 2 or more movements w/in 30 mins
Fetal tone - 1 or more active extension with return to flextion
AVF - 1 or more pockets of fluid > 2cm in vertical axis.
+/- Reactive FHR
Interpretation of FHR
Baseline - 110-160
Variability - 6-25 bpm, < 5 bpm for <40 min.
Decelerations - early decels, occasional uncomplicated variable decels.
Accelerations - >32 wks, >15 bpm lasting > 15 seconds
- < 32 wks, >10 bpm lasting >10 seconds.
- accels w/ fetal scalp stim.
FHR Complicated Decels
- < 70 bpm for >60 sec
- Loss of variability in trough or BL
- biphasic decels
- overshoots
- slow return to baseline
- decreased baseline post decel
- Baseline tachy or brady
Late Decels w/ > 50% of contractions.
Single prolonged decel of >3min
Causes of decels
Early decel - head compression
Variable decel - cord compression
Late decel - uteroplacental insufficiency
4 stages of labour
1) Contractions and cervical dilation
2) Full dilation to delivery of baby
3) separation and expulsions of placenta
4) First postpartum hour
IUGR
Symmetric
- early insult
- head circ percentile = abd circ percentile
Asymmetric
- late insult
- Head circ preserved, <abd circ.
#1 cause of PPH
Uterine Atony
4 factors of abnormal progression of labour
Power
Passage
Passenger
Psyche
Painless third Tri bleeding
Placenta previa until proven otherwise.
GDM Screening
24-28 weeks - 1 hr OGCT
- PG <7.8mmol/L = no GDM
- PG 7.9-10.2 - do 2hr 75gm OGTT
- PG >10.2 = GDM
GBS Screen
34 - 36 weeks, rectovaginal swab.
At time of delivery - 5 million units of Pen G to start, then 2.5 million units IV Q4H until delivery.
When Rhogam in Rh neg women?
- Routinely at 28 wks
- w/in 72 hours of birth of Rh +ve fetus
- w/ +ve Kleihauer-Betke test
- w/ any invasive procedure during pregnancy
-
Hormones of the menstrual cycle
Folic Acid Requirements
- 3 months prior to conception reduces risk of ONTD by 70%
- 0.4 mg daily for 3 months prior and 3 months after conception.
- 5 mg if diabetes, epilepsy, FHx of NTD or prev child with NTD.
If 3+ early losses or midtrimester losses?
Consider:
- Thrombophilia testing
- Hysterosonogram for uterine cavity abnormalities
- Progesterone supplementation?
- Genetic counseling & karyotyping
- Cervical cerclage (for cervical insufficiency)
- Low dose ASA, heparin
Cervical Cancer Risk Factors
1) HPV infection, esp subtype 16 &18.
18 is responsible for adenocarcinoma.
2) Smoking
3) immunosuppression
4) ? HSV, ?BCP
Pap smear screening
1) Begin within three years of the onset of vaginal sexual activity
2) Annual screening at first, Q 2-3 years after three consecutive normal paps.
3) No appropriate time to stop screening in women who still have a cervix.
Limitations of pap smears
1) False-positive ASCUS & LSIL
2) False negative rate of a single screening test up to 50% (hence the need for regular serial screening)
3) Visible cervical lesion needs a biopsy, cytology is not adequate for a visible lesion.
Women at greatest risk for developing cervical cancer in Ontario
Women who have a lack of regular screening.
- native
- Low socioeconomic status
- sex-trade workers
- Northern Ontario
- Immigrant women
Bethesda Classification of abnormal cervical cytology
1) Satisfactory vs. Unsatisfactory cytologic sample.
- lack of sampling entire transformation zone
- low celularity
- inflammatory cells/blood
2) Epithelial cell abnormality detected vs. no abn. detected
i) Squamous cell abnormality detected
- Atypical squamous cells of undetermined signicicance (ASC-US)
- Atypical squamous cells - Can't rule out hight grade squamous intraepithelial lesion (ASC-H)
- Low grade squamous intraepithelial lesion (LSIL)
- High grade squamous intraepithelial lesion (HSIL)
- Squamous cell carcinoma
ii) Glandular abnormality detected (endocervical, endometrial, NOS)
- Atupical glandular cells (AGS)
- Atypical clandular cells -favour neoplastic
- Adenocarcinoma in-situ
- Adenocarcinoma
Management of abnormal cervical cytology report
ASC-US - Reflex HPV testing vs. repeat cytology vs. colposcopy
ASC - H - Colposcopy
LSIL - Colposcopy
HSIL - Colposcopy
AGC - Colposcopy, ECC, endometrial biopsy
AGC - favour neoplasia -Colposcopy, ECC, endometrial biopsy, cone biopsy
Adenocarcinoma-in-situ -Colposcopy, ECC, endometrial biopsy, cone biopsy
Squamous cell carcinoma or Adenocarcinoma - URGENT colposcopy
What is Colposcopy?
- Examination of the cervix under magnification using a colposcope.
- Acetic acid is used to highlight dysplastic cells (turn acetowhite)
- Lugol's iodine may be used which stains normal epithelium, NOT dysplastic cells
- Highlighting dysplastic cells facilitates colposcopic-directed biopsy to confirm histology and guide treatment.
Treatment modalities for cervical dysplasia
1) Destructive/Ablative (destroys tissue containing dysplastic cells)
- laser ablation (CO2 laser)
- cryotherapy (freeze-thaw-freeze technique w/ nitrous oxide)
- electrocoagulation (pt needs to be grounded)
*** Must rule out cervical cancer first *** - May seriously under-treat with destruction alone.

2) Excisional
- Loop electroexcision procedure (LEEP)
- Cone Biopsy(cold knife cone vs. laser cone)
- Hysterectomy
*** Definitive pathology specimen is obtained***
When should the excisional technique be used?
- positive endocervical curettage
- suspected glandular abnormality
- histology confirmed microinvasive cervical cancer
- Significant discrepancy between cytology, colposcopy, and histologic findings
Prevention of Cervical Neoplasia
Primary Prevention
i) prevention of HPV infection
- Abstinence
- Condom use
- HPV Immunization (gardasil - 6, 11, 16, 18)
ii) Prevention of cervical dysplasia in HPV +ve women
- Avoidance of co-factors (smoking, HIV)

Secondary Prevention
- Cytologic screening ("pap smear")
- ?HPV screening?
HPV Vaccine
- Immunization against subtypes 6, 11, 16, 18 (covers 70% of burden of disease)
- Recommended for all women aged 9 - 26, regardless of previous exposure to HPV or previous development of cervical neoplasia.
- 3 injections over 6 months
Cervical cancer histologic subtypes
- Caused 420 deaths in 2003
Histologic subtypes
- Squamous cell ***
- Adenocarcinoma
- Adenosquamous
- Clear cell
- Small Cell
- Sarcoma
- Melanoma
- Secondary spread
Cervical cancer Symptoms
- Asymptomatic discovered on routine pap
- Abnormal vaginal bleeding (classically post-coital bleed)
- Malodorous vaginal discharge
- weight loss
- Pelvic pain
- Sciatica
- Obstructive uropathy
- GI symptoms
Spread of cervical cancer
1) local invasion of cervix, uterine corpus, vagina, parametrium
2) Lymphatic spread to pelvic and para-aortic lymph nodes
3) Hematologic spread to liver, lung
4) Intraperitoneal implantation (seeding)
Cervical Cancer Staging
FIGO staging system incorporates:
- Vaginal speculum
- Bimanual
- Pelvirectal
- CXR
- Cystoscopy
- Proctoscopy
- IVP
Treatment of Cervical Cancer
1) Surgery
- Very early stage - simple hysterectomy vs. cone biopsy
- Traditional early stage - Radical hysterectomy ( uterus, cervic, 1-2cm cuff of cagina, parametria, and pelvic lymphadenectomy. Ovaries may be left in situ for fertility/avoiding early menopause
- Small invasive cancer w/ desire for fertility - radical trachelectomy (removes cervix, parametrium, vaginal cuff - fundus is surrounded with cerclage to prevent incompetence during pregnancy and reconnected to the vagina. - 60% pregnancy rate)

2) Radiation - Early stage non-surgical candidates or adjunct to surgery if needed (+ve lymph node, +ve margin etc..)
- Mainstay for advanced stage as curative or palliative
- External beam RT daily over 5 weeks, followed by brachytherapy (continuous radiation) over a few days.

3) Chemotherapy
- Cisplatin given concomitantly with external beam on a weekly basis.
- Can also be used palliatively.
Dystocia
Abnormal labour or difficult childbirth
Def'n: The abnormal progression of cervical dilation and/or fetal descent during labour.
Active phase of 1st stage: >4 hours of <0.5 cm/hr cervical dilation
2nd stage: > 1 hour with no fetal descent during active pushing
aka: Cephalopelvic disproportion
aka: Failure to Progress
*** Do not make a diagnosis of dystocia when cervical dilation is less than 4 cm.***
Abnormal labour patterns
1) Primary abnormal progression in labour - protraction
2) Secondary Arrest - Adequate progress of labour followed by an arrest of dilatation in the first stage of labour (Assoc. w/ occiput posterior)
- Secondary Arrest - Second stage of labour as fetus fails to descend particularly with maternal expulsive effort.
Etiology of Dystocia
Power
- Contractions may be hypotonic or in-coordinate
- Maternal expulsive efforts may be inadequate

Passenger
- Fetal position
- Fetal size
- Fetal anomalies (ie hydrocephalus)
- Fetal attitude?

Passage
- Pelvic structure
- Soft tissue obstruction (Tumor, full bladder/full rectum, vaginal septum)

Psyche
- Anxiety
- Stress
- Pain
Prevention of Dystocia
- Pt eductation about labour
- Only admit in active labour
- Pain management in prolonged latent phase
- Supportive companion and one to one nursing care in active labour.
- Maintain ambulation and upright position in labour as much as possible.
- Maintain adequate hydration
- Do not delay - manage non-progressive active labour with ROM and Oxytocin.
Evaluation of abnormal labour
- Assess maternal status
* Vitals
*Pain
* Ctx pattern
* Membranes
* Cervical dilation/Effacement
* Pelvic architecture

- Assess fetal status
* FHR
* Fetal station
* Fetal presentation and position
Oxytocin
Initial dose: 1-2 mU/min
Increase interval: q30min
Dosage increment: 1-2 mU
Maximum dose: 40 mU
Indication for Induction
Maternal
- Post-dates
- Preeclampsia
- Any maternal medical problem

Fetal
- IUGR
- Hemorhage
- PROM
- Chorioamnionitis
- GDM
- Fetal compromise
- Iso-Immune disease
Contraindications to Oxytocin
- Severe vaginal bleeding
- Placenta previa
- Hypotension
- Abnormal fetal lie (transverse, footling breech)
- Prior classical or inverted-T uterine incision.
- Pelvic structural deformities
Adverse Effects of Oxytocin
- Fetal compromise (hyperstimulation)
- Uterine rupture (hyperstimulation)
- Water Intoxication (ADH effect)
- Hypotension (Vasodilation)
VBAC risks and successes
Risk of rupture - 1.5%
Chance of successful vaginal delivery post C/S:
- 50% - 85%
- 50% if previous C/S was for dystocia
- 85% if previous C/S was due to any non-reoccurring issue, ie
* previa
* breech
* triplets
* non-reassuring fetal HR
Indications for assisted vaginal birth (operative delivery)
Fetal
- Evidence of fetal compromise requiring immediate delivery
Maternal
- Failure to deliver spontaneously in the second stage
- Conditions which require a shortened second stage
- Inefficient maternal effort
Contra-indications for Operative delivery
- Non-cephalic presentation, face or brow
- Unengaged head
- Incompletely dilated cervix
- Low probability of success

Specific to vacuum
- <34 weeks gestation
- deflexed attitude of fetal head
- need for rotation
- fetal conditions (bleeding disorder, demineralization disorder)
Prerequisites for operative delivery
- Informed concent
- Vertex presentation
- Vertex engaged
- Term or near term
- cervix fully dilated
- Membranes ruptured
- Adequate maternal pelvis
- Adequate anaesthesia
- Maternal bladder empty
- backup plan
- Ongoing assessment
Risks of assisted vaginal birth
- Maternal soft tissue trauma
- Fetal scalp trauma (Laceration, hemorrhage)
- Fetal subgleal/subaponeurotic hemorrhage (not limited by suture lines like a cephalohematoma, therefore +++ blood loss can be fatal.)
Indications for C/S
Most Common
- Repeat C/S
- Dystocia
- Breech presentation/other malpresentations
- Non-reassuring fetal status

Absolute Indications
- Placenta Previa
- Cord Prolapse
- Previous uterine surgery
- Previous classical c/s or inverted T incision
- Previous uterine rupture
- Malpresentation
- Obstructed pelvis

Relative Indications
- Failed induction
- Abnormal progression in labour
- Pre-eclampsia/eclampsia
- DIabetes
- Cardiac Disease
- Placental Abruption
- Multiple Pregnancy
Risks of C/S
- Infection (wound, sepsis, uterine, urinary
- Hemorrhage
- Atelectasis
- Injury to bowel or bladder or ureter
- Deep venous Thrombosis
- Pulmonary Embolus
- Longer recovery time
*** All risks are increased if the C/S follows and unsuccessful trial of labour ***
Labour Pain relief
Non-pharmacologic
* Reduction of painful stimuli
- maternal movement and position change
- counter-pressure
- abdominal decompression

* Activation of peripheral sensory receptors
- Superficial heat and cold
- Immersion in water
- touch and massage
- acupuncture and acupressure
- transcutaneous electrical nerve stimulation (TENS)
- Intradermal injection of sterile water
- Aromatheraphy

* Enhancement of descending inhibitory pathways
- attention focusing and distraction
- hypnosis
- music and audio analgesia
- biofeedback

Pharmacologic
- Nitrous Oxide in latter part of 1st stage
- Narcotics IV/PCA pump
* Combined with anti-emetic
* Decreased fetal heart rate variability
* Causes neonatal respiratory depression (reverses with NALOXONE)
- Peripheral nerve blocks
- Perineal Infiltration
- Epidural block
Contraindications to VBAC
Absolute
- Previous classical, inverted-T, or unknown incision
- Other uterine surgeries
- Previous history of uterine rupture
- Opinion of previous surgeon (weak or thin myometrium observed during previous c/s- get operative note)
- Mother desires a repeat C/S

Relative
- If induction is required
- two or more previous lLSCS scars
- Multiple pregnancy
- Breech presentation
- Poor obstetrical history
- Pt desires tubal ligation
Risk of VBAC
- UTERINE RUPTURE
- Prolonged labour
- maternal fever and infection
- failed trial necessitating a repeat c/s (all c/s risk are higher after a trial of vag delivery)
Why VBAC?
- Reduced intervention, and their risks
- faster recovery
Risk of elective repeat C/S
All risks of C/S are increased with repeat c/s due to scarring, including injury to surrounding structures and hemorrhage.
Signs of Uterine Rupture
-UR occurs in 1-5/1000 VBACs

Signs
- Profound fetal bradycardia
- Constant lower abdominal pain (may be masked by epidural)
- Cessation of uterine contractions
- Vaginal bleeding
- Recession of presenting part on vaginal exam
- intra-abdominal hemorrhage
- hypovolemic shock
Causes of Uterine Rupture
- Uterine Scar (C/S, myomectomy, previous uterine perforation, salpingectomy with cornual resection.)
- Excessive uterine action (oxytocin, prostaglandins, neglected obstructed labour)
- Trauma (Forceps, manual removal of placenta, assault/MVA)
- Misc (multiparity, uterine anomalies, placenta accreta)
Placental attachment
Placenta ACCRETA - invasion of the myometrium which does not penetrate the entire thickness of the muscle. (75-78%)

Placenta INCRETA - the placenta further extends into the myometrium (17%)

Placenta PERCRETA - the placenta penetrates the entire myometrium to the uterine serosa (5-7%). The placenta can attach to other organs such as the rectum or bladder.
Indications for Induction of Labour
Emergent
- Severe gestational hypertension
- Suspected fetal compromise
- Severe intrauterine growth restriction
- maternal disease
- significant antepartum haemorrhage
- choreoamnionitis

Urgent
- PROM
- IUGR w/ no acute compromise
- Poorly controlled diabetes
- Iso-immune disease
Non-Urgent
- prolonged pregnancy
- well controlled diabetes
- prior intrauterine death
- logistical problems
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